175 Neb. Admin. Code, ch. 6, § 010

Current through September 17, 2024

Section 175-6-010 - STANDARDS OF OPERATION, CARE, AND TREATMENT

Each licensee must assure protection to consumers and compliance with state statutes and regulations. All services provided by the licensee must be provided in accordance with the Health Care Facility Licensure Act, The Uniform Credentialing Act, the Medication Aide Act, the regulations adopted under those Acts, physician orders, supervising practitioner orders, and prevailing standards of practice.

010.01LICENSEE. The licensee is responsible for implementing written policies and procedures to ensure compliance with statutes and regulations as per 175 NAC 1, the Health Care Facility Licensure Act, and this chapter and is responsible for making such available to staff and consumers. The licensee's responsibilities include:

(A) Ensuring the quality of care, treatment, and services provided to consumers, whether furnished by the children's day health service employees, volunteers, or through contract staff;

(B) Ensuring consumers are provided with a stable and supportive environment, through respect for the rights of consumers and responsiveness to consumer needs;

(C) Ensuring staff levels are sufficient to meet the consumers' needs;

(D) Monitoring policies and procedures to assure the appropriate administration and management of the children's day health service;

(E) Defining in writing the duties and responsibilities of the administrator;

(F) Designating in writing an administrator who meets the administrator requirements at 175 NAC 6 and who is responsible for the day to day management of the children's day health service;

(G) Implementing written procedures and criteria for the admission, discharge; and transfer of consumers. Such implementation shall ensure the needs of consumers that are admitted are met;

(H) Implementing written procedures for obtaining and incorporating physician and supervising practitioner verbal and written orders into a plan of care for each consumer;

(I) Establishing written policies and procedures to implement all service agreements and to create a written program description which must include the range of services provided by the children's day health service;

(J) Reviewing all elements of the written program description as described in 175 NAC 6 at least annually and must include, in this review process, relevant findings from its quality assurance and improvement program for the purpose of improving consumer services and resolving problems in consumer care, treatment and services;

(K) Ensuring maintenance of documentation to demonstrate compliance with statutes and regulations as per 175 NAC 1, the Health Care Facility Licensure Act, and this chapter;

(L) Ensuring written policies and procedures for staff and volunteers to report immediately to the administrator or, in the administrator's absence, the administrator's designee all suspected abuse, neglect, or exploitation of consumers; and

(M) Making records available for inspection and copying by an authorized representative of the Department.

010.02ADMINISTRATION. There must be an administrator to carry out the policies and directives of the licensee and to be responsible for the day-to-day management of the children's day health service. Whether employed, elected, contracted, or appointed, the administrator must report and be directly responsible to the licensee in all matters related to the maintenance, operation, and management of the children's day health service.

010.02(A)ADMINISTRATOR QUALIFICATIONS.

The administrator must have training and experience with a health care program where specialized care and treatment, as defined at 175 NAC 6-002, was provided. The administrator must be a:

(i) Physician;

(ii) Registered nurse who meets the Director of Nursing requirements at 175 NAC 6; or

(iii) An individual with:

(1) A bachelor's degree in health care administration, mental health practice, speech-language pathology, physical therapy, occupational therapy, or related field; and

(2) 3 years or more of full-time work experience in health care or mental health administration or as a practitioner in 1 of these fields.

010.02(B)ADMINISTRATOR RESPONSIBILITIES.

The administrator is responsible for the management of the children's day health service to the extent authority is delegated by the licensee. An individual who meets the administrator qualification requirements at 175 NAC 6 must be designated in writing to act in the absence of the administrator. The administrator or the administrator's written designee must be available to children's day health service staff during all hours of operation. The administrator is responsible to:

(i) Ensure compliance with statutes and regulations by all children's day health service staff, volunteers, and contracted staff;

(ii) Organize and direct the ongoing functions of the children's day health service;

(iii) Oversee and be responsible for the provision and coordination of consumer services;

(iv) Maintain communication between the licensee and staff;

(v) Implement written personnel policies and procedures and written job descriptions for each staff position that include minimum job qualifications;

(vi) Employ or contract with qualified personnel in accordance with job descriptions;

(vii) Maintain sufficient number of staff with appropriate training and skills to meet consumers' needs and to implement each consumer's service agreement and plan of care;

(viii) Maintain personnel and administrative records;

(ix) Provide orientation for new staff, volunteers and contracted staff, schedule in - service education programs and opportunities for continuing education of the staff;

(x) Ensure the completion, maintenance, and submission of reports and records as required by the Department;

(xi) Establish planned hours of operation during which consumer care, treatment, and services will be provided, and ensure daily oversight of staff, volunteers, and contracted staff and consumer scheduling so that qualified staff are available to meet each consumer's needs;

(xii) Monitor that a service agreement and a plan of care are established, implemented, and revised, as necessary, to meet the consumer's needs;

(xiii) Monitor staff, volunteers, and contracted staff, identify and review incidents and accidents, consumer complaints and grievances, patterns and trends in overall operation such as provisions of consumer care, treatment, and service, and take action to alleviate problems and prevent recurrence of problems identified;

(xiv) Develop procedures that require reporting of any evidence of abuse, neglect or exploitation of any consumer served by the children's day health service in accordance with Neb. Rev. Stat. § 28-372 or in the case of a person under the age of 18, in accordance with Neb. Rev. Stat. § 28-711;

(xv) Ensure staff and volunteers are trained to report immediately to the administrator or, in the administrators absence, the administrator's designee all suspected abuse, neglect, or exploitation of consumers;

(xvi) Ensure an investigation is completed on suspected abuse, neglect, or exploitation, and take action to prevent recurrence until, and after, the investigation is completed;

(xvii) Ensure written policies, procedures and forms are individualized for the children's day health service and contain effective dates and revision dates;

(xviii) Ensure the children's day health service maintains a copy of all active policies, procedures and forms which are available for staff use; and

(xvix) Ensure the children's day health service maintains a copy of all inactive policies, procedures and forms for a minimum of 7 years after the document becomes inactive.

010.03STAFF AND VOLUNTEER REQUIREMENTS. Sufficient number of staff with the required experience, orientation, training, and demonstrated competency to meet the needs of all consumers accepted for care, treatment, and services must be present on the premises to provide care. Before a staff member is scheduled to care for consumers, the qualification of the staff must be assessed through orientation, training, and demonstrated competency to provide consumer care, treatment, and services as ordered by the consumer's physician and supervising practitioner in a safe and timely manner.

010.03(A)STAFF-TO-CONSUMER RATIOS. There must be a system to monitor and appropriately adjust staff-to-consumer ratios based on the number of consumers in attendance daily, the complexity of those consumers' needs, and the number of qualified and trained staff available to provide care, treatment and services. When volunteers are counted in the staff-to-consumer ratios, the volunteer must meet the staff requirements for the position he or she is assuming. All volunteers must receive direct supervision by staff who meet 175 NAC 6 requirements to provide and supervise such services.

010.03(B)UNCREDENTIALED DIRECT CARE STAFF AND VOLUNTEERS. When unlicensed direct care staff are used to provide care, the licensee must maintain documentation to demonstrate compliance with the following requirements for any unlicensed direct care staff member who provides any of the following regulated services:

(i) Children's day health aide services and personal care aide services must be provided in accordance with 175 NAC 6; and

(ii) Provision of medication must be performed by a registered medication aide and in compliance with the Medication Aide Act, this chapter and 172 NAC 95 and 96.

010.03(C)STAFFING RECORDS. A daily roster of available staff must be maintained and contain the first initial and last name of the staff member, job title, license or other credential, and hours available for duty. A daily schedule of staffing and consumer assignments must be maintained.

010.04EMPLOYMENT AND VOLUNTEER ELIGIBILITY. Pre-employment criminal background and registry checks for each direct or contracted staff member and volunteer must be completed and documented. Employment and training records for each direct or contracted staff member and volunteer must be maintained. Documentation of written contracts for consumer care, treatment, and services provided by contracted staff must be maintained. Any individual who meets the restrictions identified in 175 NAC 6-010.04(B) must not be on the premises during the hours of operation, except that a parent who meets such restrictions may be allowed on the premises when accompanied by staff and only to pick up and drop off his or her child.

010.04(A)PRE-EMPLOYMENT BACKGROUND CHECKS. P re-employment background checks must be completed in accordance with 391 NAC 3. P re-employment checks must include a check for adverse findings on the Nurse Aide Registry for each direct or contracted staff member and volunteer.

010.04(B)EMPLOYMENT AND VOLUNTEER RESTRICTIONS. A children's day health service must not employ, use as a contracted staff member, or use as a volunteer, any individual who is disqualified under 391 NAC 3 and who is:

(i) Listed as a perpetrator on the Central Registry of Child Protection Cases, if the individual is age 13 or older;

(ii) Listed as a perpetrator on the Adult Protective Services central registry if the individual is age 18 or older;

(iii) Listed as a perpetrator on the State Patrol sex offender registry; or

(iv) Listed with adverse findings on the Nurse Aide Registry.

010.04(C)EMPLOYMENT RECORD. An employment record for each direct or contracted staff member must be maintained and include:

(i) The title of that individual's position, qualifications, and description of the duties and functions assigned to that position;

(ii) Evidence of licensure, certification, registration, or approval, if required;

(iii) Performance evaluations made within 6 months of employment and annually, thereafter;

(iv) Post-hire and pre-employment health history screening. All staff must have a health history screening after accepting an offer of employment and prior to assuming job responsibilities. A physical examination is at the discretion of the employer based on results of the health history screening; and

(v) Sufficient documentation to demonstrate that the requirements of this chapter are met.

010.04(D)TRAINING. All staff and contracted staff must receive training and demonstrate competency before independently performing job duties or assigned tasks. Records must be maintained of each orientation and in-service or other training program, including the signature of staff and volunteers attending, subject matter of the training, the names and qualifications of instructors, dates of training, length of training sessions, and any written materials provided. Volunteers must not be left alone with consumers.

010.04(D)(i)ORIENTATION. Orientation and training programs must be provided for all new staff, existing staff who are given new assignments, all contract staff, and volunteers. For existing staff with job duty, title, or role changes, the staff members must receive orientation and training and must demonstrate competency for all newly assigned job duties before independently performing a new duty. The orientation program must include:

(1) Job duties and responsibilities;

(2) Organizational structure;

(3) Consumer rights;

(4) Consumer care policies and procedures;

(5) Personnel policies and procedures, including confidentiality policies; and

(6) Reporting requirements for abuse, neglect, or exploitation of any consumer in accordance with these regulations and with Neb. Rev. Stat. § 28-711 of the Child Protection Act or, in the case of a consumer who has reached the age of majority, in accordance with Neb. Rev. Stat. § 28-372 of the Adult Protective Services Act.

010.04(D)(ii)ONGOING TRAINING. Ongoing and continuous training, in - services or continuing education for staff and volunteers counted in the staff-to-consumer ratios must be provided. Records to confirm this requirement is met must be kept. Documentation for ongoing and continuous in - services or continuing education must include the date provided, the topic and content, and participants' names and job titles.

010.04(D)(iii)SPECIALIZED TRAINING. T raining, whether part of a program or as individualized instruction of staff and volunteers, to perform particular procedures or to provide specialized care and treatment, such as the use of ventilators, mechanical lifts, and other similar devices necessary to safely provide prescribed care and treatment must be provided.

010.04(E)CONTRACT STAFF. The licensee may contract for consumer care, treatment and services. Documentation of all contracts between the licensee and outside resources must be maintained. Any contract with a provider must be in writing and must include:

(i) A statement that the contractor will accept consumers of the licensee only if approved by the licensee;

(ii) A description of the services and the manner in which they are to be provided;

(iii) A statement that the contractor must be in compliance with all 175 NAC 6 requirements and must conform to all applicable licensee policies and procedures, including those related to qualifications;

(iv) A statement that the contractor is responsible for participating in the development of plans of care;

(v) A statement that the care, treatment, and services are controlled, coordinated, and evaluated by the licensee;

(vi) The policies and procedures for submitting clinical and progress notes, scheduling consumer care, treatment and services, and continuing periodic consumer evaluations; and

(vii) The policies and procedures for determining charges and reimbursement.

010.05CONSUMER RIGHTS. The licensee must implement a written Bill of Rights that is equally applicable to all consumers. The licensee must protect and promote these rights. The consumer must be given a copy of the Bill of Rights before care, treatment, or services are provided to the consumer and this action must be documented.

010.05(A)CONSUMER RIGHTS. The consumer has the right to:

(i) Receive mental health services ordered by a supervising practitioner and to receive skilled nursing care services and rehabilitation services as ordered by a physician and to communicate with those physicians and practitioners;

(ii) Participate in the planning of the consumer's care and treatment, receive appropriate instruction and education regarding the plan;

(iii) Request information about the consumer's diagnosis, prognosis, and treatment, including alternatives to care and risks involved, in terms that they can readily understand so that they can give their informed consent;

(iv) Refuse care and be informed of possible health consequences of this action;

(v) Receive care without discrimination as to race, color, creed, sex, age, or national origin;

(vi) Exercise religious beliefs;

(vii) Be admitted for service only if the children's day health service has sufficient, qualified, and trained staff to provide safe and timely care, treatment, and services;

(viii) Receive the full range of services provided by the licensee;

(ix) Personal privacy and confidentiality of all records, communications, and personal information;

(x) Review and receive a copy of all health records pertaining to them;

(xi) Receive from the licensee the policies and procedures for admission, discharge, transfer, and termination of services prior to admission;

(xii) Voice complaints and grievances and suggest changes in service or staff without fear of reprisal or discrimination and be informed of the resolution;

(xiii) Be fully informed of policies and charges for services, including eligibility for third-party reimbursement, prior to receiving care;

(xiv) Be free from verbal, physical, and psychological abuse and to be treated with dignity;

(xv) Expect all efforts will be made to ensure continuity and quality of care, treatment, and services in the children's day health service setting;

(xvi) Have his or her person and property treated with respect;

(xvii) Be informed, in advance, about the care, treatment and services to be furnished, and any changes in the care, treatment and services to be furnished;

(xviii) Formulate advance directives and have the licensee comply with the directives unless the licensee notifies the consumer of the inability to do so; and

(xix) Be free from chemical and physical restraints, including locked seclusion, imposed for the purposes of discipline or convenience, and not required to treat the consumer's medical symptoms.

010.05(B)ADVANCE DIRECTIVES. The licensee must comply with the requirements of Neb. Rev. Stat. §§30-3041 to 30-3432, the Health Care Power of Attorney Act, Neb. Rev. Stat. §§ 20-401 to 20-416, and the Rights of the Terminally Ill Act. The licensee must inform and distribute written information to the consumer in advance concerning its policies and procedures on advance directives, including a description of applicable State law.

010.05(C)COMPETENCE OF CONSUMERS. The following apply related to competence of consumers:

(i) When a consumer is under 19 years of age, the parent is responsible for decisions about consumer care and treatment to be provided by the children's day health service. In the case of a consumer age 19 or older adjudged incompetent or incapacitated under the laws of the State by a court of competent jurisdiction, the rights of the consumer are exercised by the persons authorized under State law to act on the consumer's behalf; and

(ii) In the case of a consumer who has not been adjudged incompetent by the State court, any person designated in accordance with State law may exercise the consumer's rights to the extent provided by the law.

010.06ADMISSION AND RETENTION REQUIREMENTS. Written policies and procedures that encompass admission, transfer, discharge and termination of services must be implemented and delineate the scope of services provided and describe the consumer population that will be served.

010.06(A)ADMISSION. The licensee must only admit individuals when the licensee reasonably expects the individual's needs can be meet through the provision of one or more of the services listed in 175 NAC 6. A written service agreement must be signed and dated by the prospective consumer or the prospective consumer's parent before he or she is admitted.

010.06(B)SERVICE AGREEMENT. The licensee must negotiate a written service agreement with each prospective consumer or the prospective consumer's parent. The service agreement must be signed and dated by the prospective consumer or the prospective consumer's parent and must not conflict with the physician-approved or supervising practitioner-approved written plan of care. The service agreement must include:

(i) A consumer-specific written emergency plan identifying the consumer's emergency contact information, methods of contact, and assuring continuity of the consumer's external home back-up power source for life-sustaining and emergent-care equipment operation while the licensee is responsible for the consumer's care, treatment and services. For consumers that use a ventilator, this plan must include:

(1) The consumer's ventilator type and instructions for proper implementation and use of the external back-up power source;

(2) The method for staff to assure, during the daily communication report, that the consumer's external back-up power source is operational and has sufficient power to operate for a minimum of 24 hours; and

(3) Any additional information necessary to assure the consumer's safety in an emergency;

(ii) Written authorization from the consumer or the consumer's parent allowing the licensee to:

(1) Transfer the consumer for emergent care when needed; and

(2) Release and receive consumer information necessary to provide consumer care, treatment, and services as ordered by the consumer's physician;

(iii) A list of supplies, medications, and equipment necessary to provide care, treatment, and services in accordance with the consumer's physician-approved written plan of care identifying which items will be provided by the licensee and which items will be provided by the consumer;

(iv) A written description of the procedures for communication between the consumer or consumer's parent and a licensee's practitioner in accordance with the daily communication report requirements of this chapter;

(v) Acknowledgment signed and dated by the consumer or the consumer's parent that the licensee must:

(1) Receive consumer, consumer's parent, or physician notification of all changes to the consumer's current physician orders and practitioner care plan s prior to accepting the consumer for daily care, treatment or services by the children's day health service;

(2) Only accept the consumer for care, treatment, or services when the consumer's, or their parent's, instructions for his or her care, treatment, and services are not in conflict with the physician-approved and supervising practitioner written plan of care, or could compromise the consumer's health or safety; and

(3) Not accept the consumer for care, treatment, or services when the consumer does not bring the supplies, medications, and equipment necessary to provide care, treatment, or services as ordered by the consumer's physician and supervising practitioner, as shown on the consumer's care plan, and in accordance with the signed service agreement; and

(vi) A list of care, treatment and service providers authorized by the consumer to exchange consumer information necessary for the licensee to:

(1) Coordinate the licensee's consumer care plans with care, treatment or services provided by the consumer's non-licensee practitioners; and

(2) Send written summary reports when requested by the consumer or the consumer's parent.

010.06(C)DAILY COMMUNICATION REPORT. The licensee must have an established procedure for communication between the consumer and the licensee to ensure that services are appropriately provided. Such communication must occur each time the consumer is accepted for care, treatment, or services and include:

(i) Any changes in the consumer's medication, care and treatment regimen, or both;

(ii) Any changes to the consumer's health condition; and

(iii) The condition and availability of life-sustaining and emergent-care equipment needs for consumers who require such equipment.

010.06(D)ACCEPTANCE FOR DAILY CARE AND TREATMENT. The licensee must exclude the consumer from attendance when symptoms of illness are present as identified in 173 NAC 3. Written policies and procedures to prevent exposure to others when consumers develop symptoms of illness while at the premises must be implemented and revised as necessary and be consistent with prevailing professional standards to protect the health and safety of consumers.

010.06(E)TRANSFER. When the consumer is transferred to another health care facility, the licensee must provide appropriate information for continuity of the consumer's care and treatment to the receiving facility with written consumer consent or as permitted by law.

010.06(F)DISCHARGE. Oral and written notification must be provided to the consumer within 2 working days after receipt of the physician's discharge order.

010.06(G)TERMINATION OF SERVICES. If a licensee terminates services for any reason other than a physician-ordered discharge or a transfer, the consumer or the consumer's parent must receive both an oral and written explanation. Information regarding community resources must be given to the consumer or the consumer's parent.

010.06(G)(i)2-WEEK NOTICE. Consumers must receive at least a 2 week notice prior to termination of services. No notice prior to termination of services is required when a patient consumer is discharged by the physician's order, or when consumer services are being terminated based on non-compliance with the consumer's physician-approved or supervising practitioner-approved written plan of care, failure to pay for services, or disruptive, abusive, or uncooperative behavior to the extent that delivery of care, treatment or services to the consumer or the ability of the licensee to operate safely and effectively is impaired.

010.06(G)(ii)TERMINATION OF SERVICES. The licensee must make a serious effort to address presenting problems or issues that adversely affect care, treatment or services prior to termination of services and document such efforts to address problems and issues in the consumer's medical record.

010.07CONSUMER CARE, TREATMENT, AND ACTIVITIES. Written policies and procedures that address all care, treatment, services, and activities provided to, consumers must be implemented and delineate the scope of services provided, address how physician and supervising practitioner orders will be obtained, updated and incorporated into the physician-approved or supervising practitioner-approved written plan of care initially and on an ongoing basis, and to protect the health and safety of consumers.

010.07(A)PLAN OF CARE. The consumer must have a physician-approved, and when mental health services are provided, a supervising practitioner-approved, written plan of care which includes all care, treatment and services to be provided for each consumer by the licensee. The consumer's care, treatment and services must follow a written plan of care which must:

(i) Include physician's order when the following services are provided:

(1) Skilled nursing care services;

(2) Rehabilitation services; or

(3) Respiratory care services;

(ii) Include a supervising practitioner's order when mental health services are provided;

(iii) Be developed by a:

(1) Registered nurse for skilled nursing care services after an initial consumer assessment by the registered nurse; or

(2) Practitioner of the appropriate discipline for mental health practice services or rehabilitation services, after an initial consumer assessment by the practitioner of the appropriate discipline;

(iv) Specify the scope and frequency of services to be provided;

(v) Include a physician-approved medication list with complete medication orders and known medication allergies for the consumer including those medications to be administered by the licensee;

(vi) Provide for the coordination of all services to ensure the services complement one another and support the objectives in the plan of care;

(vii) Provide for coordination with any other existing plan of care for the consumer from a non licensee practitioner identified in the consumer's service agreement;

(viii) Recognize the parent and family as members of the care team;

(ix) Be reviewed by a registered nurse, or a practitioner of the appropriate discipline for mental health or rehabilitation services, as often as the consumer's condition requires, but at least every 62 days;

(x) Be reviewed, approved, and signed by the consumer's physician, and when mental health services are provided signed by a supervising practitioner, every 6 months or when the physician-approved or supervising practitioner-approved written plan of care requires a change either through a recommendation by a practitioner of the appropriate discipline or when a change in the severity of the consumer's condition requires; and

(xi) Include a written summary report of the consumer's care, treatment and services provided by the licensee which must be submitted to the consumer's ordering physician and when mental health services are provided to the supervising practitioner, every 6 months or when there has been a significant change in the consumer's condition.

010.07(B)THERAPEUTIC ACTIVITIES. The licensee must:

(i) Provide age and developmentally-appropriate daily activities designed to promote the consumer's social well-being in accordance with each consumer's plan of care. Activity areas are not required, but developmentally appropriate equipment and materials must be available for consumer daily use;

(ii) Allow flexibility with eating, toileting, sleeping, resting, and play times as needed in coordination with the consumer's plan of care; and

(iii) When activities for consumers are routinely conducted outdoors or off the premises, the children's day health service must:

(1) Develop a schedule of activities which is posted in a conspicuous place in the children's day health service or given to the parents;

(2) Obtain written permission from parents before transporting consumers on field trips or leaving the children's day health service; and

(3) While consumers are in the care of the licensee, but off the licensee's premises, the licensee must maintain staff requirements as provided in 175 NAC 6 to ensure consumer care, treatment, and services are provided as ordered in a safe and timely manner.

010.08NURSING SERVICES. The licensee must provide skilled nursing care services to consumers in a manner that protects the health and safety of the consumers.

010.08(A)REGISTERED NURSE ON DUTY. A registered nurse must be on duty and available to the direct care staff during all hours of operation.

010.08(B)DIRECTOR OF NURSING. The licensee must have a Director of Nursing when skilled nursing care services, children's day health aide services or intravenous therapy services are provided. The Director of Nursing must:

(i) Be designated in writing;

(ii) Be a registered nurse with at least 3 years of full-time registered nursing experience. Such experience must include providing direct consumer care or supervising registered nurses providing direct consumer care;

(iii) Be available to staff during all hours of operation; and

(iv) The Director of Nursing must name and designate, in writing, a registered nurse to assume the Director of Nursing responsibilities during times when the Director of Nursing is unavailable to staff. This designated registered nurse must have 2 years of full-time experience in providing direct consumer care as a registered nurse.

010.08(C)SKILLED NURSING CARE SERVICES. Skilled nursing care services must be provided by a registered nurse or licensed practical nurse in accordance with these regulations and the physician-approved written plan of care. Skilled nursing care services are:

(i) Services of such complexity that they can be safely and effectively performed only by or under the direct supervision of a registered nurse;

(ii) Services not normally requiring skilled nursing care, but which, because of special medical complications, become skilled nursing services because they must be performed or supervised by a registered nurse; and

(iii) The above services when needed to prevent a consumer's further deterioration or preserve a consumer's current capabilities even if recovery or medical improvement is not possible.

010.08(D)REGISTERED NURSE SERVICES. When skilled nursing care is ordered by a physician, the following specific services must be provided by a registered nurse:

(i) Initial consumer assessment visit;

(ii) Reevaluation of the consumer's nursing needs;

(iii) Provision of services requiring specialized nursing skill;

(iv) Initiation of appropriate preventive and rehabilitative nursing procedures;

(v) Coordination of services;

(vi) Direct supervision of other nursing staff; and

(vii) Assignment of nursing care and treatment to meet the consumer's needs.

010.08(E)LICENSED PRACTICAL NURSE SERVICES. When skilled nursing care is ordered by a physician, the following specific services may be performed by a registered nurse or by a licensed practical nurse if the licensed practical nurse is under the direct supervision of a registered nurse:

(i) Implementing the physician-approved written plan of care and necessary revisions to the plan. A registered nurse must review the plan of care as often as the severity of the consumer's condition requires, but at least every 62 days;

(ii) Preparation of clinical and progress notes;

(iii) Informing the physician and other staff of changes in the consumer's conditions and needs;

(iv) Teaching other nursing staff; and

(v) Teaching the consumer and caregiver for the purpose of meeting nursing and other related needs.

010.09CHILDREN'S DAY HEALTH AIDE AND PERSONAL CARE AIDE SERVICES. A licensee that employs children's day health aides or personal care aides must meet the following requirements for training and testing prior to the children's day health aides or personal care aides providing care and services to consumers. The children's day health service must ensure the following requirements are met:

010.09(A)EMPLOY QUALIFIED AIDES. Only children's day health aides and personal care aides who meet the qualifications as required in 175 NAC 6 may provide services.

010.09(B)IN-SERVICE PROGRAM. The licensee must provide or make available to children's day health aides and personal care aides 4 hours of in-service programs per year on multiple subjects relevant to the consumer population. Sufficient records to confirm this requirement is met must be kept. Documentation for in-service or continuing education must include the date provided, the topic and content, trainer qualifications, length of the in-service program, and participants printed name, signature, job title and attendance date.

010.09(C)PERMITTED ACTS. Children's day health aides may perform only personal care, assistance with the activities of daily living, and basic therapeutic care. A personal care aide may perform only personal care and assist with activities of daily living. Children's day health aides and personal care aides must not perform acts which require the exercise of nursing or medical judgment.

010.09(D)REQUIREMENTS. A children's day health aide and a personal care aide must be listed on the Medication Aide Registry operated by the Department before being allowed to perform the provision of medication. A children's day health aide and personal care aide must only perform the provision of medication in accordance with the Medication Aide Act, 172 NAC 95 and 96, 175 NAC 6.

010.09(E)CHILDREN'S DAY HEALTH AIDE AND PERSONAL CARE AIDE TRAINING. The training requirements are set out below:

(i) Children's day health aide and personal care aide training must meet the following standards with regard to training content, qualifications for instructors, and documentation of training. The training must, at a minimum, address each of the subject areas identified below. Personal care aide training must include Items 1 through 10 below. Children's day health aide training must include Items 1 through 13 below.

(1) Communication skills;

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

(3) Adequate nutrition and fluid intake;

(4) Basic infection control procedures;

(5) Basic elements of body functioning and changes in body functioning that must be reported to an aide's supervisor;

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

(7) Recognizing emergencies and knowledge of emergency procedures;

(8) The physical, emotional, and developmental needs of and ways to work with the populations served by the children's day health service, including the need for respect of the consumer, his or her privacy, and his or her property;

(9) Appropriate and safe techniques in personal hygiene and grooming that include:

(a) Nail and skin care;

(b) Oral hygiene; and

(c) Toileting and elimination;

(10) Safe transfer techniques and ambulation;

(11) Normal range of motion and positioning;

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

(13) Any other task which the licensee may choose to have the children's day health aide perform except children's day health aides must not perform other tasks which require the exercise of nursing or medical judgment;

(ii) Except as identified in 175 NAC 6-010.09(F)(ii), the training above will be waived for a children's day health aide or a personal care aide who successfully completes a nurse aide or nurse assistant training course approved by the Department in accordance with 172 NAC 108 and meets the requirements at 175 NAC 6-010.09(F).

(iii) Children's day health aide and personal care aide training must be provided under the direct supervision of a registered nurse or licensed practical nurse who has 2 years or more of direct consumer care experience as a registered nurse or licensed practical nurse, preferably in a pediatric setting; and

(iv) Sufficient documentation to demonstrate the requirements above are met must be kept.

010.09(F)VERIFY COMPETENCY. The competency requirements are set out below:

(i) Competency of all children's day health aides and personal care aides must be verified prior to the aides providing services and documentation of the verification must be kept;

(ii) Any children's day health aide not acting as a a children's day health aide for a period of 3 years must meet the children's day health aide training requirements identified in this chapter. Any personal care aide not acting as a personal care aide for a period of 3 years must meet the personal care aide training requirements identified in this chapter. The licensee must determine and verify competency of all children's day health aides and personal care aides as indicated below;

(iii) Children's day health aide and personal care aide competency evaluations must:

(1) Address each of the subjects specific to the type of aide being trained or evaluated or both as identified and listed in 175 NAC 6-010.09(E)(i);

(2) Be performed by a registered nurse who has 2 years or more of direct consumer care experience as a registered nurse; and

(3) Include the subject areas in 175 NAC 6-010.09(E)(i) and must be evaluated by observation and a written or oral examination:

(a) Children's day health aides must demonstrate competency for Items 1-7 below. Personal care aides must demonstrate competency for Items 1-4 below. Observations must be made with a consumer or other individual, and must include but are not limited to:

(i) Safe transfer techniques and ambulation;

(ii) Nail and skin care;

(iii) Oral hygiene;

(iv) Toileting and elimination;

(v) Reading and recording temperatures, pulse, and respiration;

(vi) Normal range of motion and positioning; and

(vii) Any other task which the licensee may choose to have the children's day health aide perform except children's day health aides must not perform other tasks which require the exercise of nursing or medical judgment; and

(b) The written or oral examination must include:

(i) Communication skills;

(ii) Observation, reporting, and documentation;

(iii) Basic infection control procedures;

(iv) Basic elements of body functioning and changes in body functioning that must be reported to the children's day health aide's supervisor;

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

(vi) Recognizing emergencies and knowledge of emergency procedures;

(vii) The physical, emotional, and developmental needs of and ways to work with the population served by the children's day health service, including respect for the consumer, his or her privacy and property;

(viii) Adequate nutrition and fluid intake.; and

(iv) A children's day health aide or personal care aide that receives an unsatisfactory on any task performed must not perform that task without direct supervision by a nurse until after he or she receives additional training in that task, is evaluated, and subsequently is evaluated as satisfactory.

010.09(G)AIDE CARE PLAN AND SUPERVISION. The aide care plan and supervision requirements are set out below:

010.09(G)(i)CHILDREN'S DAY HEALTH AIDE CARE PLAN. A registered nurse must make the initial evaluation of each consumer for whom the physician orders children's day health aide services, devise a written aide care plan, and prepare a written plan of care for the physician's approval. The registered nurse must review this aide care plan as often as the consumer's condition requires, but at least every 62 days.

010.09(G)(ii)PERSONAL CARE AIDE CARE PLAN. A registered nurse or practitioner of the appropriate discipline must make the initial evaluation of each consumer for whom the physician orders personal care aide services, devise a written aide care plan, and prepare a written plan of care for the physician's approval. The registered nurse or practitioner must review this aide care plan as often as the consumer's condition requires, but at least every 62 days.

010.09(G)(iii)SUPERVISION. The children's day health aide must provide services in accordance with the physician-approved written plan of care and the aide care plan under the direct supervision of the registered nurse. The personal care aide must provide services in accordance with the physician-approved written plan of care and the aide care plan under the direct supervision of the registered nurse or practitioner of the appropriate discipline. The aide care plans must include consumer -specific written instructions for each consumer's care, prepared by the supervising registered nurse for children's day health aides and prepared by the supervising registered nurse or practitioner of the appropriate discipline for personal care aides.

010.09(G)(iv)DOCUMENTATION. Children's day health aide and personal care aide services must be provided and documented in accordance with the written aide care plan and the plan of care prepared by the registered nurse or practitioner of the appropriate discipline as required in 175 NAC 6.

010.10ADMINISTRATION OR PROVISION OF MEDICATIONS. Consumers must receive medications only as legally prescribed by a prescribing practitioner, in accordance with the children's day health service physician-approved written plan of care, the 5 rights and prevailing professional standards.

010.10(A)ACCEPTANCE OF CONSUMER INSTRUCTIONS AND MEDICATIONS. Written policies and procedures must be implemented and revised, as necessary, for staff acceptance of consumer medications, supplies, equipment, and consumer instructions necessary to provide consumer care, treatment, services, and medications in accordance with the physician-approved written plan of care.

010.10(A)(i)ACCEPTANCE OF CONSUMER INSTRUCTIONS. If a conflict exists between the physician-approved written plan of care and the consumer's instructions for providing care, treatment, or medications, staff must contact the physician for clarification before providing the care, treatment, services or medications.

010.10(A)(ii)ACCEPTANCE OF CONSUMER MEDICATIONS. When accepting consumer medications and related supplies the licensee must:

(1) Only accept medications that are clearly labeled for the consumer; and

(2) Only accept medications in the original manufacturer's or pharmacy's container.

010.10(B)METHODS OF ADMINISTRATION. When the licensee is responsible for the administration of medications, it must be accomplished by the following methods:

010.10(B)(i)SELF-ADMINISTRATION OF MEDICATIONS. Consumers must be allowed to self-administer medications, with or without supervision, when the licensee determines that the consumer is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner. The licensee must establish, implement and revise as necessary, written policies and procedures to address consumer self-administration of medication, including:

(1) Inclusion of the determination that the consumer may safely and independently self-administer medication in the consumer's physician-approved written plan of care; and

(2) Monitoring the plan to assure continued safe and independent administration of medications by the consumer.

010.10(B)(ii)LICENSED PRACTITIONER. When the licensee uses a licensed practitioner for whom medication administration is included in the scope of practice, the licensee must ensure the medications are properly administered and documented in accordance with prevailing professional standards and state and federal law.

010.10(B)(iii)PROVISION OF MEDICATION BY OTHER THAN A LICENSED PRACTITIONER. When the children's day health service uses someone other than a licensed practitioner for whom medication administration is included in the scope of practice in the provision of medications, the children's day health service must only use individuals who are registered medication aides and must comply with the Medication Aide Act, 172 NAC 95 and 96 and this chapter.

010.10(B)(iv)MAINTAIN OVERALL SUPERVISION, SAFETY AND WELFARE OF CONSUMERS. When the licensee is not responsible for medication administration or provision, the licensee still retains responsibility for overall supervision, safety, and welfare of the consumer.

010.10(C)REPORTING OF MEDICATION ERRORS AND ADVERSE REACTIONS TO A MEDICATION. When the licensee provides for medication administration or provision, the licensee must implement a written process for reporting any adverse reactions to a medication by a consumer and any medication errors in administration or provision of any medications to the consumer, the consumer's parent, and the consumer's licensed practitioner immediately upon discovery. A written report of the adverse reaction and medication error must be completed immediately upon discovery and kept in the consumer's record. Errors must include any variance from the 5 rights or the prescription and the administration or provision of the medication.

010.10(D)STORAGE OF MEDICATION. All medications must be store d in locked areas and stored in accordance with the manufacturer's instructions for temperature, light, humidity, or other storage instructions. If children under age 13 are being served, all medications must be locked. Unused medications, when no longer needed or are expired, must be given to the consumer's parent or given to the consumer when the licensee has included a determination that the consumer may safely and independently self-administer medication in the consumer's physician-approved written plan of care.

010.10(E)ACCESS TO MEDICATION. Only staff who are designated by the licensee to be responsible for administration or provision of medications may have access to medications.

010.10(F)MEDICATION RECORD. The licensee must maintain medication records with sufficient detail to assure that:

(i) Consumers receive the medications authorized by a licensed health care professional;

(ii) The staff are alerted to theft or loss of medication; and

(iii) An individual medication administration record is maintained for each consumer. This record must include:

(1) Identification of the consumer;

(2) Name of the medication given;

(3) Date, time, dosage and method of administration for each medication administered or provided;

(4) Identification of the person who administered or provided the medication; and

(5) Consumer's medication allergies and sensitivities, if any.

010.11INTRAVENOUS THERAPY SERVICES. All intravenous therapy services, when provided, must be provided by a registered nurse in accordance with the physician-approved written plan of care, the 5 rights, and prevailing standards of practice. Intravenous therapy includes, but is not limited to:

(A) Total parenteral nutrition (TPN);

(B) Hydration therapy;

(C) Chemotherapy;

(D) Antibiotic therapy; and

(E) Blood and blood products.

010.12MEDICAL SUPPLIES AND EQUIPMENT. When medical supplies, equipment, and appliances are provided, the licensee must have a process designed for routine and preventative maintenance of equipment to ensure that it is safe and works as intended. The service agreement, prior to admitting a consumer, must set out all supplies, equipment, and appliances the consumer is expected to provide while at the children's day health service. The medical supplies and equipment in this section include such items as pulse oximetry and blood pressure machines, alcohol pads, syringes, and other similar supplies and equipment.

010.12(A)DURABLE MEDICAL EQUIPMENT. When the licensee provides durable medical equipment for use in the provision of consumer care, treatment, or services, the licensee must ensure such equipment is tested and calibrated in accordance with the manufacturer's recommendations.

010.12(B)REQUIRED EQUIPMENT. The children's day health service must provide equipment adequate for meeting each consumer's needs as specified in the service agreement and the consumer's physician-approved written plan of care.

010.13MENTAL HEALTH SERVICES. Mental health services, when provided, must be provided as follows:

(A) Mental health practice must be provided by an appropriately credentialed practitioner under the Uniform Credentialing Act; and

(B) When other activities, interventions, or directives designed to address behavioral needs outlined in the consumer -specific, written plan of care are provided by un-credentialed staff, such services must be:

(i) Supervised by a licensed mental health practitioner who must:

(1) Have a minimum of 2 years of experience in providing mental health practice services;

(2) Assume overall responsibility and direction for all mental health services provided by the un-credentialed staff; and

(3) B e immediately available, during operating hours, to the children's day health service staff by phone, and when required, available onsite; and

(ii) Provided in accordance with the plan of care.

010.14REHABILITATION SERVICES. Rehabilitation services, when provided, must be provided by an appropriately credentialed practitioner as provided in (A)-(C) below. A consumer -specific rehabilitation plan of care must be incorporated into the physician-approved written plan of care and be devised by the rehabilitation practitioner, as appropriate for the rehabilitation services provided, after performing an initial consumer assessment. If the consumer chooses not to use the rehabilitation services furnished by the licensee, the consumer is responsible to arrange for continuation of rehabilitation services by a non-licensee provider that meets the following requirements:

(A) Speech-language pathology services must be provided by persons who are credentialed under the Uniform Credentialing Act and whose scope of practice permits them to provide speech-language pathology services;

(B) Occupational therapy services must be provided by persons who are credentialed under the Uniform Credentialing Act and whose scope of practice permits them to provide occupational therapy services; and

(C) Physical therapy services must be provided by persons who are credentialed under the Uniform Credentialing Act and whose scope of practice permits them to provide physical therapy services.

010.15RESPIRATORY CARE SERVICES. Respiratory care services, when provided, for consumers must be provided by persons who are credentialed under the Uniform Credentialing Act and whose scope of practice permits them to provide respiratory care services. When a children's day health service provides a Respiratory Care Service or Department, it must designate a medical director who must be a licensed physician who has special interest and knowledge in the diagnosis and treatment of respiratory problems. Such physician must:

(A) Be an active medical staff member of a licensed health care facility; and

(B) Be qualified by special training or experience in the management of acute and chronic respiratory disorders.

010.16SOCIAL SERVICES. The licensee must provide activities to promote the development and utilization of consumers' social skills, including such things as appropriate interaction, sharing, and cooperation. All social services provided must be based on consumer assessments, development of consumer -specific activities, and include referral to outside social services when necessary to promote the consumer's social well-being. A social service needs assessment must be part of the initial consumer assessment for use in developing a written, consumer -specific plan of activities designed to promote the consumer's social well-being and, if needed, referring the consumer to outside resources when the consumer's social service needs exceed the social services provided by the licensee. The licensee must reassess the consumer's social service needs and update the - consumer -specific plan of activities as often as the severity of the consumer's condition requires reassessment. The licensee must maintain sufficient documentation in the consumer's clinical record to demonstrate these requirements are met.

010.17FOOD SERVICES. The daily nutritional needs of all consumers must be met, including any diet ordered by the consumer's physician. Food service must include:

(A) Providing food service directly or through a written agreement;

(B) Ensuring a staff member is trained or experienced in food management or nutrition with the responsibility of:

(i) Planning menus which meet the nutritional needs of each consumer, following the orders of the consumer's physician; and

(ii) Supervising the meal preparation and service to ensure that the menu plan is followed;

(C) Bing able to meet the needs of the consumer's physician-approved written plan of care; nutritional needs, and therapeutic diet; and

(D) Procuring, storing, preparing, distributing, and serving all food under sanitary conditions and in accordance with the Food Code.

010.18TRANSPORTATION SERVICES. When transportation services are provided the licensee must meet, all applicable statutes and regulations, 175 NAC 1, 175 NAC 6, and the following additional requirements:

(A) Staff in each vehicle must have a functioning cellular telephone or other functioning 2 -way voice communication device with them for use in an emergency;

(B) When a consumer who requires registered nursing observation or assessment is transported, there must be at least 2 staff members on the transporting vehicle at all times, one of whom must be a registered nurse; and

(C) When a consumer who requires a ventilator power source is transported the back-up power source must be checked before transport to confirm the power source is operational and has sufficient charge to ensure uninterrupted ventilator service during transport.

010.19CONSUMER ROSTER AND CLINICAL RECORD REQUIREMENTS. Consumer rosters and clinical records must be maintained and safeguarded in accordance with accepted professional standards and practice. The licensee must meet all applicable statutes and regulations, 175 NAC 1, 175 NAC 6, and the following additional requirements:

010.19(A)CONSUMER ROSTER. The consumer roster must identify consumers scheduled and accepted for care, treatment, and services on a daily basis. consumer roster must distinguish between child care clients and children's day health service consumers and document the hours of care the consumer is receiving children's day health service services as specified in 175 NAC 6.

010.19(B)CONTENT OF CLINICAL RECORDS.: The clinical record must contain sufficient information to identify the consumer clearly, to justify the diagnosis, care, treatment, and services and to accurately document the results of care, treatment, and services. There must be a separate clinical record for each consumer. All clinical records must contain at least the following categories of data:

(i) Identification data and consent forms;

(ii) The consumer's service agreement;

(iii) The name and address of the consumer's physicians;

(iv) The physician's signed order and physician-approved plan of care for skilled nursing care services and rehabilitation services. The supervising practitioner's signed order and supervising practitioner's-approved plan of care for mental health services. The documents must include, when appropriate:

(1) Medical diagnosis;

(2) Medication orders;

(3) Dietary orders;

(4) Activity orders; and

(5) Safety orders;

(v) Initial and periodic assessments and care plan by disciplines providing services. The children's day health service must provide pertinent current and past medical history to the credentialed staff providing services on its behalf;

(vi) Signed and dated admission, observation, progress, and supervisory notes;

(vii) Copies of summary reports sent to the consumer's physician and supervising practitioners, the consumer, and care and service coordinators as authorized by the consumer to receive medical information;

(viii) Diagnostic and therapeutic orders signed by the physician and supervising practitioner;

(ix) Reports of treatment and clinical findings; and

(x) Discharge summary report.

010.19(C)CENTRALIZED CLINICAL INFORMATION. All clinical information pertaining to the consumer's care and treatment must be centralized in the consumer's clinical record maintained by the licensee.

010.19(D)TIMELY ENTRIES. Entries into the clinical record for care, treatment, and services rendered must be written within 24 hours and incorporated into the clinical record within 7 working days.

010.19(E)PROVIDER IDENTIFICATION. Entries must be made by the individual providing services, must contain a statement of facts personally observed, and must be signed with full name and title. Initials may be used if identified in the clinical record.

010.19(F)VERBAL ORDERS. The licensee must, implement a written process that identifies staff by job title who can receive verbal orders from the physician and the supervising practitioner for mental health services and that ensures all such verbal orders for care, treatment, services, and medications are signed and dated by the physician or supervising practitioner for mental health services who gave the order and incorporated in the consumer's clinical record within 30 days.

010.19(G)REVISED PLAN OF CARE. The licensee must implement a written process that ensures a consumer's plan of care is revised immediately following receipt of a physician or supervising practitioner written or verbal order. The revised consumer plan of care must be approved and incorporated into the consumer's clinical record within 30 days following receipt of the written order.

010.19(H)SECURED. Clinical records must be secured in locked storage. The licensee must have a written process regarding use and removal of records and the conditions for release of information.

010.20EMERGENCY CARE OF CONSUMERS. The licensee must have the necessary drugs, devices, biologicals, equipment, and supplies immediately available for provision of care and treatment should an emergency arise and must meet the following requirements:

(A) At least 2 staff members with a current cardiopulmonary resuscitation (CPR) certification are on duty at all times; and

(B) Staff members are trained to use an Automated External Defibrillator (AED) and there must be an operable Automated External Defibrillator on the premises.

175 Neb. Admin. Code, ch. 6, § 010

Adopted effective 2/20/2024