216 R.I. Code R. 216-RICR-40-10-1.13

Current through November 7, 2024

Section 216-RICR-40-10-1.13 - Organization and Management

1.13.1Governing Body or Other Legal Authority

A. Each nursing facility shall have an organized governing body or other legal authority, responsible for:

1. The management and fiduciary control of the operation and maintenance of the nursing facility; and

2. The conformity of the nursing facility with all federal, state and local rules and regulations relating to fire, safety, sanitation, communicable and reportable diseases, resident quality of care and quality of life, and other relevant health and safety requirements and with this Part.

3. The administration of a policy of non-discrimination in the provision of services to residents and the employment of persons without regard to race, color, creed, national origin, gender, gender identity or expression, religion, sexual orientation, marital status, familial status, source of income, age, disability, source of payment or profession in accordance with Title VI of the Civil Rights Act of 1964; U.S. Executive Order #11246 entitled "Equal Employment Opportunity," U.S. Department of Labor Regulations; Title V of the Rehabilitation Act of 1973, the Rhode Island Fair Employment Practices Act, R.I. Gen. Laws Chapter 28-5 et seq.; the Americans with Disabilities Act; and any other federal or state laws relating to discriminatory practices.

B. The governing body or other legal authority shall provide facilities, personnel and other resources necessary to meet resident and program needs and also:

1. Describe the structure of the nursing facility's governing body, including functional and staff organizational charts;

2. Provide names and affiliations of members of the nursing facility's governing body;

3. Provide a copy of the organization's charter, constitution and/or by-laws.

C. The governing body or other legal authority shall designate a licensed administrator in accordance with R.I. Gen. Laws Chapter 5-45 and shall establish by-laws or policies to govern the organization of the nursing facility, to establish authority and responsibility, to identify program goals, and to provide for an annual evaluation of administrator performance.

D. The governing body or other legal authority shall adopt a written policy statement relating to conflict of interest on the part of members of the governing body receiving financial gain from ownership, medical staff and employees who may influence corporate decisions.

E. The governing body or other legal authority, through the administrator, shall be responsible for the procurement of a sufficient number of trained, experienced and competent personnel to provide appropriate care and supervision for all residents and to ensure that their personal needs are met.

1.13.2Quality Improvement Program

A. Pursuant to R.I. Gen. Laws § 23-17-12.11, each licensed nursing facility shall develop and implement a quality improvement program and establish a quality improvement committee. The governing body shall ensure that this program is effective, ongoing, nursing facility-wide and shall have a written plan of implementation.

B. Each licensed nursing facility shall designate a qualified individual, who shall be determined by the nursing facility's administrator, to coordinate and manage the nursing facility's quality improvement program.

1. The nursing facility's quality improvement committee shall include at least the following members:

2. The nursing facility administrator;

3. The director of nursing;

4. The medical director;

5. A social worker; and

6. A representative of dietary services.

C. The quality improvement committee shall meet at least quarterly; shall maintain records of all quality improvement activities; and shall keep records of committee meetings that shall be available to the licensing agency during any on-site visit.

D. The quality improvement committee for a nursing facility shall annually review and approve the quality improvement plan for the nursing facility. Said plan shall be available to the public upon request.

E. Each nursing facility shall establish a written quality improvement plan that shall be reviewed by the licensing agency during the nursing facility's annual survey and that includes:

1. Program objectives;

2. Oversight responsibility (e.g., reports to the governing body, QI records);

3. Nursing facility-wide scope;

4. Involvement of all resident care disciplines/services;

5. Includes methods to identify, evaluate, and correct identified problems;

6. Provides criteria to monitor nursing care and services, including, but not limited to:

a. Medication administration;

b. Prevention and treatment of decubitus ulcers;

c. Dehydration, and nutritional status and weight loss or gain;

d. Accidents, injuries and unexpected deaths;

7. Changes in mental or psychological status;

8. Resident and/or Family Council grievances;

9. Plans of correction developed in response to licensing agency's inspection reports, and

10. Any other data appropriate to monitor resident's quality of care and quality of life.

F. All resident care services, including services rendered by a contractor, shall be evaluated.

G. The nursing facility shall take and document appropriate remedial action to address problems identified through the quality improvement program. The nursing facility administrator shall take appropriate remedial actions based on the recommendations of the nursing facility's quality improvement committee. The outcome(s) of the remedial action shall be documented and submitted to the governing body for their consideration.

H. The Director may not require the quality improvement committee to disclose the records and the reports prepared by the committee except as necessary to assure compliance with the requirements of this section.

I. Good faith attempts by the quality improvement committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

J. If the licensing agency determines that a nursing facility is not implementing its quality improvement program effectively and that quality improvement activities are inadequate, the licensing agency may impose sanctions on the nursing facility to improve quality of resident care including mandated hiring of, directly or by contract, an independent quality consultant acceptable to the licensing agency.

1.13.3Health Care Quality Program

A. All nursing facilities licensed under R.I. Gen. Laws Chapter 23-17 shall meet all applicable requirements of Part 10-10-7 of this Title, Health Care Quality Program, promulgated by the licensing agency.

1.13.4Administrator

A. Every nursing facility shall have a full-time administrator licensed in accordance with R.I. Gen. Laws Chapter 5-45, who shall be directly responsible to the governing body or other legal authority for its management and operation, and shall provide liaison between the governing body, medical and nursing staff and other professional staff.

1. When the administrator does not spend full-time in the nursing facility, a substitute shall be designated only with the approval of the licensing agency.

2. In the absence of the administrator, a person shall be designated or authorized in writing, as a substitute on an interim basis.

3. A substitute must be licensed in Rhode Island as a nursing home administrator.

B. The administrator shall be responsible to ensure that services required by residents shall be available on a regular basis, and provided in an appropriate environment in accordance with established policies and the prevailing community standard. Direct resident care shall be provided through a system of consistent assignment and utilizing self-directed work teams whenever possible.

C. The administrator shall be responsible for maintaining accurate time records on all personnel and for posting the work schedule of all direct resident care personnel on a weekly basis. Time records shall be retained by the nursing facility for no less than three (3) years.

D. Nursing facilities shall provide the licensing agency with prompt notice of pending and actual labor disputes/actions which would impact delivery of patient care services including, but not limited to, strikes, walk-outs, and strike notices. Nursing facilities shall provide a plan, acceptable to the Director, for continued operation of the nursing facility, suspension of operations, or closure in the event of such actual or potential labor dispute/action.

E. The licensing agency shall be promptly notified of any change of the administrator of a nursing facility.

1.13.5Medical Director and Attending Physicians

A. The governing body or other legal authority shall designate a physician to serve as medical director. The medical director shall be a physician licensed to practice in Rhode Island in accordance with the provisions of Subchapter 05 Part 1 of this Chapter, Licensure and Discipline of Physicians. Upon appointment, the name of the medical director shall be submitted to the licensing agency. Each time a new medical director is appointed, the name of said physician shall be reported promptly to the licensing agency. The medical director's Rhode Island medical license number, medical office address, telephone number, emergency telephone number, hospital affiliation and other credentialing information shall be maintained on file at the nursing facility and updated as needed.

1.13.6Duties and Responsibilities of the Medical Director

A. Responsibilities of the medical director shall include, but not be limited to:

1. Coordination of medical care in the nursing facility,

2. Ensuring completion of employee health screening and immunization requirements contained in §§1.14.4(A) and 1.14.5 of this Part.

3. The implementation of nursing facility policies and procedures related to the medical care delivered in the nursing facility;

4. Physician and advanced practice practitioner credentialing;

5. Practitioner performance reviews;

6. Employee health including infection control measures;

7. Evaluation of health care delivery, including oversight of medical records and participation in quality improvement;

8. Provision of staff education on medical issues;

9. Participation in State survey process, including the resolution of deficiencies, as needed.

B. The medical director, charged with the aforementioned duties and responsibilities for the delivery of medical care in the nursing facility, shall be immune from civil or criminal prosecution for reporting to the Board of Medical Licensure and Discipline the unprofessional conduct, incompetence or negligence of a nursing facility physician or limited registrant;

C. Provided, that the report, testimony, or other communication was made in good faith and while acting within the scope of authority conferred by §1.13.5 of this Part.

D. The administrator shall notify the medical director immediately when any enforcement order as described in § 1.11 of this Part is issued by the licensing agency or when the administrator is notified of any Medicare/Medicaid certification enforcement action. The administrator shall provide copies of all statements of deficiencies and related plans of correction to the medical director in a timely fashion.

E. The medical director shall attend the quarterly quality assurance/improvement meetings, as required in §1.13.2(C) of this Part. The administrator, or his or her designee, shall provide the medical director with adequate notice of the quarterly quality assurance/improvement meeting.

F. Each nursing facility shall maintain an active file of all physicians attending residents for any reason(s), including their phone numbers and addresses, an emergency phone number, their current medical license numbers, and the physician's preferred admitting hospital. This file of physicians shall be revised and updated, as needed, but no less than annually.

G. The governing body or other legal authority shall make available to each physician attending residents in the nursing facility all of the policies governing resident care management and services.

1.13.7COVID-19 Practices and Procedures

A. Nursing Home Residents

1. The nursing facility must have policies and procedures in place for addressing residents who refuse testing or are unable to be tested. In accordance with the provisions of 42 C.F.R. § 483.10(c)(6), residents (or their representatives) may exercise their right to decline COVID-19 testing.

2. Upon the identification of residents who test positive for COVID-19, the facility shall take proper actions to prevent the transmission of COVID-19.

3. The nursing facility shall document all COVID-19 testing. The documentation shall at a minimum include the individual's name, date of test, and test result.

B. Nursing Home Personnel

1. For the purposes of §1.13.7 of this Part, "Personnel" includes employees, as well as volunteers, students, trainees, and any individuals whether paid or unpaid, directly employed by or under contract with the nursing facility on a part-time or full-time basis.

2. The nursing facility shall develop and implement policies and procedures for ongoing tracking of personnel who are employed outside of the nursing facility. Tracking shall include the name and location of the establishment, and any other pertinent information.

216 R.I. Code R. 216-RICR-40-10-1.13

Amended effective 7/3/2022
Amended effective 8/25/2022
Amended effective 10/2/2023, exp. 1/30/2024(Emergency)
Amended effective 3/7/2024