216 R.I. Code R. 216-RICR-40-10-1.17

Current through November 7, 2024

Section 216-RICR-40-10-1.17 - Special Care Units

1.17.1Alzheimer and Other Dementia Special Care Units or Programs

A. Any nursing facility that provides or offers to provide care or services for residents in a manner as defined in this Part shall disclose to the licensing agency and any person seeking placement in such Alzheimer and Other Dementia Special Care Unit/Program the form of specialized care and treatment provided that is in addition to the care and treatment required in this Part.

1. The information disclosed shall be on a form prescribed by the Department.

2. The nursing facility shall provide care and services as described in the disclosure form, and consistent with this Part. The information disclosed shall explain the additional care provided in each of the following areas:

a. Philosophy - The special care unit/program's written statement of its overall philosophy and mission which reflects the needs of residents afflicted with dementia.

b. Pre-Admission, Admission and Discharge - The process and criteria for placement (which shall include a diagnosis of dementia), transfer or discharge from the unit.

c. Assessment, Care Planning and Implementation - The process used for assessment and establishing the plan of care and its implementation, including the method by which the plan of care evolves and is responsive to changes in condition.

d. Staffing Patterns and Training - Staff patterns and training and continuing education programs, which shall emphasize the effective management of the physical and behavioral problems of those with dementia.

e. Physical Environment - The physical environment and design features shall be appropriate to support the functioning and safety of cognitively impaired adult residents.

f. Therapeutic Activities - The frequency and types of resident activities. Therapeutic activities shall be designed specifically for those with dementia.

g. Family Role in Care - The nursing facility shall provide for the involvement of families and family support program.

h. Program Costs - The cost of care and any additional fees.

3. Any significant changes in the information provided by the nursing facility will be reported to the licensing agency at the time the changes are made.

B. In accordance with R.I. Gen. Laws § 23-1.7-6, the nursing facility must complete and implement an operational plan for the recognition and management of residents with Alzheimer's disease or dementia.

1. Such plan shall include a protocol for the following:

a. Identifying the signs and symptoms of cognitive impairments, including Alzheimer's Disease;

b. Management and treatment of residents with Alzheimer's Disease;

c. Training of clinical and non-clinical staff; and

d. Advance care planning; and resources for family members.

2. Such plan shall be maintained by the nursing facility and made available to the licensing agency upon request.

1.17.2Rehabilitation Special Care Unit and Subacute Special Care Unit

A. Any nursing facility that provides or offers to provide care for patients or residents by means of a Rehabilitation Special Care Unit or a Subacute Special Care Unit shall be required to disclose to the licensing agency and to any person seeking placement in a Rehabilitation Special Care Unit or a Special Care Unit of a nursing facility the form of specialized care and treatment provided that is in addition to the care and treatment required in this Part.

1. The information disclosed shall be on a form prescribed by the licensing agency.

2. The nursing facility shall provide care and services as described in the disclosure form, and consistent with this Part.

3. Any significant changes in the information provided by the nursing facility shall be reported to the licensing agency at the time the changes are made.

1.17.3Dietetic Services

A. Each nursing facility shall maintain a dietetic service under the supervision of a full-time person who, as a minimum, is a graduate of a Rhode Island-approved course that provided instruction in food service supervision and nutrition and has experience in the organization and management of food service.

1. When the dietary manager is absent, a responsible person shall be assigned to supervise dietetic service personnel and food service operations.

B. When the dietary manager is not a qualified dietitian who is registered or eligible for registration by the commission of dietetic registration and/or licensed by Rhode Island, the nursing facility shall obtain per written contractual arrangement adequate and regularly scheduled consultation from a qualified dietitian.

C. The responsibilities of the qualified dietitian shall include but not be limited to:

1. Advising the administration and the supervisor of dietetic services on all nutritional aspects of resident care, food service and preparation;

2. Reviewing food service policies, procedures and menus to ensure the nutritional needs of all residents are met in accordance with Dietary Reference Intakes: The Essential Guide to Nutrient Requirements;

3. Serving as liaison with medical and nursing staff on nutritional aspects of resident care;

4. Advising on resident care policies pertaining to dietetic services;

5. Providing dietary counseling to residents when necessary;

6. Planning and conducting regularly scheduled in-service education programs which shall include training in food service sanitation;

7. Preparing reports which shall include date and time of consultation and services rendered, which reports shall be signed and kept on file in the nursing facility; and

8. Recording observations and information pertinent to dietetic treatment in the resident's medical record;

9. Input in care plan development.

D. Adequate space, equipment and supplies shall be provided for the efficient, safe and sanitary receiving, storage, refrigeration, preparation and service of food and other related aspects of the food service operation in accordance with Part 50-10-1 of this Title, Rhode Island Food Code.

E. Policies and procedures shall be established for the dietetic service, pertaining to but not limited to the following:

1. Responsibilities and functions of personnel;

2. Standards for nutritional care in accordance with Dietary Reference Intakes: The Essential Guide to Nutrient Requirements;

3. Alterations or modifications to diet orders or schedules;

4. Food purchasing storage, preparation and service;

5. Safety and sanitation relative to personnel and equipment in accordance with Part 50-10-1 of this Title, Rhode Island Food Code; and

6. Ancillary dietary services, including food storage and preparation in satellite kitchens and vending operations in accordance with Part 50-10-1 of this Title, Rhode Island Food Code; and

7. A plan to include alternate methods and procedures for food preparation and service, including provisions for potable water, to be used in emergencies.

F. All nursing facilities shall provide sufficient and adequately trained supportive personnel, competent to carry out the functions of the dietetic services.

1. The dietetic services shall have employees on duty over a period of twelve (12) or more hours per day, seven (7) days per week.

2. Except as provided in §1.17.3(F) of this Part, those employees involved in direct preparation of food (as opposed to distribution of food, dishwashing, etc.) shall not be involved in providing resident direct care.

3. Except where employees are designated and qualified as "universal workers," housekeeping and nursing personnel qualified in accordance with §1.14.6(A)(6)(b) of this Part may assist in food distribution, and food preparation. Careful hand washing shall be done prior to assisting in food distribution and/or preparation.

G. The nursing facility's food service operation shall comply with all appropriate standards of Part 50-10-1 of this Title, Rhode Island Food Code.

1. Diet kitchens, nourishment stations, and any other related areas shall be the responsibility of the dietetic service.

H. All menus including alternate choices shall be planned at least one (1) week in advance, to meet the standards for nutritional care in accordance with Dietary Reference Intakes: The Essential Guide to Nutrient Requirements and to provide for a variety of foods, adjusted for seasonal changes, and reflecting the dietary preferences of residents.

1. Menus shall indicate nourishments offered to residents between evening meal and bedtime.

2. Menus shall be posted in a conspicuous place in the dietary department and in resident areas.

3. Records of menus actually served shall be retained for thirty (30) days.

I. All diets shall be ordered in writing by the attending physician.

1. All diets shall be planned, prepared and served to conform to the physician's orders and to meet the standards of Dietary Reference Intakes: The Essential Guide to Nutrient Requirements to the extent medically possible.

2. Diet orders shall be reviewed by the attending physician on same schedule as other physician orders.

J. There shall be a diet manual, approved by the dietitian and available to all dietetic and nursing services personnel. Diets served to residents shall comply with the principles set forth in the diet manual.

K. Each resident shall receive and the nursing facility shall provide at least three (3) meals daily, at regular times comparable to normal mealtimes based upon the individual preference of a resident or group of residents in a residential area and/or at regular times comparable to normal mealtimes in the community.

1. There shall be no more than fourteen (14) hours between a substantial evening meal and breakfast the following day, except as provided in §1.17.3(K)(3) of this Part.

2. The nursing facility shall offer snacks at bedtime daily.

3. When a nourishing snack is provided at bedtime, up to sixteen (16) hours may elapse between a substantial evening meal and breakfast the following day if a resident, or group of residents in a residential area agrees to this meal span, and there is a nourishing snack.

L. Foods shall be prepared by methods that conserve nutritive value, flavor and appearance, and shall be prepared and served at proper temperatures and in a form to meet individual needs. Food substitutes of similar nutritive value shall be offered when residents refuse foods served for good reason.

1. A file of tested recipes, adjusted to appropriate yield, shall be maintained and utilized corresponding to items on the menu.

2. House diets shall be appropriately seasoned.

3. There shall be a supply of staple foods for a minimum of seven (7) days and of perishable foods for a minimum of two (2) days in the nursing facility.

M. Food shall be attractively served on dinnerware of good quality, such as ceramic, plastic or other materials that are durable and aesthetically pleasing.

N. A dining room shall be available for those residents or residents who wish to participate in group dining in accordance with §1.19.9(A) of this Part.

O. Self-help feeding devices shall be available to those residents who need them to maintain maximum independence in the activities of daily living.

P. A nursing facility contracting for food service shall require as part of the contract, that the contractor comply with the provisions of this Part.

1.17.4Pharmaceutical Services

A. Each nursing facility shall provide pharmaceutical services either directly within the nursing facility or per contractual arrangement. Such services shall be provided in accordance with the requirements of Subchapter 15 Part 1 of this Chapter, Pharmacists, Pharmacies and Manufacturers, Wholesalers and Distributors, and Part 20-20-4 of this Title, Pain Management, Opioid Use, and the Registration of Distributors of Controlled Substances in Rhode Island.

1. In either instance, appropriate methods and procedures for the procurement and the dispensing of drugs and biologicals shall be established in accordance with appropriate Federal and State laws and Regulations.

B. There shall be written policies and procedures relating to the pharmaceutical service which shall require no less than:

1. The authority, responsibility and duties of the registered pharmacist;

2. The selection, procurement, distribution, storage, dispensing or other disposition of drugs and biologicals in accordance with appropriate Federal and State laws and Regulations;

3. Maintenance of records of all transactions, including recording of receipt and dispensing or other disposition of all drugs and biologicals;

4. Inspection of all drug and biological storage and medication areas and documented evidence of findings;

5. Automatic stop orders for drugs or biologicals;

6. The use of only approved drugs and biologicals;

7. Control of medicines from any source;

8. A monitoring program to identify adverse drug reactions, interactions and incompatibilities and antibiotic antagonisms; and

9. Labeling of drugs and biologicals including name of resident, name of physician, drug dosage, cautionary instructions, and expiration date.

C. Adequate space, equipment, supplies and locked storage areas shall be provided for the storage of drugs and biologicals based on the scope of services provided. Refrigerated food storage units shall not be utilized for storage of drugs and/or biologicals except:

1. In facilities of thirty (30) beds or less, a refrigerated food storage unit may be used for drugs and biologicals provided they are locked in an appropriate container.

D. Drugs may be administered to residents from bulk inventories of non-legend and non-controlled substance items such as aspirin, milk of magnesia, etc. as ordered by a licensed physician.

E. An emergency medication kit, approved by the pharmaceutical service committee or its equivalent, shall be available in each residential area.

F. Each residential area shall have adequate drug and biological preparation areas with provisions for locked storage in accordance with Federal and State laws and Regulations.

1.17.5In Nursing Facilities

A. The pharmaceutical service committee or its equivalent, consisting of not less than a registered pharmacist, a registered nurse, a physician and the administrator, shall:

1. Serve as an advisory body on all matters pertaining to pharmaceutical services;

2. Establish a program of accountability for all drugs and biologicals;

3. Develop and review periodically all policies and procedures for safe and effective drug therapy in accordance with §1.17.4(B) of this Part; and

4. Monitor the service.

B. A registered pharmacist shall assist in developing, coordinating and supervising all pharmaceutical services in conjunction with the pharmaceutical services committee. In addition, a registered pharmacist shall:

1. Review the drug and biological regimen of each resident at least monthly;

2. Report any irregularities to the attending physician and director of nurses. These reports must show evidence of review and response; and

3. Document in writing the performance of such review, which documentation shall be kept on file by the nursing facility and shall be made accessible to inspectors on request.

1.17.6Dental Services

A. Each nursing facility shall provide or obtain from outside resources, dental services for routine and emergency care.

1. Each resident shall have the right to receive dental services from a dentist of his or her choice.

B. A list of community dentists shall be maintained and available to all residents.

C. When necessary, arrangements shall be made by nursing facilities for the transportation of residents to and from the dental care office.

1.17.7Laboratory and Radiologic Services

A. All nursing facilities shall make provisions for laboratory, x-ray and other services to be provided either directly by the nursing facility or per contractual arrangements with an outside provider.

1. If the nursing facility provides its own laboratory and x-ray services, these shall meet all applicable statutory and regulatory requirements.

B. All services shall be provided only per order of the attending physician who shall be promptly notified of the findings in accordance with a protocol established by the nursing facility. Such a protocol shall describe which laboratory values mandate a call to the resident's attending physician.

C. Signed and dated reports of all findings shall become part of the resident's medical record.

1.17.8Social Services

A. Every nursing facility shall provide social services to attain or maintain the highest practicable physical, mental and psychological well-being of each resident. Social services must be provided either directly by a qualified social worker or by arrangement with an appropriate health or social service agency or through consultation with a qualified social worker who would supervise a social work designee appointed by the administrator.

1. Services shall pertain to no less than the following:

a. Identification of social and emotional needs of residents through a comprehensive psychosocial assessment including a social history;

b. Establishment of a plan of care based on residents' needs;

c. Procedures for referral of residents, when indicated, to appropriate social agencies and discharge planning as indicated

B. A qualified social worker is defined as an individual with a minimum of a BSW from an accredited School of Social Work. A social work designee is defined as a staff member appointed by the administrator who is suited by training or experience to implement plans and procedures enumerated in accordance with §1.17.8(A)(1) of this Part.

C. Notwithstanding any provisions in R.I. Gen. Laws Chapter 5-39.1 or any other general or public law to the contrary, any nursing facility licensed under R.I. Gen. Laws Chapter 23-17 that employs a social worker or social worker designee who meets all of the criteria in §1.17.8(D) of this Part shall be granted a variance to the "qualified social worker" provisions stated in this Part.

D. Such criteria shall be limited to:

1. Meets the Centers for Medicare and Medicaid requirements for long-term care facilities under 42 C.F.R. Part 483, subpart B (or any successor Regulation);

2. Is currently employed by a nursing facility licensed under R.I. Gen. Laws Chapter 23-17; and

3. Has been continuously employed in a nursing facility licensed under R.I. Gen. Laws Chapter 23-17 commencing on or before July 1, 2003.

E. Sufficient supportive personnel shall be available to meet resident needs.

F. Appropriate records shall be maintained of all social services rendered, including consultation services, and reports shall be included in the resident's medical record.

G. Policies and procedures shall be established to assure confidentiality of all resident information consistent with the requirements of R.I. Gen. Laws Chapter 5-37.3.

1.17.9Specialized Rehabilitative Services

A. Each nursing facility shall provide directly or per written agreement with outside providers specialized rehabilitative and supportive services as needed by residents to improve, restore or maintain functioning.

1. Residents shall not be admitted or retained in a nursing facility not providing either directly or per contractual arrangement, those rehabilitative or other specialized services required to meet individual medical care needs of residents.

B. The specialized rehabilitative services, which include physical therapy, speech pathology, audiology and occupational therapy shall be provided per written order of the attending physician and in accordance with accepted professional practice by licensed therapists or assistants.

C. Written administrative and resident care policies and procedures shall be developed for rehabilitative services by appropriate therapists and representatives of the medical, administrative and professional staff.

D. Rehabilitative services shall be provided under a written plan of care initiated by the attending physician and developed in consultation with appropriate therapist(s) and nursing personnel.

E. Entries of all rehabilitative or supportive services rendered, including evaluation of progress and other pertinent information, shall be recorded in the resident's medical record and signed by personnel rendering the service(s).

F. Safe and adequate space and equipment shall be available commensurate with the scope of services provided.

1.17.10Resident Activities

A. Each nursing facility shall provide for an ongoing activities program that is person-centered, appropriate to the needs and interests of each individual resident, encourages self-care, and engages residents in activities that are important to the resident, and that will assist in the maintenance of an optimal level of psychosocial functioning, socialization, and quality of life for the resident.

B. The activities program must be directed by a qualified professional as defined in Requirements for Long Term Care Facilities," 42 C.F.R. Part 483.

C. The ongoing activities program shall make provisions to:

1. Promote opportunities for engaging in normal pursuits including religious activities of the resident's choice;

2. Promote the physical, social and mental well-being of each resident;

3. Promote independent as well as group activities; and

4. Harmonize with each resident's needs and medical treatment plan, subject to approval by the resident's attending physician.

D. Adequate space, supplies and equipment shall be available to meet resident care needs in accordance with the activities program and as stipulated in §1.19.9 of this Part.

E. Each resident must have an activities plan, and all pertinent observations and information must be recorded in the medical record.

1.17.11Equipment

A. Each nursing facility shall maintain sufficient and appropriate types of equipment consistent with resident needs and sufficient to meet emergency situations.

B. All equipment to meet the needs of the residents shall be maintained in safe and good operational condition.

216 R.I. Code R. 216-RICR-40-10-1.17

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