Section 1 GENERAL PROVISIONS 1.1. Statement of Purpose and Scope. It is the purpose of these rules to implement state and federal law governing the licensing, operation, and standard of care in nursing homes, also referred to in these rules as "nursing facilities" or "facilities", located in the State of Vermont. Compliance with these rules will help each resident attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with a comprehensive assessment and plan of care and prevailing standards of care and will promote a standard of care that assures that the ability of each resident to perform activities of daily living does not diminish unless the resident's ability is diminished solely as a result of a change in the resident's clinical condition.
1.2. Authority. These rules are promulgated pursuant to 33 V.S.A. § 7117 to implement the provisions of 33 V.S.A. Chapters 71 and 73, 18 V.S.A. Chapter 221, 18 V.S.A. Chapter 231, 42 U.S.C. §§ 13951-3 and 1396r, and 42 C.F.R. Part 483, Subpart B.
1.3. Exception and Severability. A determination that any provision or application of any provision of these rules is invalid shall not affect the validity of any other provision of these rules or its applicability.
1.4. Effective Date. These rules are effective June 1, 2018.
1.5. Variances from these Rules. a. In accordance with 33 V.S.A. § 7106, the department may grant a variance from any provision of these rules if it determines that: 1. strict compliance would impose substantial hardship on the licensee;2. the licensee will otherwise meet the goal of the rule; and3. a variance will not result in less protections of the health, safety and welfare of the residents.b. A variance will not be granted from a rule pertaining to residents' rights.c. Separate federal variance procedures may apply for provisions of these rules also contained in federal nursing facility regulations.d. Variances from requirements related to fire safety and building construction standards regulated by the Vermont Department of Public Safety must be requested from that Department.1.6. Definitions. The words and phrases listed below, as used in these regulations, have the following meanings, unless otherwise specifically provided:
a. "Advance Directive" means a written record executed pursuant to 18 V.S.A. Chapter 231, which may include appointment of an agent, identification of a preferred primary care clinician, instructions on health care desires or treatment goals, an anatomical gift, disposition of remains, and funeral goods and services. The term includes documents designated under prior law as a durable power of attorney for health care or a terminal care document.b. "Agent" means an adult with capacity to whom authority to make health care decisions is delegated under an advance directive, including an alternate agent if the agent is not reasonably available.c. "Capacity" means an individual's ability to make and communicate a decision regarding the issue that needs to be decided. 1. An individual shall be deemed to have capacity to appoint an agent if the individual has a basic understanding of what it means to have another individual make health care decisions for oneself and of who would be an appropriate individual to make those decisions, and can identify whom the individual wants to make health care decisions for the individual; and2. An individual shall be deemed to have capacity to make a health care decision if the individual has a basic understanding of the diagnosed condition and the benefits, risks, and alternatives to the proposed health care.d. "Clinician order for life sustaining treatment" (COLST) means a clinician's order or orders for treatment, such as intubation, mechanical ventilation, transfer to hospital, antibiotics, artificially administered nutrition, or another medical intervention. A COLST order is designed for use in outpatient settings and health care facilities and may include a DNR order that meets the requirements of 18 V.S.A. § 9708.e. "Commissioner" means the Commissioner of the Department of Disabilities, Aging and Independent Living.f. "Department" means the Vermont Department of Disabilities, Aging and Independent Living.g. "Discharge" means movement of a resident out of the nursing home, without expectation that the resident will return.h. "Do Not Resuscitate Order" (DNR) means a written order of the resident's clinician directing health care providers not to attempt resuscitation.i. "DNR/COLST" means a DNR or COLST, or both.j. "Facility" means a nursing home licensed or required to be licensed pursuant to the provisions of 33 V.S.A. chapter 71.k. "Informed consent" means the consent given voluntarily by an individual with capacity, on his or her own behalf or on behalf of another in the role of an agent, guardian, or surrogate in the case of DNR/COLST orders, after being fully informed of the nature, benefits, risks, and consequences of the proposed health care, alternative health care, and no health care.l. "Interested individual" means: 1. the resident's spouse, adult child, parent, adult sibling, adult grandchild, clergy person; or2. A any adult who has exhibited special care and concern for the resident and who is personally familiar with the resident's values.m. "Legal representative" means a person appointed by an individual or by a duly authorized agency or court, or otherwise authorized by law to act on behalf of an individual, and includes the terms "representative payee" and "guardian."n. "Licensee" means the person or persons who hold a license to operate a nursing home.o. "Licensing agency" means the Department's Division of Licensing and Protection Survey and Certification Unit.p. "Life sustaining treatment" means any medical intervention, including nutrition and hydration administered by medical means and antibiotics, which is intended to extend life and without which the resident is likely to die.q. "Medicaid" means the medical assistance program established pursuant to Title XIX of the Social Security Act.r. "Medicare" means the medical insurance program established pursuant to Title XVIII of the Social Security Act.s. "Next of Kin" means the resident's spouse or civil union partner, an individual in a long-term relationship of indefinite duration, in which the individual has demonstrated an actual commitment to the resident similar to the commitment of a spouse, and in which this individual and the resident consider themselves to be responsible for each other's well-being, the resident's adult children, resident's parents; and the resident's adult siblings.t. "Nursing home", which is also referred to in these rules as "nursing facility" or "facility", means an institution or a distinct part of an institution (excluding intermediate care facilities for individuals with intellectual disabilities) which is primarily engaged in providing to its residents: 1. skilled nursing care and related services for residents who require medical or nursing care;2. rehabilitation services for the rehabilitation of injured, disabled or sick persons; or3. on a 24-hour basis, health related care and services to individuals who because of their mental or physical condition require care and services which can be made available to them only through institutional care.u. "Ombudsman" means the individual selected from among individuals with expertise and experience in the fields of long-term care and advocacy who heads the Office of the State Long-Term Care Ombudsman and is responsible personally, or through representatives of the Office of the Long-Term Care Ombudsman, to fulfill the functions, responsibilities and duties set forth in the Older Americans Act of 1965, as amended.v. "Options counseling" means providing an applicant to or resident of a nursing home with complete information on all available long-term care services and benefits for which he or she might be eligible and giving him or her the opportunity to make a fully informed choice from among the available options and services.w. "Psychosocial needs" means any combination of mental health, emotional, spiritual or behavioral needs, concerns or aspects of the resident's life which are identified as important to the resident.x. "Representative Payee" means an individual or organization certified by the Commissioner of Social Security to receive benefits for or on behalf of a resident pursuant to 42 U.S.C. § 1007.y. "Resident" means an individual admitted for care in a nursing home, and, for purposes of these rules, includes, except as limited by context, any legal representative or next of kin acting on behalf of the resident according to law.z. "Special Care Unit" means a unit located in an identified distinct part of a nursing home and provides an intensity of specialized services that is not routinely available in the rest of the facility.aa. "Surrogate" means an interested individual who provides or withholds, pursuant to 18 V.S.A. Chapter 231, subchapter 2, informed consent for a DNR/COLST.bb. "Transfer" means movement of a resident to another bed within the same nursing home or transfer to another health care setting with return anticipated.cc. "Vermont Nurse Aide Registry" means the registry established and maintained by the Vermont State Board of Nursing containing the names of and other information about all persons who have successfully completed a competency evaluation or who have been otherwise deemed competent as a nurse assistant by the Vermont State Board of Nursing.Section 4 QUALITY OF LIFE A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life.
4.1. Dignity. Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and in care of his or her personal needs. The resident shall have the exclusive right to use and enjoy his or her property, and such property shall not be used by other residents or staff without the express permission of the resident.
4.2. Privacy. a. The resident may associate and communicate privately with persons of his or her choice.b. The resident may receive his or her personal mail unopened.c. If married or in a civil union, a resident shall be assured privacy for visits; if both are residents of the facility; they are permitted to share a room.d. Residents shall be assured reasonable access to a telephone located in a quiet area where the resident can conduct a private conversation.4.3. Self-Determination and Participation. The resident has the right to:
a. choose activities, schedules, and health care consistent with his or her interests, assessments and plans of care;b. interact with members of the community both inside and outside the facility;c. make choices about aspects of his or her life in the facility that are significant to the resident; andd. retain and use his or her personal clothing and possessions as space permits, unless to do so would infringe upon rights of other residents.4.4. Resident and Family Groups. Each resident shall be encouraged and assisted, throughout his or her period of stay, to exercise his or her rights as a resident and as a citizen and to this end may voice grievances and recommend changes in policies and services to facility staff or to outside representatives of his or her choice, free from restraint, interference, coercion, discrimination or reprisal.
a. The resident has the right and the facility must provide immediate access to any resident by the following: any representative of the State, the Ombudsman, and any other person of the resident's choosing.b. Residents and their families shall have the right to organize, maintain, and participate in either resident or family councils, or both.c. resident has the right to organize and participate in resident groups in the facility.d. resident's family has the right to meet in the facility with the families of other residents.e. The facility must provide a resident or family group, if one exists, with private space for meetings.f. The facility shall provide assistance for meetings, if requested.g. Staff or visitors may attend meetings only at the group's invitation.h. The facility shall respond in writing to written requests from council meetings. Resident councils and family councils shall be encouraged to make recommendations regarding facility policies.i. The facility must provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings.j. When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operation decisions affecting resident care and life in the facility.4.5. Participation in Other Activities. A resident has the right, at his or her discretion, to participate in social, religious and community activities that do not interfere with the rights of other residents in the facility.
4.6. Accommodation of Residents' Needs. a. resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.b. resident has the right to receive notice before the resident's room or roommate in the facility is changed.4.7. Activities. a. The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.b. The activities program must be directed by a qualified professional who: 1. is a qualified therapeutic recreation specialist or an activities professional who i. is licensed or registered andii. is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or2. has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a resident activities program in a health care setting; or 3. is a qualified occupational therapist or occupational therapy assistant; or4. has completed a training course approved by the licensing agency; or5. has demonstrated the ability to provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each resident and serves with the regularly scheduled consultation of an individual who meets the qualifications outlined above.4.8. Social Services. a. The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.b. A facility with more than 120 beds must employ a qualified social worker on a full-time basis.c. qualified social worker is an individual with the following qualifications: 1. both i. a bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology, andii. one year of supervised social work experience in a health care setting working directly with individuals;2. or a demonstrated ability to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.4.9. Environment. A nursing home must provide:
a. a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible;b. housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;c. a clean bed and bath linens that are in good condition;d. private closet space in each resident room as specified in subsection 8.4 (c.)4.e. adequate and comfortable lighting levels in all areas;f. comfortable and safe temperature levels (not lower than 710 F); andg. for the maintenance of comfortable sound levels.Section 7 QUALITY OF CARE Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
7.1. Activities of Daily Living. Based on the comprehensive assessment of a resident, the facility must ensure that:
a. a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to: 1. bathe, dress, and groom;2. transfer and ambulate;5. use speech, language or other functional communication systems.b. a resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in subsection 7.1 (a.) above; andc. a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.7.2. Vision and Hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident:
a. in making appointments; andb. by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.7.3. Pressure Sores. Based on the comprehensive assessment of a resident, the facility must ensure that:
a. a resident who enters the facility without pressure sores does not develop pressure sores unless the individuals clinical condition demonstrates that they were unavoidable; andb. a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.7.4. Urinary Incontinence. Based on the resident's comprehensive assessment, the facility must ensure that:
a. a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; andb. a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.7.5. Range of Motion. Based on the comprehensive assessment of a resident, the facility must ensure that:
a. a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; andb. a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.7.6. Mental and Psychosocial Functioning. Based on the comprehensive assessment of a resident, the facility must ensure that:
a. a resident who displays mental or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem; andb. a resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry or depressive behaviors, unless the resident's clinical condition demonstrates that such a pattern is unavoidable.7.7. Naso-Gastric Tubes. Based on the comprehensive assessment of a resident, the facility must ensure that:
a. a resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident's clinical condition demonstrates that use of a naso-gastric tube was unavoidable; andb. a resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.7.8. Accidents. The facility must ensure that:
a. the resident's environment remains as free of accident hazards as is possible; andb. each resident receives adequate supervision and assistive devices to prevent accidents.7.9. Nutrition. Based on a resident's comprehensive assessment, the facility must ensure that a resident:
a. maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; andb. receives a therapeutic diet when there is a nutritional problem.7.10. Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.
7.11. Special Needs. The facility must ensure that residents receive proper treatment and care for the following special services:
b. parenteral and enteral fluids;c. colostomy, ureterostomy or ileostomy care;7.12. Medication/Drugs. a. General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: 1. in excessive dose (including duplicate therapy); or2. for excessive duration; or3. without adequate monitoring; or4. without adequate indications for its use; or5. in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or6. any combinations of the reasons above.b. Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: 1. residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and2. residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.c. Medication Errors. The facility must ensure that 1. it is free of medication error rates of five percent or greater; and2. residents are free of any significant medication errors.d. Controlled Drugs Policy. Facilities shall have policies and procedures regarding controlled drugs as required in 7.18 and in state law at 18 V.S.A. §§ 4201-4255.7.13. Nursing Services. The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care or as specified by the licensing agency.
a. Sufficient staff The facility must provide services by sufficient numbers of each of the following types of personnel on a (twenty-four (24)-hour basis to provide nursing care to all residents in accordance with resident care plans: 2. other nursing personnel.b. The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.c. Registered Nurse. 1. The facility must use the services of a registered nurse for at least eight (8) consecutive hours a day, seven (7) days a week.2. The facility must designate a registered nurse to serve as the director of nursing on a full-time basis.3. The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of sixty (60) or fewer residents.d. Staffing Levels. The facility shall maintain staffing levels adequate to meet resident needs. 1. At a minimum, nursing homes must provide: i. no fewer than three (3) hours of direct care per resident per day, on a weekly average, including nursing care, personal care and restorative nursing care, but not including administration or supervision of staff; andii. of the three hours of direct care, no fewer than two (2) hours per resident per day must be assigned to provide standard LNA care (such as personal care, assistance with ambulation, feeding, etc.) performed by LNAs or equivalent staff and not including meal preparation, physical therapy or the activities program.2. A The facility shall provide staffing information to the licensing agency in a manner and on a schedule prescribed by the licensing agency.7.14. Dietary Services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.
a. Staffing. The facility must employ a qualified dietitian either full-time, part-time, or on a consultant basis.1. If a qualified dietitian is not employed full-time, the facility must designate a person to serve as the director of food service who receives frequently scheduled consultation from a qualified dietitian.2. qualified dietitian is one who is qualified based upon either registration by the Commission on Dietetic Registration of the American Dietetic Association, or on the basis of education, training or experience in identification of dietary needs, planning and implementation of dietary programs.3. Sufficient staff The facility must employ sufficient support personnel competent to carry out the functions of the dietary service.b. A Menus and nutritional adequacy. Menus must: 1. meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences;2. be prepared in advance; andc. Food. Each resident shall receive and the facility shall provide: 1. food prepared by methods that conserve nutritive value, flavor and appearance;2. food that is palatable, attractive, and at the proper temperature;3. food prepared in a form designed to meet individual needs;4. substitutes offered of similar nutritive value to residents who refuse food served.d. Therapeutic diets. Therapeutic diets must be prescribed by the attending physician.e. Frequency of meals. 1. Each resident shall receive and the facility shall provide at least three meals daily, at regular times comparable to normal mealtimes in the community.2. There must be no more than 14 hours between a substantial evening meal and breakfast the following date, except as provided in number 4. below.3. The facility must offer snacks at midday and bedtime daily.4. When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, and a nourishing snack is served.f. Assistive devices. The facility must provide special eating equipment and utensils for residents who need them.g. Sanitary conditions. The facility must: 1. procure food from sources approved or considered satisfactory by Federal, State, or local authorities;2. store, prepare, distribute and serve food under sanitary conditions; and3. dispose of garbage and refuse properly.7.15. Physician Services. A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician.
a. Physician supervision. The facility must ensure that:1. the medical care of each resident is supervised by a physician; and2. A another physician supervises the medical care of residents when their attending physician is unavailable.b. Physician visits. The physician must:1. review the resident's total program of care, including medications and treatments, and examine the resident personally at each visit required by subsection 7.15(c).2. write, sign and date progress notes at each visit; and3. sign and date all orders.c. Frequency of physician visits. The resident must be seen by a physician: 1. within forty-eight (48) hours prior to admission or within forty-eight (48) hours following admission; and2. at least every six (6) months thereafter and as the resident's condition warrants. The facility must assure that physician visits occur as clinically indicated for the resident.d. Except as provided in subsection 7.15 e., all required physician visits must be made by the physician personally.e. After the initial visit, at the option of the physician, required six-month visits, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with subsection 7.15 g. below.f. Availability of physicians for emergency care. The facility must provide or arrange for the provision of physician services twenty-four (24) hours a day in case of emergency.g. Physician delegation of tasks. Except as specified in subsection 7.15 h., a physician may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist who: 1. is licensed as such by the State;2. is acting within the scope of practice as defined by State law; and3. is under the supervision of the physician.h. A physician may not delegate a task when these rules specify that the physician must perform it personally, or when the delegation is prohibited under State law or by the facility's own policies.7.16. Specialized Rehabilitative Services. a. Provision of Services. If specialized rehabilitative services such as, but not limited to, physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and intellectual disabilities, are required in the resident's comprehensive plan of care, the facility must: 1. provide the required services; or2. obtain the required services from an outside resource (in accordance with section 11.2) from a provider of specialized rehabilitative services.b. Qualifications. Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel.7.17. Dental Services. a. The facility must assist residents in obtaining routine and twenty-four (24) hour emergency dental care.b. The facility must provide or obtain from an outside resource (in accordance with section 11.2) the following dental services to meet the needs of each resident. 1. routine dental services (to the extent covered under the Medicaid State Plan); and2. emergency dental services.c. The facility must, if necessary, assist the resident:1. in making appointments;2. by arranging for transportation to and from the dentist's office; and3. by promptly referring residents with lost or damaged dentures to a dentist.7.18. Pharmacy Services. The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in section 11.2. All drugs must be administered in conformance with the requirements of 18 V.S.A. Chapter 84.
a. Procedures. A facility must provide pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.b. Service consultation. The facility must employ or obtain the services of a licensed pharmacist who: 1. provides consultation on all aspects of the provision of pharmacy services in the facility;2. establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and3. determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.c. Drug regimen review. The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.d. The pharmacist must report any irregularities to the attending physician and the director of nursing, and these reports must be acted upon.e. Labeling of drugs and biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, with the expiration date when applicable.f. Storage of drugs and biologicals. 1. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the key2. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, 42 U.S.C. § 812, and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.g. This section is not intended to prohibit residents from purchasing drugs or biologicals from outside sources.7.19. Infection Control. a. The facility must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.b. Infection control program. The facility must establish an infection control program under which it: 1. investigates, controls, and prevents infections in the facility;2. decides what procedures such as isolation should be applied to an individual resident; and3. maintains a record of incidents and corrective actions related to infections.c. Preventing spread of infection. 1. When the infection control program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident.2. The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.3. The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.d. Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.Section 8 PHYSICAL ENVIRONMENT The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public.
8.1. Life Safety from Fire. a. The facility must meet the applicable provisions of the Vermont Fire Prevention and Building Code.b. After consideration of state licensing agency findings, the Vermont Department of Public Safety may waive specific provisions of the Vermont Fire Prevention and Building Code which, if rigidly applied, would result in unreasonable hardship upon the facility, but only if the waiver does not adversely affect the health and safety of residents or personnel.8.2. Emergency Power. a. An emergency electrical power system must supply power adequate at least for lighting all entrances and exits; equipment to maintain the fire detection, alarm and extinguishing systems; and life support systems in the event the normal electrical supply is interrupted.b. When life support systems are used, the facility must provide emergency electrical power with an emergency generator (as defined in Vermont Fire Prevention and Building Code) that is located on the premises.8.3. Space and Equipment. The facility must:
a. provide sufficient space and equipment in dining, health services, recreation and program areas to enable staff to provide residents with needed services as required by these standards and as identified in each residents plan of care; andb. maintain all essential mechanical, electrical and patient-care equipment in safe operating condition.8.4. Resident Rooms. a. Resident rooms must be designed and equipped for adequate nursing care, comfort and privacy of residents.b. Bedrooms must: 1. accommodate no more than two residents, except as provided in e. below;2. measure at least eighty (80) square feet per resident in multiple resident bedrooms, and at least one hundred (100) square feet in single resident rooms;3. have direct access to an exit corridor;4. be designed or equipped to assure full visual privacy for each resident;5. in facilities initially certified after March 31, 1992, except in private rooms, have ceiling suspended curtains for each bed that extend around the bed to provide total visual privacy in combination with adjacent walls and curtains;6. have at least one window to the outside; and7. have a floor at or above grade level.c. The facility must provide each resident with:1. a separate bed of proper size and height for the convenience of the resident;2. a clean, comfortable mattress;3. bedding appropriate to the weather and climate; and4. functional furniture appropriate to the resident's needs, and individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident.d. The licensing agency may permit variations in requirements specified in sub sections 8.4 b.1. and 2. of this section relating to rooms in individual cases when the facility demonstrates in writing that the variations: 1. are in accordance with the special needs of the residents; and2. will not adversely affect residents' health and safety.e. Resident bedrooms in existence on the effective date of this rule that are designed to accommodate three or four persons may remain in operation, subject to the following conditions: 1. At least annually, residents who reside in three- or four-bed rooms will be offered the first vacant bed in a semi-private or private room (depending upon payment source) when such bed becomes available and prior to admission of a new resident into such bed. The resident's patient record shall record the date on which the resident was offered the opportunity to relocate to a semi-private or private room, the resident's response and, if the resident requests a transfer to a semi-private or private room, the date on which the transfer occurred.2. Admission of a new resident to a three- or four-bed room may occur only with the resident's or the resident's legal representative's consent3. Any downsizing or reduction in licensed capacity initiated by the facility must first reduce the number of beds contained in three- and four-bed rooms such that these rooms are converted to semi-private or private occupancy.4. Proposals for new construction, expansion, renovation or substantial rehabilitation of a facility requiring Certificate of Need approval pursuant to 18 V.S.A. § 9434 will not be approved by the licensing agency unless the construction proposal includes a plan for elimination or conversion of all three- and four-bed rooms to rooms which accommodate no more than 2 (two) persons.i. The terms "renovation or substantial rehabilitation" shall not be deemed to include routine maintenance or repairs due to normal wear and tear.ii. "Routine maintenance or repairs" includes, but is not limited to, furnace replacement, roof replacement, rewiring, and repainting and other improvements that do not alter the appearance or layout of the facility.iii. Construction that alters the appearance or layout of the facility, including relocation of walls, partitions, doors, creation or subdivision of rooms, or conversion of a portion of the facility for a different use, shall be considered "renovation or substantial rehabilitation" and not "routine maintenance or repair".5. Facilities shall provide private space for residents of three or four bedrooms to visit with family, relatives, friends, clergy, etc.8.5. Toilet Facilities. Each resident room must be equipped with or located near toilet facilities.
8.6. Resident Call System. The nurses' station must be equipped to receive resident calls through a communication system from:
b. toilet and bathing facilities.8.7. Dining and Resident Activities. The facility must provide one or more rooms designated for resident dining and activities. These rooms must:
b. be well ventilated, with non-smoking areas identified;c. be adequately furnished; andd. have sufficient space to accommodate all activities.8.8. Other Environmental Conditions. The facility must provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. The facility must:
a. establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply;b. have adequate outside ventilation by means of windows or mechanical ventilation, or a combination of the two;c. equip corridors with firmly secured handrails on each side; andd. maintain an effective pest control program so that the facility is free of pests and rodents.Section 10 NURSE AIDE TRAINING 10.1. Nurse Aide Registration. General Rule. A facility must not use an individual working in the facility as a nurse aide for more than four (4) months, on a full-time basis, unless that individual:
a. is included on the Vermont Nurse Aide Registry; andb. is competent to provide nursing and nursing related services.10.2. Non-Permanent Employees. A facility must not use on a temporary, per diem, leased or any basis other than a permanent employee any individual who does not meet the requirements in Section 10. 1.
10.3. Competency. A facility must not use any individual who has worked less than four (4) months as a nurse aide in that facility unless the individual:
a. is a full-time employee enrolled in a state approved training and competency evaluation program;b. has demonstrated competence through satisfactory participation in a state-approved nurse aide training and competency evaluation program; orc. is included on the Vermont Nurse Aide Registry.10.4. Registry Verification. a. Before allowing an individual to serve as a nurse aide, a facility must receive verification from the Vermont Nurse Aide Registry that the individual has met competency evaluation requirement unless: 1. the individual is a full-time employee in a training and competency evaluation program approved by the state; or2. the individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the state and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered.b. Multi-State Registry Verification. Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry, established under 42 U.S.C. §§ 1395i-3(e)(2)(A) or 1396r(e)(2)(A), which the facility believes will include information on the individual.10.5. Required Retraining. If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of twenty-four (24) consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.
10.6. Regular In-Service Education. a. Performance reviews. The facility must complete a performance review of every nurse aide at least once every twelve (12) months, and must provide regular in-service education based on the outcome of these reviews.b. In-service training. The in-service training must:1. be sufficient to ensure the continuing competence of nurse aides, but must be no less than twelve (12) hours per year.2. address areas of weakness as determined in nurse aide's performance reviews and may address special needs of residents as determined by the facility staff; and3. for nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.10.7. Proficiency of Nurse Aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care.
10.8. Developmental Services. Individuals providing specialized services to residents with developmental disabilities do not meet the definition of a nurse aide.
Section 20 DEFINITIONS Unless otherwise required by the context, as used in these rules, the following definitions apply:
"Advance Directive" means a written instruction of an individual, such as a terminal care document (living will) executed in accordance with 18 V.S.A. Chapter 111; durable power of attorney for health care, executed in accordance with 14 V.S.A. Chapter 121; or general durable power of attorney, executed in accordance with 14 V.S.A. § 3051; recognized under state law and relating to the provision of health care when the individual is unable to direct his or her own health care.
"Commissioner" means the commissioner of the Department of Aging and Disabilities.
"Department" means the Vermont Department of Aging and Disability.
"Discharge" means movement of a resident out of the licensed facility, without expectation that the resident will return.
"Do Not Resuscitate (DNR) Order" or "No Code Order" means a written physician's order supported by appropriate consent of the resident and medical documentation, to suspend the otherwise automatic initiation of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest.
"HCFA" mean the United States Health Care Financing Administration.
"Legal representative" means a person appointed by an individual or by a duly authorized agency or court, or otherwise authorized by law to act on behalf of the individual, and includes the terms "representative payee" and "guardian".
"Licensee" means the person or persons who hold a license to operate a facility.
"Medicaid" means the medical assistance program established pursuant to Title XIX of the Social Security Act.
"Medicare" means the medical insurance program established pursuant to Title XVIII of the Social Security Act.
"Next of Kin" means, in descending order of priority:
1) the resident's spouse, civil union partner or reciprocal beneficiary; 2) an individual in a long-term relationship of indefinite duration, in which the individual has demonstrated an actual commitment to the resident similar to the commitment of a spouse, and in which this individual and the resident consider themselves to be responsible for each other's well-being; 3) the resident's adult children;4) the resident's parents; and5) the resident's adult siblings. "Nursing facility" or "facility" means an institution or a distinct part of an institution (excluding intermediate care facilities for the mentally retarded) which is primarily engaged in providing to its residents (a) skilled nursing care and related services for residents who require medical or nursing care; (b) rehabilitation services for the rehabilitation of injured, disabled or sick persons; or (c) on a 24 hour basis, health related care and services to individuals who because of their mental or physical condition require care and services which can be made available to them only through institutional care.
"Ombudsman" means any person or organization designated by the State Ombudsman, in accordance with 33 V.S.A. § 7501(3), as part of the Office of the State Long-Term Care Ombudsman.
"Options counseling" means providing consumers with complete information on all available long term care services and benefits for which the consumer might be eligible and giving the consumer the opportunity to make a fully informed choice from among the available options and services.
"Psychosocial needs" means any combination of mental health, emotional, spiritual or behavioral needs, concerns or aspects of the resident's life which are identified as important to the resident.
"Reciprocal beneficiary" means a person who has established a reciprocal beneficiaries' relationship pursuant to law.
"Representative Payee" means an individual or organization certified by the Commissioner of Social Security to receive benefits for or on behalf of a resident pursuant to 42 U.S.C. § 405(j).
"Resident" means an individual admitted for care in a facility. For the purposes of these rules whenever "resident" is used it includes (except when limited by the context) any legal representative or next of kin acting on the resident's behalf according to law.
"Skilled Nursing Facility" means a facility or distinct part of a facility that is certified for participation in the Medicare program as a skilled nursing facility.
"Special Care Unit" means a unit located in an identified distinct part of a nursing facility and provides an intensity of specialized services that is not routinely available in the rest of the facility.
"Transfer" means movement of a resident to another bed within the same facility or transfer to another health care setting with return anticipated.
"Vermont State Nurse Assistants Registry" means the registry established and maintained by the department containing the names of and other information about all persons who have successfully completed a competency evaluation or who have been otherwise deemed competent as a nurse assistant by the Department.