Statutes, codes, and regulations
West Virginia Administrative Code
Agency 64 - HealthTitle 64 - LEGISLATIVE RULE WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES
Series 64-13 - Nursing Home Licensure Rule
Section 64-13-10 - Administration and Human Resources

W. Va. Code R. § 64-13-10

Download
PDF
Current through Register Vol. XLI, No. 24, June 14, 2024
Section 64-13-10 - Administration and Human Resources
10.1. A nursing home shall be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
10.2. Licensure.
10.2.1. A nursing home shall be licensed under the provisions of this rule.
10.2.2. A nursing home shall operate and provide services in compliance with all applicable federal, state, and local laws, rules, and codes and with accepted professional standards and principles that apply to professionals providing services in a nursing home.
10.3. Governing Body.
10.3.1. A nursing home shall have a governing body.
10.3.2. The governing body shall adopt and enforce rules governing the health care and safety of residents, the protection of their personal and property rights, and the operation of the nursing home.
10.3.3. The governing body shall develop a written nursing home plan that will be reviewed annually. In addition to the other requirements described in law and in this rule, the nursing home plan shall include:
10.3.3.a. An annual operating budget, including all anticipated income and expenses; and
10.3.3.b. A capital expenditure plan for at least a three year period.
10.3.4. The governing body shall assure the development and maintenance of written policies and procedures that govern the services the nursing home provides.
10.3.4.a. The policies and procedures shall include at a minimum all policies and procedures required by this rule.
10.3.4.b. A copy of each written policy and procedure shall be available for inspection on request by the nursing home's staff and residents and by members of the public.
10.4. Professional Staff. A nursing home shall employ on a full-time, part-time, or consultant basis those professionals necessary to carry out the provisions of this rule.
10.5. Professional Qualifications. Professional staff shall be licensed, certified, or registered in accordance with applicable laws.
10.6. Criminal Background Checks.
10.6.1. All direct access personnel, as defined in W. Va. Code §§ 16-49-1, et seq., of a nursing home shall be subject to the provisions of the West Virginia Clearance for Access: Registry and Employment Screening Act, W. Va. Code §§ 16-49-1, et seq., and W. Va. Code R. §§ 69-10-1, et seq.
10.6.2. All direct access personnel, as defined in W. Va. Code §§ 16-49-1, et seq., of a nursing home shall have received an eligibility fitness determination or variance from the West Virginia Clearance for Access: Registry and Employment Screening.
10.6.3. The nursing home shall maintain documentation that each direct access personnel, as defined in W. Va. Code §§ 16-49-1, et seq., has received an eligibility fitness determination or variance from the West Virginia Clearance for Access: Registry and Employment Screening.
10.7. Use of Outside Resources.
10.7.1. If a nursing home does not employ a qualified professional person to furnish a specific service to be provided by the nursing home, the nursing home shall have that service furnished to residents by a person or agency outside the nursing home under an arrangement or an agreement as described in 42 U.S.C. § 1395x(w) or an agreement as described within this rule, and services shall meet the ongoing identified needs of residents to ensure implementation of the plan of care and to avoid unnecessary duplication of services.
10.7.2. Under arrangements as described in 42 U.S.C. § 1395x(w) or written agreements pertaining to services furnished by outside resources, the nursing home is responsible for the following:
10.7.2.a. Obtaining services that meet professional standards and principles that apply to professionals providing services in a nursing home; and
10.7.2.b. The timeliness of the services.
10.8. Staff Development.
10.8.1. All personnel shall attend and participate in regularly scheduled in-service training programs developed for the staff by either nursing home personnel or outside resources. The purpose of the in-service program shall be to:
10.8.1.a. Plan and organize a system of training that begins with an orientation program and continues throughout employment with scheduled in-service training programs;
10.8.1.b. Develop in each employee an awareness of his or her abilities and limitations in providing care for residents; and
10.8.1.c. Develop the abilities of each employee by an in-depth review of operational policies and procedures, instruction of methods, and procedures to follow in implementing assigned duties as it relates to a specific job description, and to provide current information that will assist in providing quality care.
10.8.2. A nursing home shall maintain records of attendance, and if absences occur shall schedule a make-up class to be completed.
10.8.3. A nursing home shall complete a performance review of every employee at least once every 12 months and provide regular in-service education based on the outcome of these reviews. The inservice training shall:
10.8.3.a. Be sufficient to ensure the continuing competence of registered nurse aides, but shall be no less than 12 hours per year;
10.8.3.b. Address areas of weakness as determined in the employee's evaluation and may address the special needs of residents as determined by the nursing home staff;
10.8.3.c. For nursing staff providing services to residents with cognitive impairments, also address the care of the cognitively impaired; and
10.8.3.d. Include in-service instruction to all personnel on the following:
10.8.3.d.1. The problems and needs of the aged, ill, and disabled;
10.8.3.d.2. The prevention and control of infections;
10.8.3.d.3. Disaster preparedness and fire and safety rules;
10.8.3.d.4. Accident prevention;
10.8.3.d.5. Confidentiality of resident information;
10.8.3.d.6. Protection of a resident's privacy and personal property rights, and dignity and protection of residents' rights; and
10.8.3.d.7. Complaint procedures, abuse, neglect, and misappropriation of personal property.
10.8.3.e. The nursing home shall provide training to all new employees, staff, and independent health contractors used by the nursing home, within 30 days of employment or the next regularly scheduled orientation program, whichever occurs first, on Alzheimer's disease and other dementias. The training shall be a minimum of two hours in duration and shall include all of the following: a basic explanation of how the disease process affects persons with Alzheimer's disease and other dementias, communication approaches and techniques for use when interacting with persons with Alzheimer's disease or other dementias, prevention and management of problem behaviors, and activities and programming appropriate for these individuals.
10.8.3.f. The nursing home shall provide training on Alzheimer's disease and other dementias to all employees, staff, and independent health contractors used by the nursing home each calendar year. The training shall be a minimum of two hours in duration and shall include all of the following: a basic explanation of how the disease process affects persons with Alzheimer's disease and other dementias, communication approaches and techniques for use when interacting with persons with Alzheimer's disease or other dementias, prevention and management of problem behaviors, and activities and programming appropriate for these individuals.
10.9. Personnel Records. A nursing home shall maintain a confidential personnel record for each employee containing the following information:
10.9.1. A dated application;
10.9.2. Reference verification;
10.9.3. Results indicating a satisfactory health status for the employees' current job assignment as required within the provisions of this rule;
10.9.4. Evaluations of work performance;
10.9.5. Current license, registration, or certification status if applicable to the job;
10.9.6. A summary of each employee's in-service training for the previous two years;
10.9.7. Any nursing home specific required forms;
10.9.8. A job description signed by the employee; and
10.9.9. Records required to be retained for criminal background checks as defined by the provisions of this rule.
10.10. Medical Director. A nursing home shall designate, in writing, a physician accountable to the governing body to serve as medical director to ensure that medical care provided to residents is adequate and appropriate. The medical director is responsible for:
10.10.1. Reviewing policies, procedures, and guidelines to ensure adequate, comprehensive services;
10.10.2. Coordinating medical care provided, including the attending physician, in the nursing home so it is adequate and appropriate;
10.10.3. Assisting in the evaluation of credentialing and re-credentialing of licensed independent practitioners, physicians' assistants and nurse practitioners to determine whether they will be authorized to practice within the organization by recommendation;
10.10.4. Approving in-service training programs;
10.10.5. Reviewing and evaluating incident reports or summaries of incident reports, identifying hazards to health and safety, and making recommendations as needed; and
10.10.6. Providing or arranging for medical coverage of residents who do not have an attending physician.

W. Va. Code R. § 64-13-10