W. Va. Code R. § 64-13-8

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 64-13-8 - Quality of Care

8.1. Each resident shall receive, and the nursing home shall provide, the necessary care and services to attain or maintain the highest practicable physical, spiritual, mental, and psychosocial well-being of the residents, in accordance with the comprehensive assessment and plan of care.

8.2. Activities of Daily Living. Based on the comprehensive assessment of a resident, the nursing home shall ensure that:

8.2.1. A resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that diminution was unavoidable. Activities of daily living include the resident's ability to:

8.2.1.a. Bathe, dress, and groom;

8.2.1.b. Transfer and ambulate;

8.2.1.c. Use the toilet;

8.2.1.d. Eat; and

8.2.1.e. Use speech, language, or other functional communication systems.

8.2.2. A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in this rule.

8.2.2.a. Assistive devices. The nursing home shall provide special eating equipment and utensils for residents who need them.

8.2.2.b. The nursing home shall evaluate residents having potential to benefit from the assistive devices to assure that the assistive devices meet the resident's needs; and

8.2.3. 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.

8.3. Vision and Hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the nursing home shall, if necessary, assist the resident:

8.3.1. In making appointments; and

8.3.2. 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.

8.4. Pressure Sores. Based on the comprehensive assessment of a resident, the nursing home shall ensure that:

8.4.1. A resident who enters the nursing home without pressure sores does not develop pressure sores unless the resident's clinical condition demonstrates that they were unavoidable; and

8.4.2. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

8.5. Urinary Incontinence. Based on the resident's comprehensive assessment, the nursing home shall ensure that:

8.5.1. A resident who enters the nursing home without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization is necessary;

8.5.2. A resident who has an in-dwelling catheter has a documented medical reason for the catheter; and

8.5.3. 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, unless the restoration of function is not possible due to the physical or cognitive condition of the resident.

8.6. Range of Motion. Based on the comprehensive assessment of a resident, the nursing home shall ensure that:

8.6.1. A resident who enters the nursing home without a limited range of motion does not experience a reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

8.6.2. A resident with a limited range of motion receives appropriate treatment and services to increase range of motion or to prevent further decrease in a range of motion.

8.7. Mental and Psychosocial Functioning. Based on the comprehensive assessment of a resident, the nursing home shall ensure that:

8.7.1. A resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem; and

8.7.2. A resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction or increased withdrawn, angry or depressive behaviors, unless the resident's clinical condition demonstrates that such a pattern is unavoidable.

8.8. Feeding Tubes. Based on the comprehensive assessment of a resident, the nursing home shall ensure that:

8.8.1. A resident who has been able to eat enough alone or with assistance is not fed by tube unless the resident's clinical condition demonstrates that use of a feeding tube is unavoidable; and

8.8.2. A resident who is fed enterally receives the appropriate treatment and services to prevent secondary complications such as reflux, aspiration, aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities, and to restore, if possible, normal eating skills.

8.9. Accidents.

8.9.1. A nursing home shall provide an environment that remains as free from accident hazards as possible.

8.9.2. A nursing home shall provide an environment where each resident receives adequate supervision and assistive devices to prevent accidents.

8.9.3. The nursing home shall complete a written report of any incident or accident in which a resident is involved, either inside or outside of the nursing home.

8.9.4. The report shall include the:

8.9.4.a. Date of the occurrence;

8.9.4.b. Time of the occurrence;

8.9.4.c. Place of the occurrence;

8.9.4.d. Details of the occurrence; and

8.9.4.e. Date and signature of the reviewing physician.

8.9.5. The report shall be written and signed by the person who is responsible for the resident at the time that the accident or incident occurred.

8.10. Nutrition. Based on a resident's comprehensive assessment, the nursing home shall ensure that a resident:

8.10.1. Maintains acceptable parameters of nutritional status, unless the resident's clinical condition demonstrates that this is not possible;

8.10.2. Receives a therapeutic diet when there is a nutritional problem; and

8.10.3. Who has an unplanned weight loss or gradual progressive unexplained weight loss shall have a thorough nutritional assessment, including appropriate laboratory studies. The unplanned or unexplained weight loss shall be assessed by the following parameters:

8.10.3.a. A significant weight loss of five percent or a severe weight loss of greater than five percent in a one month interval;

8.10.3.b. A significant weight loss of seven and a half percent or a severe weight loss of greater than seven and a half percent in a three month interval;

8.10.3.c. A significant weight loss of 10 percent or a severe weight loss of greater than 10 percent in a six month interval.

8.11. Hydration. A nursing home shall provide each resident with sufficient fluid intake to maintain proper hydration and health.

8.12. Special Needs. A nursing home shall ensure that residents receive proper treatment and care for the following special needs:

8.12.1. Injections;

8.12.2. Parenteral and enteral fluids;

8.12.3. Colostomy, ureterostomy, or ileostomy care;

8.12.4. Tracheostomy care;

8.12.5. Tracheal suctioning;

8.12.6. Respiratory care;

8.12.7. Foot care;

8.12.8. Prostheses; and

8.12.9. Skin conditions.

8.13. Medications and Drugs.

8.13.1. Each resident's drug regimen shall be free from unnecessary drugs. An unnecessary drug is any drug used in any of the following circumstances or combinations of circumstances:

8.13.1.a. In excessive doses (including duplicate therapy);

8.13.1.b. For excessive duration;

8.13.1.c. Without adequate monitoring;

8.13.1.d. Without adequate indications for its use; or

8.13.1.e. In the presence of adverse consequences that indicate the dose should be reduced or discontinued.

8.13.2. Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the nursing home shall ensure that:

8.13.2.a. 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;

8.13.2.b. Residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

8.13.2.c. Residents do not receive antipsychotic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.

8.13.2.d. PRN orders for antipsychotic drugs are limited to 14 days. Except as provided in subdivision 8.13.2.e. of this rule, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order;

8.13.2.e. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication;

8.13.2.f. Residents, and the resident's legal representative in the case of incapacity to make health care decisions, receive a full explanation of the reasons for using the psychotropic drug, including the benefits and risks of the psychotropic drug; and

8.13.2.g. Residents, and the resident's legal representative in the case of incapacity to make health care decisions, provide written consent to the use of the psychotropic drug. The nursing home shall maintain documentation of the information provided and consent received in the resident's medical record.

8.13.3. Medication Errors. The nursing home shall ensure that:

8.13.3.a. It is free of medication error rates of five percent or greater; and

8.13.3.b. Residents are free of any significant medication errors.

8.13.4. Controlled Drugs Policy. The nursing home shall have policies and procedures regarding the procurement, storage, dispensing, administration, and disposition of controlled substances that conforms to the Uniform Controlled Substances Act, W. Va. Code §§ 60A-1-101, et seq. federal regulations and the rules of the West Virginia Board of Pharmacy.

8.14. Nursing Services Staffing.

8.14.1. A nursing home shall have sufficient nursing personnel 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. Staffing shall not, other than during short unforeseeable emergencies, be less than an average of 2.25 hours of nursing personnel time per resident per day.

8.14.a.1. Minimum hours of resident care personnel to residents are outlined in Table 64-13.A. of this rule.

8.14.a.2. Facilities with fewer than 51 beds are staffed at higher hours as outlined in table 64-13.A. of this rule.

8.14.2. A nursing home shall provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:

8.14.2.a. Licensed nurses; and

8.14.2.b. Other nursing personnel. Based on the residents' needs and the nursing home services, the nursing home may determine the combination of licensed nurse time and nurse aide time if the total meets the minimum 2.25 hours nursing personnel time requirement.

8.14.3. Charge Nurse. A nursing home shall designate a licensed nurse to serve as a charge nurse on each shift;

8.14.4. Registered Nurse. A nursing home shall have a registered nurse on duty in the facility for at least eight consecutive hours, seven days a week. In facilities with fewer than 60 beds, the director of nursing may serve to meet this requirement.

8.14.5. Nurse on Call. If there is not a registered professional nurse on duty, there shall be a registered professional nurse on call.

8.14.6. Director of Nursing. A nursing home shall designate in writing a registered nurse to serve as the director of nursing services on a full-time basis, who shall be on duty at least five days a week, eight hours a day during the day shift.

8.14.7. The director may require staffing ratios above the specified minimum ratios if necessary to meet the residents' needs.

8.14.8. Paid Feeding Assistants. Paid feeding assistants are authorized to feed residents who have no feeding complications, under the direct supervision of a registered professional nurse (RN) or a licensed practical nurse (LPN).

8.14.8.a. Paid feeding assistants may set up a resident's meal tray for dining, assist in feeding the resident, and record the resident's intake at the meal.

8.14.8.b. Paid feeding assistants are to be used in accordance with the West Virginia Department of Health and Human Resources Office of Health Facility Licensure and Certification Guidelines for Paid Feeding Assistants which can be located at ohflac.wvdhhr.org.

8.14.9. Posting of Nurse Staffing Information. The nursing home shall post the following information on a daily basis.

8.14.9.a. The current date, resident census, and the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift, including:

8.14.9.a.1. Registered nurses;

8.14.9.a.2. Licensed practice nurses; and

8.14.9.a.3. Registered nurse aides.

8.14.9.b. The nursing home must post this information in a clear and readable document; and in a prominent place readily accessible to residents and visitors.

8.14.9.c. The nursing home shall, upon oral or written request, make the nurse staffing data available to the public for review. Copies of the nurse staffing data is subject to a charge not to exceed 25 cents per page.

8.14.9.d. The nursing home shall maintain the posted nurse staffing data for a minimum of 18 months.

8.15. Dietary Services.

8.15.1. Dietary Staffing.

8.15.1.a. Dietitian. A nursing home shall employ a qualified dietitian either full-time, part-time, or on a consultant basis.

8.15.1.a.1. A qualified dietitian is one who is registered by the Commission on Dietetic Registration and licensed by the West Virginia Board of Licensed Dietitians; or

8.15.1.a.2. Is qualified as defined by the West Virginia Board of Licensed Dietitians, and is licensed by that board to provide professional nutritional services in West Virginia.

8.15.1.a.3. Consultation shall be based upon the residents' needs and shall occur at intervals of no less than 37 days and for no less than eight hours.

8.15.1.b. A dietary manager shall be employed if a dietitian is not employed full-time and shall be one of the following:

8.15.1.b.1. A dietetic technician, registered by the Academy of Nutrition and Dietetics;

8.15.1.b.2. A certified dietary manager, as certified by the Association of Nutrition and Food service Professionals;

8.15.1.b.3. A graduate of an associate or baccalaureate degree program in foods and nutrition or food service management; or

8.15.1.b.4. A person enrolled in an approved program to become a certified dietary manager within 60 days of accepting responsibility for the position. This person shall successfully complete the program within the specific timeframes outlined by the enrolled program and shall successfully pass the Certified Dietary Manager (CDM) examination within no more than two months of completing the approved program.

8.15.1.c. The dietary manager, under the direction of the dietitian, is responsible for the daily operation of the dietetic service;

8.15.2. Sufficient staff. A nursing home shall employ sufficient support personnel competent to carry out the functions of the dietary service.

8.15.3. Menus and Nutritional Adequacy. A nursing home shall meet the nutritional needs of residents in accordance with the Reference Dietary Intake (RDI) of the Food and Nutrition Board of the National Research Council, National Academy of Sciences.

8.15.4. Food. A nursing home shall provide each resident with:

8.15.4.a. Food prepared by methods that conserve nutritive value, flavor, and appearance;

8.15.4.b. Meals shall be prepared and served the same day;

8.15.4.c. Food that is palatable, attractive, and at the proper temperature;

8.15.4.d. At the time of receipt by the resident, foods shall be at a temperature of no less than 120 F for hot foods and at no more than 50 F for cold foods;

8.15.4.e. Food prepared in a form designed to meet individual needs;

8.15.4.f. Food substitutes of similar nutritive value for food the resident refuses;

8.15.4.g. Food prepared with seasoning, unless contraindicated by a physician's order; and

8.15.4.h. Iodized salt, if used.

8.15.5. Diets including regular diets. All residents shall have a physician's order for the specific type of diet he or she is to receive as set forth in the nursing home's diet manual.

8.15.5.a. Therapeutic and texture modified diets shall be served to residents in accordance with physician's orders.

8.15.5.b. Nursing personnel shall advise food service in writing of each resident's diet order, and a copy of the order shall be kept on file for at least one year.

8.15.5.c. Therapeutic Diets. Therapeutic diets shall be prescribed by the attending physician. A current therapeutic diet manual that is not more than five years old and is approved by the dietitian shall be available for nursing personnel and physicians.

8.15.5.d. Recognizing that the resident has the right to refuse medical treatment, all residents have the right to request substitute foods even when this violates the physician's orders.

8.15.5.d.1. A nursing home shall provide education to the resident regarding the benefits of the prescribed diet and consequences of his or her refusal to eat the prescribed diet.

8.15.5.d.2. A nursing home shall document the informed decision in the resident's clinical record.

8.15.6. Frequency of meals.

8.15.6.a. A nursing home shall provide at least three meals daily at regular times, or in accordance with residents' preferences and customary routines.

8.15.6.b. No more than 14 hours shall elapse between a substantial evening meal and breakfast the following day. Breakfast shall not be served before 7:00 a.m., unless by a resident's request.

8.15.6.c. A nursing home shall offer a nourishing snack at bedtime daily, as determined by the resident's needs.

8.15.6.c.1. The amount of the snacks consumed by the resident shall be recorded in the resident's medical record.

8.15.6.c.2. The amount of supplement consumed by the resident shall be recorded in the resident's medical record.

8.15.7. Sanitary conditions. A nursing home shall:

8.15.7.a. Procure food from sources approved or considered satisfactory by federal, state, or local authorities;

8.15.7.b. Store, prepare, distribute, and serve food under sanitary conditions;

8.15.7.b.1. Hold hot foods at or above 135 F and cold foods at or below 40 F, or the current Food and Drug Administration Food Code located at www.fda.gov.

8.15.7.b.2. Temperatures of foods are taken and documented prior to placement in the hot or cold food holding area.

8.15.7.c. Dispose of garbage and refuse properly.

8.15.8. Emergency supplies.

8.15.8.a. A nursing home shall have a planned three day disaster menu that correlates with the emergency food supply.

8.15.8.b. The emergency food supply shall be maintained on the premises with non-perishable foods and disposable supplies to meet all resident needs for three days.

8.15.8.c. The emergency food supply may be incorporated with the regular stock of food supplies.

8.15.9. A nursing home shall maintain a dietetic service that is organized either directly by a nursing home or through a written agreement with a contractor who complies with the standards of this rule.

8.15.10. The dietetic service shall be in substantial compliance with the Department of Health and Human Resources' Legislative Rule, Food Establishments, W. Va. Code R. §§ 64-17-1, et seq.

8.16. Physician and Physician Extender Services.

8.16.1. A physician shall personally approve in writing a recommendation that a person be admitted to a nursing home. Each resident shall remain under the care of a physician.

8.16.2. Physician supervision. A nursing home shall ensure that:

8.16.2.a. The medical care of each resident is supervised by a physician; and

8.16.2.b. Another physician supervises the medical care of residents when their attending physician is unavailable.

8.16.3. Physician visits. The physician shall:

8.16.3.a. Review the resident's total program of care, including medications and treatments, and examine the resident personally at each visit required under the provisions of this rule;

8.16.3.b. Write, sign, and date progress notes at each visit; and

8.16.3.c. Sign and date all orders.

8.16.4. Frequency of physician visits. The resident shall be seen face-to-face by a physician:

8.16.4.a. Within five days prior to admission or within 72 hours following admission; and

8.16.4.b. At least every 30 days for the first 90 days after admission, and as the resident's condition warrants. A nursing home shall assure that physician visits occur as clinically indicated for the resident.

8.16.4.c. After the 90 day requirement has expired, the physician shall visit every 60 days and as the resident's condition warrants.

8.16.5. Except as provided under the provisions of this rule, all required physician visits shall be made by the physician personally.

8.16.6. After the initial visit, at the option of the physician, the required visit every 60 days may be alternated between personal visits by the physician and visits by a physician's assistant, nurse practitioner, or clinical nurse specialist under the provisions of this rule.

8.16.7. Availability of physicians for emergency care. A nursing home shall provide or arrange for the provision of physician services 24 hours a day, in case of an emergency.

8.16.8. Physician delegation of tasks. Except as specified under the provisions of this rule, a physician may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist who:

8.16.8.a. Is licensed by the state;

8.16.8.b. Is acting within the scope of practice as defined by W. Va. Code §§ 30-3-1et seq.; and

8.16.8.c. Is under the supervision of the physician.

8.17. Specialized Rehabilitative Services.

8.17.1. Provision of services. If specialized rehabilitative services such as, but not limited to, physical therapy, speech-language pathology, occupational therapy, and psychological or psychiatric rehabilitative services, are required in the resident's comprehensive plan of care, a nursing home shall:

8.17.1.a. Provide the required services; or

8.17.1.b. Obtain the required services from an outside resource, in accordance with subsection 10.7. of this rule, from a provider of specialized rehabilitative services.

8.17.2. Qualifications. Specialized rehabilitative services shall be provided under the written order of a physician by qualified personnel as determined by licensing boards of those personnel.

8.18. Dental Services.

8.18.1. A nursing home shall provide, or obtain from an outside resource in accordance with subsection 10.7. of this rule, the following dental services to meet the needs of each resident:

8.18.1.a. Routine dental services, to the extent the resident is covered under the State Medicaid Plan; and

8.18.1.b. Emergency dental services 24 hours a day.

8.18.2. A nursing home shall assist a resident in need of dental services by:

8.18.2.a. Making dental appointments;

8.18.2.b. Arranging for transportation to and from the dentist's office; and

8.18.2.c. Referring residents with lost or damaged dentures to a dentist.

8.19. Pharmacy Services.

8.19.1. A nursing home shall provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described under the provisions of this rule.

8.19.2. All drugs shall be provided in conformance with the requirements of federal, state, and local laws, regulations, and rules.

8.19.3. Procedures. A nursing home shall provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident.

8.19.4. Service consultation. A nursing home shall employ or obtain the services of a licensed pharmacist who:

8.19.4.a. Provides consultation on all aspects of the provision of pharmacy services in the nursing home;

8.19.4.b. Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

8.19.4.c. Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

8.19.5. Drug regimen review.

8.19.5.a. The drug regimen of each resident shall be reviewed, by a licensed pharmacist, at least every 37 days.

8.19.5.b. The drug regimen review shall include substances that are regarded as herbal products or dietary supplements.

8.19.6. The nursing home shall conduct a drug regimen review on the premises.

8.19.7. The pharmacist shall report any irregularities in the drug regimen review to the attending physician and the director of nursing, who shall act upon these reports.

8.19.8. Labeling of drugs and biologicals. Drugs and biologicals used in the nursing home shall be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, with the expiration date when applicable.

8.19.9. Storage of drugs and biologicals.

8.19.9.a. In accordance with state and federal laws, the nursing home shall store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys.

8.19.9.b. A nursing home shall provide separately locked, permanently affixed compartments for the 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 nursing home uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

8.20. Infection Control.

8.20.1. A nursing home shall 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.

8.20.2. Infection control program. A nursing home shall establish and implement an infection control program under which it:

8.20.2.a. Investigates, controls, and prevents infections in the nursing home;

8.20.2.b. Determines what procedures, such as isolation, shall be applied to a resident and isolates only to the extent that is required to protect the resident and others; and

8.20.2.c. Maintains a record of incidents, investigations, and corrective actions related to infections. The records shall provide for analysis of causal factors and identification of preventative actions to be implemented.

8.20.3. Preventing spread of infection.

8.20.3.a. Policies and Procedures. A nursing home shall establish and implement policies and procedures consistent with current accepted standards of practice regarding the administration of pneumococcal vaccine, influenza vaccine, and screening for tuberculosis.

8.20.3.b. Isolation. When the nursing home staff determines by means of the infection control program that a resident needs isolation to prevent the spread of infection, the nursing home shall isolate the resident or make arrangements to have the resident transferred to a nursing home which can better meet the needs of the resident if the nursing home is unable to provide the required degree of isolation.

8.20.3.c. A resident who is transferred under the provisions of this rule and desires to return to the original nursing home shall be readmitted immediately to the first available bed in a semi-private room when the need for isolation has abated, provided that the resident still requires the care provided by the original nursing home and that nursing home is able to meet the resident's needs.

8.20.3.d. Employee restrictions. A nursing home shall 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.

8.20.3.e. Hand-washing. A nursing home shall require staff to wash their hands after each direct resident contact and after engaging in any activity for which hand washing is indicated by accepted standards of professional practice.

8.20.4. Linens. Personnel shall handle, store, process, and transport linens in order to prevent the spread of infection.

8.21. Trauma-informed care. The nursing home shall ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

8.22. Pain management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive personcentered care plan, and the resident's goals and preferences.

W. Va. Code R. § 64-13-8