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APPENDIX B Existing SNF Conditions of Participation and ICE Standards A. SNF Conditions of participation (42 CFR 405.1120 through 405.1137 (1974~) 1. CONDITION OF PARTICIPATION--COMPLIANCE WITH FEDERAL, STATE, AND LOCAL LAWS. The skilled nursing facility is in compliance with applicable Federal, State, and local laws and regulations. (a) Standard: Licensure. The facility, in any State in which State or applicable local law provides for licensing of facilities of this nature: (1) Is licensed pursuant to such law; or (2) If not subject to licensure, is approved by the agency of the State or locality responsible for licensing skilled nursing facilities as meeting fully the standards established for such licensing, and (3) Except that a facility which formerly met fully such licensure requirements, but is currently determined not to meet fully all such requirements, may be recognized for a period specified by the State standard-setting authority. 254

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APPENDIX B / 255 (b) Standard: Licensure or registration of personnel. Staff of the facility are licensed or registered in accordance with applicable laws. (c) Stand arc: Con fortuity with other Fed eral, State, and local laws. The facility is in conformity with all Federal, State, and local laws relating to fire and safety, sanitation, communicable and reportable diseases, postmortem procedures, and other relevant health and safety requirements. 2. CONDITION OF PARTICIPATION--GOVERNING BODY AND MANAGEMENT. The skilled nursing facility has an effective governing body, or designated persons so functioning, with full legal authority and responsibility for the operation of the facility. The governing body adopts and enforces rules and regulations relative to health care and safety of patients, to the protection of their personal and property rights, and to the general operation of the facility. (a) Standard. Disclosure of ownership. The facility complies with the disclosure requirements of 42 CFR 420.206 (b) Standard: Staffing patterns. The facility furnishes to the State survey agency information from payroll records setting forth the average numbers and types of personnel (in full-time equivalents) on each tour of duty during at least 1 week of each quarter. Such week will be selected by the survey agency. (c) Standards: Byinws. The governing body adopts effective patient care policies and administrative policies and bylaws governing the operation of the facility, in accordance with legal requirements. Such policies and bylaws are in writing, dated, and made available to all members of the governing body which ensures that they are operational, and reviews and revises them as necessary. (d) Stand ard . Ind e pend ent Ned ical evaluation (medical reviews. The governing body adopts policies to ensure that the facility cooperates in an effective program which provides for a regular program of

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256 / APPENDIX B independent medical evaluation and audit of the patients in the facility to the extent required by the programs in which the facility participates (including, at least annually, medical evaluation of each patient's need for skilled nursing facility care). (e) Stanciarct: Administrator. The governing body appoints a qualified administrator who is responsible for the overall management of the facility, enforces the rules and regulations relative to the level of health care and safety of patients, and to the protection of their personal rights, and plans, organizes, and directs those responsibilities delegated to him by the governing body. Through meetings and periodic reports, the administrator maintains ongoing liaison among the governing body, medical and nursing staffs, and other professional and supervisory staff of the facility, and studies and acts upon recommendations made by the utilization review and other committees. In the absence of the administrator, an employee is authorized, in writing, to act on his behalf. (f) Standard: Institutional planning. The skilled nursing facility, under the direction of the governing body, prepares an overall plan and budget which provides for an annual operating budget and a capital expenditure plan. (1) Annual operating budget. There is an annual operating budget which includes all anticipated income and expenses related to items which would, under generally accepted accounting principles, be considered income and expense items (except that it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense). (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period (including the year to which the operating budget described in paragraph (f)(l) of this section is applicable), which includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure in excess of $100,000 for items which would, under generally

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APPENDIX B / 257 accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $100,000, the cost of studies, surveys, designs, plans, working drawings, specifications and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions which are separated in time but are components of an overall plan or patient care objective are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of such financing is, in any part, the anticipated reimbursement from title V (Maternal and Child Health and Crippled Children's Services) or title XVIII (Health Insurance for the Aged and Disablecl) or title XIX (Grants to States for Medical Assistance Programs) of the Social Security Act, the plan states: (a) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed pursuant to the Public Health Service Act of the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963, to meet the need for adequate health care facilities in the area covered by the plan or plans so developed; (b) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval pursuant to section 1122 of the Social Security Act (42 U.S.C. 1320a-1) and implementing regulations; (c) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it has been so presented.

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258 / APPENDIX B (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the skilled nursing facility by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (or chief medical officer, or patient care policies advisory group as described in 405.1122(a)) of the skilled nursing facility. (4) Annual review of plan and budget. The overall plan ant! budget is reviewed and updated at least annually by the committee referred to in paragraph (f)~3) of this section under the direction of the governing body of the skilled nursing facility. (g) Standard: Personnel policies and procedures. The governing body, through the administrator, is responsible for implementing and maintaining written personnel policies and procedures that support sound patient care and personnel practices. Personnel records are current and available for each employee and contain sufficient information to support placement in the position to which assigned. Written policies for control of communicable disease are in effect to ensure that employees with symptoms or signs of communicable disease or infected skin lesions are not permitted to work, and that a safe and sanitary environment for patients and personnel exists and incidents and accidents to patients and personnel are reviewed to identify health and safety hazards. Employees are provided, or referred for, periodic health examinations, to ensure freedom from communicable clisease. (h) Standard: Staff clevelopment. An ongoing educational program is planned and conducted for the development and improvement of skills of all the facility's personnel, including training related to problems and needs of the aged, ill, and disabled. Each employee receives appropriate orientation to the facility and its policies, and to his position and duties. Inservice training includes at least prevention and control of infections, fire prevention and safety, accident prevention, confidentiality of patient information, and preservation of patient dignity,

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APPENDIX B / 259 including protection of his privacy and personal and property rights. Records are maintained which indicate the content of, and attendance at, such staff development programs. (i) Standard: Use of outside resources. If the facility does not employ a qualified professional person to render a specific service to be provided by the facility, it makes arrangements to have such a service provided by an outside resource--a person or agency that will render direct service to patients or act as a consultant to the facility. The responsibilities, functions, and objectives, and the terms of agreement, including financial arrangements and charges, of each such outside resource are delineated in writing and signed by an authorized representative of the facility and the person or agency providing the service. Agreements pertaining to services must specify that the facility assumes professional and administrative responsibility for the services rendered. The outside resource, when acting as a consultant, appraises the administrator of recommendations, plans for implementation, and continuing assessment through dated signed reports, which are retained by the administrator for followup action and evaluation of performance. (See requirement under each service--405.1125 through 405.1 1 32.) (j) Standard: Notification of changes in patient status. The facility has appropriate written policies and procedures relating to notification of the patient's attending physician and other responsible persons in the event of an accident involving the patient, or other significant change in the patient's physical, mental, or emotional status, or patient charges, billings, and related administrative matters. Except in a medical emergency, a patient is not transferred or discharged, nor is treatment altered radically, without consultation with the patient or, if he is incompetent, without prior notification of next of kin or sponsor. (k) Standard: Patients' rights. The governing body of the facility establishes written policies regarding the rights and responsibilities of patients and, through the administrator, is responsible for

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260 / APPENDIX B development of, and adherence to, procedures implementing such policies. These policies and procedures are made available to patients, to any guardians, next of kin, sponsoring agency~ies), or representative payees selected pursuant to section 205(j) of the Social Security Act, and Subpart Q of 20 CFR Part 404, and to the public. The staff of the facility is trained and involved in the implementation of these policies and procedures. These patients' rights policies and procedures ensure that, at least, each patient admitted to the facility: (1) Is fully informed, as evidenced by the patient's written acknowledgment, prior to or at the time of admission and during stay, of these rights and of all rules and regulations governing patient conduct and responsibilities; (2) Is fully informed, prior to or at the time of admission and during stay, of services available in the facility, and of related charges including any charges for services not covered under titles XVIII or XIX of the Social Security Act, or not covered by the facility's basic per diem rate; (3) Is fully informed, by a physician, of his medical condition unless medically contraindicated (as documented, by a physician, in his medical record), and is afforded the opportunity to participate in the planning of his medical treatment and to refuse to participate in experimental research; (4) Is transferred or discharged only for medical reasons, or for his welfare or that of other patients, or for nonpayment of his stay (except as prohibited by titles XVIII or XIX or the Social Security Act), and is given reasonable advance notice to ensure orderly transfer or discharge, and such actions are documented in his medical record; (5) Is encouraged and assisted, throughout his period of stay, to exercise his rights as a patient and as a citizen, and to this end may voice grievances and recommend changes in policies and services to facility staff and/or to outside representatives of his choice, free from restraint, interference, coercion, discrimination, or reprisal;

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APPENDIX B / 261 (6) May manage his or her personal financial affairs, may designate another person to manage them, or may authorize the facility, in writing, to hold, safeguard, and account for his or her personal funds in accordance with paragraph (m) of this section. In the event that the Social Security Administration has determined that a Title II or Title XVI (SSI) benefit to which the patient is entitled should be paid through a representative payee, the provisions in 20 CFR 404.1601 through 404.1610 (for OASDI benefits) and 20 CFR 416.601 through 416.690 (for SSI benefits) apply; (7) Is free from mental and physical abuse, and free from chemical and (except in emergencies) physical restraints except as authorized in writing by a physician for a specified and limited period of time, or when necessary to protect the patient from injury to himself or to others; (8) Is assured confidential treatment of his personal and medical records, and may approve or refuse their release to any individual outside the facility, except, in case of his transfer to another health care institution, or as required by law or third-party payment contract; (9) Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs; (10) Is not required to perform services for the facility that are not included for therapeutic purposes in his plan of care; (11) May associate and communicate privately with persons of his choice, and send and receive his personal mail unopened, unless medically contraindicated (as documented by his physician in his medical record); (12) May meet with, and participate in activities of, social, religious, and community groups at his discretion, unless medically contraindicated (as documented by his physician in his medical record); (13) May retain and use his personal clothing and possessions as space permits, unless to do so would infringe upon rights of other patients, and unless

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262 / APPENDIX B medically contraindicated (as documented by his physician in his medical record); and (14) If married, is assured privacy for visits by his/her spouse; if both are inpatients in the facility, they are permitted to share a room, unless medically contraindicated (as documented by the attending physician in the medical record). All rights and responsibilities specified in paragraphs (k)(l) through (4) of this section--as they pertain to (i) a patient adjudicated incompetent in accordance with State law, (ii) a patient who is found, by his physician, to be medically incapable of understanding these rights, or (iii) a patient who exhibits a communication barrier--clevolve to such patient's guardian, next of kin, sponsoring agency~ies), or representative payee (except when the facility itself is representative payee) selected pursuant to section 205(j) of the Social Security Act and Subpart Q of 20 CFR Part 404. (1) Standard: Patient care policies. The skilled nursing facility has written patient care policies to govern the continuing skilled nursing care and related medical or other services provided. (1) The facility has policies, which are developed by the medical director or the organized medical staff (see 405.1122), with the advice of (and with provision for review of such policies from time to time, but at least annually, by a group of professional personnel including one or more physicians and one or more registered nurses, to govern the skilled nursing care and related medical or other services it provides. The policies, which are available to admitting physicians, sponsoring agencies, patients, and the public, reflect awareness of, and provision for, meeting the total medical and psychosocial needs of patients, including admission, transfer, and discharge planning; and the range of services available to patients, including frequency of physician visits by each category of patients

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APPENDIX B / 263 admitted. These policies also include provisions to protect patients' personal and property rights. Medical records and minutes of staff and committee meetings reflect that patient care is being rendered in accordance with the written patient care policies, and that utilization review committee recommendations regarding the policies are reviewed and necessary steps taken to ensure compliance. (2) The medical director or a registered nurse is designated, in writing, to be responsible for the execution of patient care policies. If the responsibility for day-to-day execution of patient care policies has been delegated to a registered nurse, the medical director serves as the advisory physician from whom she receives medical guidance. (See 405.1 1 22(b).) (m) Standard protection of patients' funds. (1) Definition: Representative. "Representative" as used in this paragraph is a patient's legal guardian, conservator, or representative payee as designated by the Social Security Administration, or person designated in writing by the patient to manage his or her personal funds. (2) Statement provided at time of administration. The facility must provide each patient and representative with a written statement, at the time of admission, that: (i) Lists all services provided by the facility, distinguishing between those services included in the facility's basic rate and those services not included in the facility's basic rate, that can be charged to the patient's personal funds; (ii) States that there is no obligation for the patient to deposit funds with the facility; (iii) Describes the patient's right to select how personal funds will be handled.- The following alternatives must be included: (A) The patient's right to receive, retain and manage his or her personal funds or have this done by a legal guardian, if any; (B) The patient's right to apply to the Social Security Administration to have a representative payee designated for purposes of Federal or State benefits to which he or she may be entitled; (C) Except when

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264 / APPENDIX B paragraph (B) of this section applies, the patient's right to designate, in writing, another person to act for the purpose of managing his or her personal funds; and (D) The facility's obligation, upon written authorization by the patient, to hold, safeguard, and account for the patient's personal funds in accordance with this paragraph. (iv) States that any charge for this service is included in the facility's basic rate. (v) States that the facility is permitted to accept a patient's funds to hold, safeguard, and account for, only upon the written authorization of the patient or representative, or if the facility is appointed as the patient's representative payee; (vi) States that, if the patient becomes incapable of managing his or her personal funds and does not have a representative, the facility is required to arrange for the management of his or her personal funds in accordance with paragraph (m)(14) of this section. (3) Basic requirements. The facility must, upon written authorization by the patient, accept responsibility for holding, safeguarding and accounting for the patient's personal funds. The facility may make arrangements with a Federally or State insured banking institution to provide these services but the responsibility for the quality and accuracy of compliance with the requirements of paragraph (m)~4) through (m)~13) of this section remains with the facility. The facility may not charge the patient for these services, but must include any charges in the facility's basic daily rate. (4) Individual records. The facility must maintain current, written, individual records of all financial transactions involving patients' personal funds which the facility has been given for holding, safeguarding, and accounting. The facility must keep these records in accordance with the American Institute of Certified Public Accountants' Generally Accepted Accounting Standards, and the records must include at least the following: (i) Patient's name; (ii) Identification of patient's representative, if

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304 / APPENDIX B essential to assuring ICF services for eligible individuals in the community. 17. Arrangements with outside resources. (a) If the ICF does not employ a qualified professional to furnish a required institutional service, it must have in effect a written agreement with a qualified professional outside the ICF to furnish the required service. (b) The agreement must: (1) Contain the responsibilities, functions, objectives, and other terms agreed to by the ICF and the qualified professional; and (2) Be signed by the administrator or his representative and by the qualified professional. (c) The ICF must maintain effective arrangements with ,.. .. outside resources for promptly providing medical and remedial services required by a resident but not regularly provided within the ICF. 18. Resident record system. (a) The ICF must maintain an organized resident record system that contains a record for each resident. (b) The ICF must make resident records available to staff directly involved with the resident and to appropriate representatives of the Medicaid agency. (c) Each resident's record must contain: (1) Identification information; (2) Admission information, including the medical and social history of the resident; (3) An overall plan of care as described in 442.3 1 9; (4) Copies of the initial and periodic examin- ations, evaluations, progress notes, all plans of care with subsequent changes, and discharge summaries; (5) Description of treatments and services provided and medications administered; and (6) All indications of illness or injury including the date, theme, and action taken regarding each. (d) The ICF must protect the resident records against destruction, loss, and unauthorized use.

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APPENDIX B / 305 (e) The ICF must keep a resident's record for at least 3 years after the date the resident is discharged. 19. Overall plan of care. The overall plan of care required by 442.318 must: (a) Set the goals to be accomplished by the resident; (b) Prescribe an integrated program of activities, therapies, and treatments designed to help each resident achieve his goals; and (c) Indicate which professional service or individual is responsible for each service prescribed in the plan. 20. Resid ent f inancial record s. (a) The ICF must maintain a current, written financial record for each resident that includes written receipts for: (1) All personal possessions and funds received by or deposited with the ICF; and (2) All disbursements made to or for the resident. (b) The financial record must be available to the resident and his family. SAFETY STANDARDS 21. Fire protection. (a) Except as provided in 442.322 and 442.323 and paragraph (b) of this section, the ICF must meet the provisions of the Life Safety Code of the National Fire Protection Association, 1967 edition, that apply to institutional occupancies. (b) If the Secretary finds that the State has a fire and safety code imposed by State law that adequately protects residents in ICF's, the State survey agency may apply the State code for the purposes of the Medicaid certification instead of the Life Safety Code. 22. Fire protection: Exception for smaller ICF's. The State survey agency may apply the lodgings or rooming houses section of the residential occupancy requirements of the Life Safety Code of the National Fire Protection Association, 1967 edition, instead of the institutional

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306 / APPENDIX B occupancy provisions required by 442.321 to an ICF that has 15 beds or less if the ICF is primarily engaged in the treatment of alcoholism and drug abuse and a physician certifies that each resident is: (a) Ambulatory, (b) Engaged in an active program for rehabilitation designed to and reasonably expected to lead to independent living; and (c) Capable of following directions and taking appropriate action for self-preservation under emergency conditions. 23. Fire protection: Waivers. (a) The State survey agency may waive specific provisions of the Life Safety Code required by 442.321, for as long as it considers appropriate, if: (1) The waiver would not adversely affect the health and safety of the residents; (2) Rigid application of specific provisions of the Code would result in unreasonable hardship for the ICF as determined under guidelines contained in the HCFA Long-Term Care Manual; and (3) The waiver is granted in accordance with criteria contained in the Long-Term Care Manual. (b) If the State survey agency waives provisions of the Code for an existing building of two or more stories that is not built of at least 2-hour fire-resistive construction, the ICF may not house a blind, nonambulatory, or physically handicapped resident above the street-level floor unless it is built of: (1) One-hour protected, noncombustible construction as defined in National Fire Protection Association Standard No. 220; (2) Fully sprinklered, 1-hour protected, ordinary construction; or (3) Fully sprinklered, 1-hour protected, wood frame construction. ENVIRONMENTAL AND SANITATION STANDARDS 24. Resident living areas. The ICF must: (a) Design and equip the resident living areas for the comfort and privacy of each resident; and

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APPENDIX B / 307 (b) Have handrails that are firmly attached to the walls in all corridors used by residents. 25. Residents' rooms. (a) Each resident room must: (1) Be equipped with or conveniently located near toilet and bathing facilities; (2) Be at or above grade level; (3) Contain a suitable bed for each resident and other appropriate furniture; Have closet space that provides security and (4) privacy for clothing and personal belongings; (5) Contain no more than four beds (6) Measure at least 100 square feet for a single-resident room or 80 square feet for each resident for a multi-resident room; and (7) Be equipped with a device for calling the staff member on duty. (b) For an existing building, the State survey agency may waive the space and occupancy requirements of paragraphs (a)~5) and (6) of this section for as long as it is considered appropriate if it finds that: (1) The requirements would result in unreasonable hardship on the ICF if strictly enforced; and (2) The waiver serves the particular needs of the residents and does not adversely affect their health and safety. 26. Bathroom facilities. The ICF must: (a) Have toilet and bathing facilities that are located in or near residents' rooms and are appropriate in number, size, and design to meet the needs of the residents; (b) Provide an adequate supply of hot water at all times for resident use; and (c) Have plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by residents. 27. Li''e'' supplies. The ICF must have available at all times enough linen for the proper care and comfort of the residents and have clean linen on each bed.

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308 / APPENDIX B 28. Opera py and isolation areas. (a) The ICF's therapy area must be of sufficient size and appropriate design to: (1) Accommodate the necessary equipment; (2) Conduct an examination; and (3) Provide treatment. (b) The ICF must make provision for isolating residents with infectious diseases. 29. Dining, recreation, and social rooms. (a) The ICF must provide one or more areas, not used for corridor traffic, for dining, recreation, and social activities. (b) A multipurpose room may be used if it is large enough to accommodate all of the activities without their interfering with each other. 30. Building accessibility arid use. (a) The ICF must: (1) Be accessible to and usable by all residents, personnel, and the public, including individuals with disabilities; and (2) Meet the requirements of American National Standards Institute (ANSI) standard No. A117.1 (1961), American standard specifications for making building and facilities accessible to and usable by the physically handicapped. (b) The State survey agency may waive, for as long as it considers appropriate, provisions of ANSI standard No. A117.1 (1961) if: (1) The construction plans for the ICF or a part of it were approved and stamped by the responsible State agency before March 18, 1974; (2) The provisions would result in unreasonable hardship on the ICF if strictly enforced; and (3) The waiver does not adversely affect the - health and safety of the residents. - 3lEAL SERVICE 31. Meal service. The ICF must:

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APPENDIX B / 309 (a) Serve at least three meals or their equivalent each day at regular times, with not more than 14 hours between a substantial evening meal and breakfast; (b) Procure, store, prepare, distribute, and serve all food under sanitary conditions; and (c) Provide special eating equipment and utensils for residents who need them. 32. Menu planning and! supervision. (a) The ICF must have a staff member trained or experienced in food management or nutrition who is responsible for: (1) Planning menus that meet the nutritional needs of each resident, following the orders of the resident's physician and, to the extent medically possible, the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences (Recommended Dietary Allowances (8th ea., 1974) is available from the Printing and Publications Office, National Academy of Sciences, Washington, D.C. 20418~; and (2) Supervising the meal preparation and service to insure that the menu plan is followed. (b) If the ICF has residents who require medically prescribed special diets, the ICF must: (1) Have the menus for those residents planned by a professionally qualified dietitian, or reviewed and approved by the attending physician; and (2) Supervise the preparation and serving of meals to insure that the resident accepts the special diet. (c) The ICF must keep for 30 days a record of each menu as served. lllEDICA TIONS 33. Licensed pharmacist. The ICF must either: (a) employ a licensed pharmacist; or (b) Have a formal arrangement with a licensed pharmacist to advise the ICF on ordering, storage, administration, disposal, and recordkeeping of drugs and biologicals.

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310 / APPENDIX B 34. Orclers for nzealications. (a) The resident's attending or staff physician must order all medications for the resident. (b) The order may be either oral or written. (c) If the order is oral: (1) The physician must give it only to a licensed nurse, pharmacist, or another physician; and (2) The individual receiving the order must record and sign it immediately and have the attending physician sign it in a manner consistent with good medical practice. 35. Met1'ocis to control medication dosage. The ICF must have written policies and procedures for controlling medication dosage, by automatic stop orders or other methods, when the physician does not include in the order a specific limit on the time or number of doses. These procedures must include notice to the attending physician that the medication is being stopped as of a certain date or after a certain number of doses. 36. Review of meclications. (a) A registered nurse must review medications monthly for each resident and notify the physician if changes are appropriate. (b) The attending or staff physician must review the medications quarterly. 37. Administering medications. (a) Before administering any medication to a resident, a staff member must complete a State-approved training program in medication administration. (b) The ICF may allow a resident to give himself a medication only if the attending physician gives ~ permission. HEALTH SERVICES 38. Health services. (a) The ICF must provide for each resident health services that:

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APPENDIXB/311 (1) Meet the requirements of 442.339 through 442.342; and (2) Include treatment, medications, diet, and any other health service prescribed or planned for the resident. (b) The ICF must provide these services 24 hours a day. 39. Supervision. . (a) The ICF must have a registered nurse or a licensed practical or vocational nurse to supervise the ICF's health services full time, 7 days a week, on the day shift. (b) The nurse must have a current license to practice in the State. (c) If the ICF employs a licensed or practical or vocational nurse to supervise health services, the ICF must have a formal contract with a registered nurse to consult with the licensed practical or vocational nurse at regular intervals, but not less than 4 hours each week. (~) To be qualified to serve as a health services supervisor, a licensed practical or vocational nurse must: (1) Be a graduate of a State-approved school of practical nursing; (2) Have education or other training that the State authority responsible for licensing practical nurses considers equal to graduation from a State-approved school of practical nursing; or (3) Have passed the Public Health Service examination for waivered licensed practical or vocational nurses. (e) The ICF may employ as charge nurse an individual who is licensed by the State in a category other than registered nurse or licensed practical or vocational nurse if: (1) The individual has completed a training program to get the license that included at least the same number of classroom and practice hours in all nursing subjects as in the program of a State-approved school of practical or vocational nursing; and

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312 / APPENDIX B (2) The State agency responsible for licensing the individual submits a report to the Medicaid agency comparing State-licensed practical nurse or vocational nurse course requirements with those for the program completed by the individual. 40. 24-hour staffing. The ICF must have responsible staff members on duty and awake 24 hours a day to take prompt, appropriate action in case of injury, illness, fire, or other emergency. 41. Individual health care plan. (a) Appropriate staff must develop and implement a written health care plan for each resident according to the instructions of the attending or staff physician. (b) The plan must be reviewed and revised as needed but at least quarterly. 42. Nursing care. The ICF must provide nursing care for each resident as needed, including restorative nursing care that enables each resident to achieve and maintain the highest possible degree of function, self-care, and independence. OILIER SERVICES 43. Rehabilitative services. (a) The ICF must prov each resident as needed. (b) The ICF must either provide these services itself or arrange for them with qualified outside resources. (c) The rehabilitative services must be designed to: (1) Maintain and improve the resident's ability to function independently; (2) Prevent, as much as possible, advancement of progressive disabilities; and . ide rehabilitative services for (3) Restore maximum function. (d) The rehabilitative services must be provided by: (1) Qualified therapists or qualified assistants, as defined in 42 CFR 405.1101(m), (n), (qj, (r), and (t), in accordance with accepted professional practices; and

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APPENDIX B / 3 1 3 (2) Other supportive personnel under appropriate ~ supervision. (e) The rehabilitative services must be provided under a written plan of care that is: (1) Developed in consultation with the attending physician and, if necessary, an appropriate therapist; and (2) Based on the attending physician's orders and an assessment of the resident's needs. (f) The resident's progress under the plan must be reviewed regularly and the plan must be changed as necessary. 44. Social services. (a) The ICF must provide social services for each resident as needed. (b) The ICF must either provide these services itself or arrange for them with qualified outside resources. (c) The ICF must designate one staff member, qualified by training or experience, to be responsible for: (1) Arranging for social services; and (2) Integrating social services with other elements of the plan of care. (d) These services must be provided under a written plan of care that is: (1) Placed in the resident's record; and (2) Evaluated periodically in conjunction with the resident's overall plan of care. 45. Activities program. The ICF must: (a) Provide an activities program designed to encourage each resident to maintain normal activity and to return to self-care; (b) Designate one staff member, qualified by training or experience in directing group activity, to be responsible for it; (c) Have a plan for independent and group activities for each resident that is: (1) Developed according to his needs and interests; (2) Incorporated in his overall plan of care; (3) Reviewed, with his participation, at least quarterly; and

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314 / APPENDIX B (4) Changed as needed. (~) Provide adequate recreation areas with sufficient equipment and materials to support the program. 46. Physician services. (a) The ICF must have policies and procedures to insure that the health care of each resident is under the continuing supervision of a physician. (b) The physician must see the resident whenever necessary but at least once every 60 days unless the physician decides that this frequency is unnecessary and records the reasons for that decision. C. Standards for Hospitals and SNFs Providing ICF Services (42 CFR 442.254) (a) If a hospital or SNF participating in Medicare or Medicaid is also a provider of ICF services other than ICF/MR services, it must meet the following ICF standards (1) Section 442.304, resident services director. (2) Section 442.317(a), (b), agreements with outside resources for institutional services. (3) Section 442.319, plan of care. (4) Section 442.320, resident financial records. (5) Section 442.324(b), handrails. (6) Sections 442.338 through 442.342, health services. (7) Section 442.343, rehabilitative services. (~) Section 442.344, social services. (9) Section 442.345, activities program. (10) Section 442.346, physician services. (b) If a hospital or SNF participating in Medicare or Medicaid is also a provider of ICF/MR services, it must meet the standards in Subpart G of this part.