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OCR for page 254
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
OCR for page 255
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
OCR for page 256
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
OCR for page 257
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.
OCR for page 258
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,
OCR for page 259
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
OCR for page 260
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;
OCR for page 261
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
OCR for page 262
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
OCR for page 263
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
OCR for page 264
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
OCR for page 304
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.
OCR for page 305
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
OCR for page 306
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
OCR for page 307
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.
OCR for page 308
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:
OCR for page 309
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.
OCR for page 310
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.
Representative terms from entire chapter:
nursing facility
