Kenneth Vercammen Law Office. 732-572-0500. Edison, NJ.
Kenneth Vercammen, Esq is Chair of the ABA Elder Law Committee and presents seminars to attorneys and the public on Wills, Probate and other legal topics related to Estate Planning and Elder law. He is author of the ABA's book "Wills and Estate Administration. Kenneth Vercammen & Associates, 2053 Woodbridge Avenue - Edison, NJ 08817 (732) 572-0500 More information at www.njlaws.com/
(a)Provision of services.If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and intellectual disability, are required in the resident's comprehensive plan of care, the facility must—
(1)Provide the required services; or
(2)Obtain the required services from an outside resource (in accordance with § 483.75(h) of this part) from a provider of specialized rehabilitative services.
(b)Qualifications.Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel.
[56 FR 48875, Sept. 26, 1991, as amended at 57 FR 43925, Sept. 23, 1992]
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician.
(a)Physician supervision.The facility must ensure that—
(1)The medical care of each resident is supervised by a physician; and
(2)Another physician supervises the medical care of residents when their attending physician is unavailable.
(b)Physician visits.The physician must—
(1)Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;
(2)Write, sign, and date progress notes at each visit; and
(3)Sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
(c)Frequency of physician visits.
(1)The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.
(2)A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.
(3)Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.
(4)At the option of the physician, required visits in SNFs after the initial visit may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist in accordance with paragraph (e) of this section.
(d)Availability of physicians for emergency care.The facility must provide or arrange for the provision of physician services 24 hours a day, in case of an emergency.
(e)Physician delegation of tasks in SNFs.
(1)Except as specified in paragraph (e)(2) of this section, a physician may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist who—
(i)Meets the applicable definition in § 491.2 of this chapter or, in the case of a clinical nurse specialist, is licensed as such by the State;
(ii)Is acting within the scope of practice as defined by State law; and
(iii)Is under the supervision of the physician.
(2)A physician may not delegate a task when the regulations specify that the physician must perform it personally, or when the delegation is prohibited under State law or by the facility's own policies.
(f)Performance of physician tasks in NFs.At the option of the State, any required physician task in a NF (including tasks which the regulations specify must be performed personally by the physician) may also be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility but who is working in collaboration with a physician.
[56 FR 48875, Sept. 26, 1991, as amended at 67 FR 61814, Oct. 2, 2002]
The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.
(a)Staffing.The facility must employ a qualified dietitian either full-time, part-time, or on a consultant basis.
(1)If a qualified dietitian is not employed full-time, the facility must designate a person to serve as the director of food service who receives frequently scheduled consultation from a qualified dietitian.
(2)A qualified dietitian is one who is qualified based upon either registration by the Commission on Dietetic Registration of the American Dietetic Association, or on the basis of education, training, or experience in identification of dietary needs, planning, and implementation of dietary programs.
(b)Sufficient staff.The facility must employ sufficient support personnel competent to carry out the functions of the dietary service.
(c)Menus and nutritional adequacy.Menus must—
(1)Meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences;
(2)Be prepared in advance; and
(d)Food.Each resident receives and the facility provides—
(1)Food prepared by methods that conserve nutritive value, flavor, and appearance;
(2)Food that is palatable, attractive, and at the proper temperature;
(3)Food prepared in a form designed to meet individual needs; and
(4)Substitutes offered of similar nutritive value to residents who refuse food served.
(e)Therapeutic diets.Therapeutic diets must be prescribed by the attending physician.
(f)Frequency of meals.
(1)Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community.
(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided in (4) below.
(3)The facility must offer snacks at bedtime daily.
(4)When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, and a nourishing snack is served.
(g)Assistive devices.The facility must provide special eating equipment and utensils for residents who need them.
(h)Paid feeding assistants—
(1)State-approved training course.A facility may use a paid feeding assistant, as defined in § 488.301 of this chapter, if—
(i)The feeding assistant has successfully completed a State-approved training course that meets the requirements of § 483.160 before feeding residents; and
(ii)The use of feeding assistants is consistent with State law.
(i)A feeding assistant must work under the supervision of a registered nurse (RN) or licensed practical nurse (LPN).
(ii)In an emergency, a feeding assistant must call a supervisory nurse for help on the resident call system.
(3)Resident selection criteria.
(i)A facility must ensure that a feeding assistant feeds only residents who have no complicated feeding problems.
(ii)Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings.
(iii)The facility must base resident selection on the charge nurse's assessment and the resident's latest assessment and plan of care.
(i)Sanitary conditions.The facility must—
(1)Procure food from sources approved or considered satisfactory by Federal, State, or local authorities;
(2)Store, prepare, distribute, and serve food under sanitary conditions; and
(3)Dispose of garbage and refuse properly.
[56 FR 48874, Sept. 26, 1991, as amended at 68 FR 55539, Sept. 26, 2003]
The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.
(1)The facility must 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:
(i)Except when waived under paragraph (c) of this section, licensed nurses; and
(ii)Other nursing personnel.
(2)Except when waived under paragraph (c) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
(1)Except when waived under paragraph (c) or (d) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
(2)Except when waived under paragraph (c) or (d) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis.
(3)The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
(c)Nursing facilities: Waiver of requirement to provide licensed nurses on a 24-hour basis.To the extent that a facility is unable to meet the requirements of paragraphs (a)(2) and (b)(1) of this section, a State may waive such requirements with respect to the facility if—
(1)The facility demonstrates to the satisfaction of the State that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel;
(2)The State determines that a waiver of the requirement will not endanger the health or safety of individuals staying in the facility;
(3)The State finds that, for any periods in which licensed nursing services are not available, a registered nurse or a physician is obligated to respond immediately to telephone calls from the facility;
(4)A waiver granted under the conditions listed in paragraph (c) of this section is subject to annual State review;
(5)In granting or renewing a waiver, a facility may be required by the State to use other qualified, licensed personnel;
(6)The State agency granting a waiver of such requirements provides notice of the waiver to the State long term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965) and the protection and advocacy system in the State for the mentally ill and mentally retarded; and
(7)The nursing facility that is granted such a waiver by a State notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver.
(d)SNFs: Waiver of the requirement to provide services of a registered nurse for more than 40 hours a week.
(1)The Secretary may waive the requirement that a SNF provide the services of a registered nurse for more than 40 hours a week, including a director of nursing specified in paragraph (b) of this section, if the Secretary finds that—
(i)The facility is located in a rural area and the supply of skilled nursing facility services in the area is not sufficient to meet the needs of individuals residing in the area;
(ii)The facility has one full-time registered nurse who is regularly on duty at the facility 40 hours a week; and
(iii)The facility either—
(A)Has only patients whose physicians have indicated (through physicians' orders or admission notes) that they do not require the services of a registered nurse or a physician for a 48-hours period, or
(B)Has made arrangements for a registered nurse or a physician to spend time at the facility, as determined necessary by the physician, to provide necessary skilled nursing services on days when the regular full-time registered nurse is not on duty;
(iv)The Secretary provides notice of the waiver to the State long term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965) and the protection and advocacy system in the State for the mentally ill and mentally retarded; and
(v)The facility that is granted such a waiver notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver.
(2)A waiver of the registered nurse requirement under paragraph (d)(1) of this section is subject to annual renewal by the Secretary.
(e)Nurse staffing information—
(1)Data requirements.The facility must post the following information on a daily basis:
(ii)The current date.
(iii)The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(B)Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C)Certified nurse aides.
(i)The facility must post the nurse staffing data specified in paragraph (e)(1) of this section on a daily basis at the beginning of each shift.
(ii)Data must be posted as follows:
(A)Clear and readable format.
(B)In a prominent place readily accessible to residents and visitors.
(3)Public access to posted nurse staffing data.The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.
(4)Facility data retention requirements.The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
(a)Activities of daily living.Based on the comprehensive assessment of a resident, the facility must ensure that—
(1)A resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to—
(i)Bathe, dress, and groom;
(ii)Transfer and ambulate;
(v)Use speech, language, or other functional communication systems.
(2)A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section; and
(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.
(b)Vision and hearing.To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident—
(1)In making appointments, and
(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.
(c)Pressure sores.Based on the comprehensive assessment of a resident, the facility must ensure that—
(1)A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and
(2)A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
(d)Urinary Incontinence.Based on the resident's comprehensive assessment, the facility must ensure that—
(1)A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and
(2)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.
(e)Range of motion.Based on the comprehensive assessment of a resident, the facility must ensure that—
(1)A resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and
(2)A resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
(f)Mental and Psychosocial functioning.Based on the comprehensive assessment of a resident, the facility must ensure that—
(1)A resident who displays mental or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem, and
(2)A resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that such a pattern was unavoidable.
(g)Naso-gastric tubes.Based on the comprehensive assessment of a resident, the facility must ensure that—
(1)A resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident's clinical condition demonstrates that use of a naso-gastric tube was unavoidable; and
(2)A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.
(h)Accidents.The facility must ensure that—
(1)The resident environment remains as free of accident hazards as is possible; and
(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
(i)Nutrition.Based on a resident's comprehensive assessment, the facility must ensure that a resident—
(1)Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and
(2)Receives a therapeutic diet when there is a nutritional problem.
(j)Hydration.The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.
(k)Special needs.The facility must ensure that residents receive proper treatment and care for the following special services:
(2)Parenteral and enteral fluids;
(3)Colostomy, ureterostomy, or ileostomy care;
(7)Foot care; and
(1)General.Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
(i)In excessive dose (including duplicate drug therapy); or
(ii)For excessive duration; or
(iii)Without adequate monitoring; or
(iv)Without adequate indications for its use; or
(v)In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(vi)Any combinations of the reasons above.
(2)Antipsychotic Drugs.Based on a comprehensive assessment of a resident, the facility must ensure that—
(i)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; and
(ii)Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
(m)Medication Errors.The facility must ensure that—
(1)It is free of medication error rates of five percent or greater; and
(2)Residents are free of any significant medication errors.
(n)Influenza and pneumococcal immunizations—
(1)Influenza.The facility must develop policies and procedures that ensure that—
(i)Before offering the influenza immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization;
(ii)Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii)The resident or the resident's legal representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A)That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B)That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.
(2)Pneumococcal disease.The facility must develop policies and procedures that ensure that—
(i)Before offering the pneumococcal immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization;
(ii)Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii)The resident or the resident's legal representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A)That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B)That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
(v)Exception.As an alternative, based on an assessment and practitioner recommendation, a second pneumococcal immunization may be given after 5 years following the first pneumococcal immunization, unless medically contraindicated or the resident or the resident's legal representative refuses the second immunization.
Kenneth Vercammen, Esq is Chair of the ABA Elder Law Committee and presents seminars to attorneys and the public on Wills, Probate and other legal topics related to Estate Planning and Elder law. Kenneth Vercammen is a Middlesex County trial attorney who has published 130 articles in national and New Jersey publications. He was awarded the NJ State State Bar Municipal Court Practitioner of the Year.He will be lecturing at the 2008 ABA Annual Meeting.