100
INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED
(Pertains to sixteen (16) bed or more facilities)
In addition to meeting all standards outlined in Federal
Regulations, Intermediate Care Facilities for the Mentally Retarded must comply
with the following requirements.
200
LICENSURE
Intermediate Care Facilities for the Mentally Retarded
(ICFs/MR), or related institutions, shall be operated, conducted, or maintained
in this State by obtaining a license pursuant to the provisions of these
Licensing Standards. Separate institutions operated by the same management
require separate licenses. Separate licenses are not required for separate
buildings on the same grounds.
Whenever ownership or controlling interest in the operation of
a facility is sold, both the buyer and the seller must notify the Office of
Long Term Care at least thirty (30) days prior to the completed sale. The
thirty (30) day notice shall be the date the paperwork is stamped received by
the Office of Long Term Care.
201
APPLICATION FOR
LICENSE
Applicants for license shall file a notarized application with
the Division upon forms prescribed by the Division and shall pay an annual
license fee determined by multiplying ten dollars ($10.00) by the total
licensed resident beds or a maximum licensed client population. This fee shall
be paid to the State Treasury. If the license is denied, the fee will be
returned to the applicant. Facilities operated by any unit or division of state
or local government shall be exempted from payment of a licensing fee.
Application shall be signed by the owner if individually owned, by one partner
if owned under partnership, by two officers of the board if operated under a
corporation, church or non-profit association, and in case of a governmental
unit, by the head of the governmental entity having jurisdiction over it.
Applicants shall set forth the full name and address of the institutions for
which license is sought, the names of the persons in control, a signed
statement by a registered nurse indicating responsibility for nursing services
of the home, and such other information as the Division may require.
In these instances where a distinct part of a facility is to be
licensed as an Intermediate Care Facility for the Mentally Retarded and the
remainder of the facility is to be licensed under some other category,
separate applications must be filed for each license and separate
licensure fees will be required with each application.
Each facility applying for and receiving a license must furnish
the following information:
* The identity of each person directly or indirectly having an
ownership interest of five (5) percent or more in such facility.
* In case such facility is organized as a corporation or
limited liability corporation (LLC), the identity of each officer and director
of the corporation.
* In case such facility is organized as a partnership, the
identity of each partner.
* Identity of owners of building and equipment leased including
ownership breakdown of leasing entity. For purposes of this section,
equipment leased refers to major equipment, such as
heating/cooling, that is necessary and vital to the operation of the
facility.
202
RENEWAL OF APPLICATION FOR LICENSURE
Application for annual license renewal shall be postmarked or
delivered to the Office of Long Term Care no later than June 1 of the year in
which renewal is sought. Any fee not paid when due shall be delinquent and
shall be subject to assessment of a ten percent (10%) penalty.
203
ISSUANCE OF
LICENSE
License shall be effective on a state fiscal year basis and
shall expire on June 30 of each year. License shall be issued only for the
premises and persons in the application and shall not be assignable or
transferable.
204
DENIAL, REVOCATION, OR SUSPENSION OF LICENSE
The Division is empowered to deny, suspend, or revoke licenses
on any of the following grounds:
204.1
Violation of any of the provisions of Act 28 of 1979 or the rules and
regulations lawfully promulgated hereunder. (Note: The aforementioned act
refers to Title 20, Subtitle 2, Chapter 10 of the Arkansas Code
Annotated.)
204.2 Permitting,
aiding, or abetting the commission of any unlawful act in connection with the
operation of the institution, as defined in these regulations.
204.3 Conduct or practices detrimental to the
health or safety of residents and employees of any such institutions, but this
provision shall not be construed to have any reference to healing practices
authorized by law, as defined in these regulations.
204.4 Failure to comply with the provisions
of Act 58 or 1969 and the rules and regulations promulgated thereunder. (Note:
The aforementioned act requires the licensure of nursing home administrators.)
205
NOTICES AND PROCEDURE ON HEARING PRIOR TO DENIAL, SUSPENSION, OR
REVOCATION OF LICENSE
Whenever the Division decides to deny, suspend, or revoke a
license, it shall send to the applicant or licensee a notice stating the
reasons for the action by certified mail. The applicant or licensee may appeal
such notice to the Long Term Care Facility Advisory Board as permitted by Ark.
Code Ann. §
20-10-301
etseq.
206
APPEALS TO COURTS
Any applicant or licensee who considers himself injured in his
person, business, or property by final agency action shall be entitled to
judicial review thereof. Proceedings for review shall be made by filing a
petition in the Circuit Court of any county in which the petitioner does
business or in the Circuit Court of Pulaski County within thirty (30) days
after service upon the petitioner of the agency's final decision. All petitions
for judicial review shall be in accordance with the Administrative Procedures
Act.
207
PENALTIES
Any person, partnership, association, or corporation,
establishing, conducting, managing, or operating any institution without first
obtaining a license therefor, or who violates any provision of applicable law
or regulations lawfully promulgated shall be guilty of a misdemeanor, and upon
conviction thereof shall be liable to a fine of not less than Twenty-Five
Dollars ($25) nor more than One-Hundred Dollars ($100) for the first offense
and not less than One-Hundred Dollars ($100) nor more than Five-Hundred Dollars
($500) for each subsequent offense, and each day such institution shall operate
after a first conviction shall be considered a subsequent offense.
208
INSPECTION
All institutions to which these rules and regulations apply
shall be subject to inspection for reasonable cause at any time by the
authorized representation of the division.
209
COMPLIANCE
An initial license will not be issued until the applicant has
demonstrated to the satisfaction of the division that the facility is in
substantial compliance with the licensing standards set forth in these
regulations.
210
NONCOMPLIANCE
When noncompliance of the licensing standards are detected
during surveys, licensees will be notified of the violations and will be
requested to provide a plan of correction with a timetable for corrections. The
Office of Long Term Care may impose remedies as set forth in Ark. Code Ann.
§§
20-10-205
and
20-10-206, and
20-10-1004.
211
VOLUNTARY
CLOSURE
Any ICF/MR, or related institution, that voluntarily closes
must meet the regulations for new construction to be eligible for
re-licensure.
212
EXCEPTION TO LICENSING STANDARDS
The Division reserves the right to make temporary exceptions to
these standards where it is determined that the health and welfare of the
community requires the services of the institution. Exceptions will be limited
to unusual circumstances and the safety and well being of the residents will be
carefully evaluated prior to making such exceptions.
Overbeds will be authorized only in cases of emergency. An
emergency exits when it can be demonstrated that the resident's health or
safety would be placed in immediate jeopardy if relocation were not
accomplished. A fire, natural disaster (e.g., tornado, flood, etc.) or other
catastrophic event that necessitates resident relocation will be considered an
emergency. The Office of Long Term Care must be contacted for prior
authorization of the overbed, and all authorizations must be in writing.
300
CHIEF
EXECUTIVE OFFICER
The Chief Executive Officer of the facility must be a licensed
nursing home administrator in Arkansas. In facilities with fifteen (15) beds or
less the administrator may be a QMRP and would not be required to have an
administrator's license if the small facility is a satellite of a larger
facility which has a licensed nursing home administrator.
301
GENERAL
ADMINISTRATION
301.1 There
shall be keys available for all locked doors within the facility. Keys for all
locked doors may be available in the main office or a designated
place.
301.2 All containers of
substances used in the facility shall be legibly and accurately labeled as to
contents.
301.3 Fire extinguishers
shall be adequate, of the correct type, and properly located and
installed.
301.4 Laboratories and
radiological facilities operated in the ICF/MR shall comply with the rules and
regulations for these services as contained in the rules and regulations for
hospitals and related institutions in Arkansas. Pharmacies operated in the
ICF/MR shall be operated in compliance with Arkansas laws and shall be subject
to inspection by personnel from the Division.
302
PERSONNEL
ADMINISTRATION
302.1 A
personnel file shall be maintained for each employee.
302.2 All employees requiring licensure shall
have this licensure verified at appropriate intervals.
302.3 No employee afflicted with a
communicable disease or infected skin lesion shall be permitted to
work.
302.4 All employees and
voluntary workers must have a skin test for tuberculosis and be determined free
of communicable disease prior to employment or service. These personnel shall
have such re-determination annually.
302.5 Written job descriptions shall be
developed for each employee classification and shall include as a minimum
responsibilities and/or actual work to be performed, physical and educational
qualifications, and licensure required.
303
STAFF
DEVELOPMENT
303.1 Job
orientation shall be provided for all personnel to acquaint them with the needs
of the clients, the physical facility, disaster plan, and the employees
specific duties and responsibilities.
303.2 All employees shall be involved in the
continuing education program. Documentation shall be kept of participation in
such continuing education programs.
303.3 Personnel for each shift shall be
trained at least on a quarterly basis in the proper use of all fire
extinguishers and the procedure to follow in the case of fire or explosion.
Tornado drills shall be conducted semi-annually for each shift. Other disaster
drills should be held annually for each shift. A record shall be maintained of
the drills held, and this record shall include the time and date the drill was
held, along with the signatures of all staff participating.
304
REPORTS
A report by telephone or in writing shall be promptly submitted
to the Administrator, Certification Division, Office of Long Term Care, in all
cases of:
(A) fire; (B) damage to the
facility due to any natural disaster; (C) major incidents; (D) any change in
Administrator or Director of Nursing Services; (E) change in ownership; (F) all
cases of reportable disease; and (G) any other unusual occurrence which
threatens the welfare, safety, or health of residents or personnel. Telephone
reports should be followed-up by a written confirmation.
305
INFECTION
CONTROL
Written policies and procedures shall be established for
investigating, controlling, and preventing infections. Procedures shall be
reviewed annually and revised as necessary for effectiveness and improvement.
The policies and procedures shall include as a minimum:
305.1 Aseptic and isolation
techniques.
305.2 Proper disposal
techniques for infected dressing, disposable syringes, needles, etc.
305.3 Prohibiting the use of the common
towel, common bath and hand soap, and the common drinking cup or
glass.
305.4 Proper reporting of
communicable disease.
306
HANDLING OF OXYGEN AND FLAMMABLE GASES
Policies shall be written for the proper handling of oxygen and
flammable gases. There shall also be written procedures for the care of
equipment such as humidifiers, masks, cannulas, etc.
307
TRANSPORTATION OF
CLIENTS
The facility shall establish a written policy regarding
transportation of clients, when necessary, to the hospital, medical clinics,
and dentist offices.
308
PHYSICAL ENVIRONMENT
308.1 New Construction
308.1.1 All new construction shall meet the
following standards outlined in
Part IV of the rules and regulations:
* General.
* Site location, inspection, approvals, and subsoil
investigation.
* Submission of plans, specifications, and estimates.
* Plans and specifications.
* Codes and standards.
308.1.2 Adequate built-in closets shall be
provided in each patient room for storage of clothing and other
possessions.
308.1.3 Each room
shall have direct access to a corridor and outside exposure, with the floor at
or above grade level.
308.1.4
Corridors shall be at least eight (8) feet wide.
308.1.5 Community laundries in new facilities
must provide complete separate (by partition) of the soiled laundry area
(including washer) and the clean laundry area. A lavatory with soap and towel
dispensers must be provided for the staff in each area and a rinsing sink
provided in the soiled laundry area. A linen folding table must be provided in
the clean laundry area.
308.1.6 The
total area set aside for clients' dining and recreation purposes shall not be
less than twenty (20) square feet per bed. The areas shall be well lighted and
well ventilated.
308.1.7 Janitors'
closets shall be provided for each unit. These closets shall be provided with
hot and cold running water, a floor receptor or service sink, and shelves for
the storage of janitorial equipment and supplies. The closets shall be
mechanically ventilated to the outside when janitorial supplies are present;
closets must be kept locked.
308.1.8 Space shall be provided for storage
of soiled linen pending pick up. This dirty linen storage shall be in a
separate room and ventilated to the outside.
308.1.9 Each facility shall have an
electrically-supervised, manually operated fire alarm system in accordance with
Section 6-3, NFPA 101, Life Safety Code Handbook that applies to their
facility. The fire alarm system shall be installed to transmit an alarm
automatically to the fire department that is legally committed to serve the
area in which the facility is located by the most direct and reliable method
approved by the OLTC. An alarm signaling system may be connected to the fire
department by:
* Direct connection to the fire department monitoring
panel.
* Direct connection to the police or sheriffs department
monitoring panel if they do or can do the dispatching of the fire
department.
* Direct connection to the monitoring panel of a twenty-four
(24) hour monitoring service that has a direct telephone line to the fire
department.
* If none of the above are available to a facility, these
regulations will not be enforced in that facility until their fire department
obtains the capability.
308.1.10 The construction and facility
provisions shall comply with the
American National Standards Institute (ANSI) Standard No. (A
117.1).
308.2
Existing Construction
308.2.1 All existing facilities must be
maintained, managed, and equipped to provide adequate care, safety, and
treatment of each resident.
308.2.2
All exterior doors shall be effectively weather-stripped.
308.2.3 Doors which open onto corridors shall
swing into rooms except closet and toilet doors.
308.2.4 Exit doors shall not be locked in
such a way that a key is necessary to open the door from the inside of the
building. A latch or other fastening device on the door shall be provided with
a knob, handle, panic bar, or other simple type of releasing device which is
part of the door handle hardware of which the method of operation is obvious
even in the dark, except with automatic unlocking system connected to the fire
alarm system.
308.2.5 Each client's
room shall have a window not less than one- sixteenth (1/16) of the floor space
or outside door arranged and located so that it can be openable. The window
shall be so located that the patients have an outside view.
308.2.6 Corridors shall be at least six (6)
feet wide.
308.2.7 A well lighted,
clean, orderly, ventilated room or rooms shall be provided for patient
activities and for dining areas. A minimum of twenty (20) square feet per bed
shall be provided for this purpose.
308.2.8 Each client's room shall have an
adequate amount of natural light during the day and have general lighting and
night lighting. Natural lighting shall be augmented when necessary by
artificial illumination.
308.2.9
Approved "exit" lights shall be provided at all exit areas of building housing
thirty (30) people or more.
308.2.10 The facility shall provide an
emergency source of electrical power necessary to protect the health and safety
of the clients in the event the normal electrical supply is interrupted. The
emergency electrical power system must supply power adequate at least for
lighting all means of egress, equipment to maintain fire detection, alarm, and
extinguishing systems.
308.2.11 The
water supply used by the institution shall meet the requirements of the
Department of Health.
308.2.12
There shall be procedures to ensure water to all essential areas in the event
of loss of normal water supply. This may be in the form of a written
agreement.
308.2.13 The water
service shall be brought into the building to comply with the requirements of
the Arkansas State Plumbing Code and shall be free of cross
connections.
308.2.14
Hot Water Heaters
* The hot water heating and storage equipment shall have
sufficient capacity to supply six and one-half (6 1/2) gallons of water at
one-hundred ten (110) degrees F. (forty-three [43] degrees C.) per hour per bed
for institution fixtures; Five (5) gallons at one-hundred eighty (180) degrees
F. ( eighty-two [82] degrees C.) per hour per bed for the laundry; and four (4)
gallons at one-hundred eighty (180) degrees F. (eighty-two [82] degrees C.) per
hour per bed for the kitchen. The water temperature in patient areas shall not
exceed one-hundred ten (110) degrees F. (forty-three [43] degrees C).
* The hot water storage tank, or tanks, shall have a capacity
equal to fifty percent (50%) of heater capacity.
* Tanks and heaters shall be fitted with pressure temperature
relief valves.
* Temperatures of hot water at plumbing fixtures used by
resident shall be automatically regulated by control valves.
* All gas, oil, or coal heaters shall be properly vented to the
outside.
308.2.15
Plumbing and Other Piping Systems
All plumbing systems shall be designed and installed in
accordance with the requirements of Arkansas State Plumbing Code. From the cold
water service and hot water tanks, cold water and hot water mains and branches
shall be run to supply all plumbing fixtures and equipment which require hot
and cold water, or both, for their operation. Pipes shall be sized to supply
hot and cold water to all fixtures with a minimum pressure of fifteen (15)
pounds at the top-floor fixtures' maximum demand periods.
* Any replacement of water closets shall be of the elongated
type, and water closet seats shall be of open-front type.
* Gooseneck spouts shall be used for patients' lavatories and
sinks which may be used for filling pitchers.
* Knee, elbow, wrist, or foot-action faucets shall be used in
treatment rooms.
* Elbow or wrist-action blade handle controls shall be used on
all other lavatories and sinks designated for use by facility employees
(community laundry, kitchen, nurses' station, janitors' closet, clean and dirty
utility rooms.)
* An electrically-operated water fountain of an approved type
shall be so located as to be accessible to patients.
* Back-flow preventers (vacuum breakers) shall be appropriately
installed with any water supply fixture where the end of the outlet may at
times be submerged. Examples of such fixtures are hoses, sprays,
direct-flushing valves, aspirators, and under-rim water supply connections to a
plumbing fixture or receptacle in which the surface of the water in the fixture
or receptacle is exposed at all times to atmospheric pressure.
309
FURNISHINGS, EQUIPMENT, AND SUPPLIES
309.1 Each resident shall be provided with a
rigid single bed in good repair measuring a minimum of thirty-six (36) inches
in width. The beds shall be equipped with a suitable, comfortable pillow and a
comfortable, firm mattress in good repair which is four (4) to five (5) inches
thick and shall be covered with a moisture repellant material. Beds in areas
housing non-ambulatory residents shall be provided with three (3) inch casters
and at least two (2) of the four (4) casters shall be of the locking
type.
309.2 Each resident shall be
provided with appropriate storage space for personal items within his/her
bedroom area.
309.3 Each resident
shall be provided with a comfortable chair at the bedside unless
contraindicated for programmatic reasons.
309.4 Each window shall be provided with
flame-retardant curtains.
309.5 All
wastebaskets shall meet the flame retardant requirements under the NFPA
standards.
310
LINENS AND BEDDING
310.1 A sufficient supply of clean bed linen
shall be available at all times. A minimum of two (2) clean sheets and one (1)
clean pillowcase shall be provided for each bed on a weekly basis. Linens shall
be changed as often as indicated in order to keep the resident clean,
comfortable, and dry.
310.2 Each
bed shall be covered with a suitable bedspread at least during the hours of the
day when the bed is not occupied.
310.3 Sufficient blankets shall be provided
to assure the warmth of each resident and shall be laundered as often as
necessary to assure cleanliness and freedom from odors. The blankets shall be
individually assigned to residents and not passed indiscriminately to residents
without first being laundered.
310.4 Table linens shall be laundered
separately from bed linen and clothing.
311 EQUIPMENT AND
SUPPLIES
Nursing supplies and equipment shall be provided as indicated
to meet the needs of the residents. As a minimum, the following shall be
maintained:
* Items for personal care and grooming
* Individual soap dishes
* Hypodermic syringes and needles
* One oxygen unit
* F orcep s and forcep s j ars
* Enema equipment
* Hot water bottles and ice caps with covers
* Suction machines
* Weight scales
* Flashlight at each station
* Thermometers
* Gloves (non-sterile and sterile)
* A stretcher
* First aid equipment and supplies
* Blood pressure equipment
Thermometers shall be disinfected by a suitable method as
approved by the Office of Long Term Care. A suitable method is to clean the
thermometer thoroughly with soap and water and place in solution of iodine one
percent and isopropyl alcohol for at least ten (10) minutes; rinse thoroughly
with cold water before use. Any other method approved by the Office of Long
Term Care may be used.
312
HOUSEKEEPING/MAINTENANCE
312.1 All rooms and every part of the
building (exterior and interior) shall be kept clean, orderly, and free of
offensive odors. Bath and toilet facilities and all food areas shall be clean
and sanitary at all times.
312.2
Deodorants shall not be used to cover up odors. Odor control shall be achieved
by prompt cleansing and by approved ventilation.
312.3 Attics, cellars, beneath stairs, and
similar areas shall be kept clean of accumulation of refuse, old newspapers,
and discarded furniture.
312.4
Storage areas shall be kept in a safe and neat order.
312.5 Combustibles such as rags and cleaning
compounds and fluids shall be kept in closed metal containers.
312.6 Buildings and grounds shall be kept
free from refuse and litter.
312.7
Adequate storage facilities with proper ventilation shall be provided for
mattresses.
312.8 All useless items
and materials shall be removed from the institution area and
premises.
312.9 Matches and other
flammable, or dangerous, items shall be stored in metal containers with tight
fitting lids.
312.10 Mechanical
rooms, boiler rooms, and similar areas shall not be used for storage
purposes.
312.11 All inside
openings to attics and false ceilings shall be kept closed at all times. The
attic area shall be clear of all storage.
312.12 Mop heads shall be of the removable
type and shall be laundered or replaced at frequent intervals to ensure a
standard of cleanliness.
312.13
Garbage must be kept in substantial containers with tight fitting covers. The
containers must be thoroughly cleaned before reuse. Garbage, or rubbish, and
trash shall be disposed of by incineration, burial, sanitary fill, or approved
method and within a time limit set by the Division. Garbage areas shall be kept
clean and in a state of good repair.
312.14 All poisons, bleaches, detergents, and
disinfectants shall be kept in a safe place accessible only to employees or
clients who use such products under supervision. They shall not be kept in
storage areas or containers previously containing food or medicine.
313
PROFESSIONAL NURSE SUPERVISION
313.1 A registered nurse shall be employed
full-time as the Director of Nursing Services and work on the day
shift.
313.2 The Director of
Nursing Services shall be responsible for the development and maintenance of
nursing service objectives; standards of nursing practice; nursing policy and
procedure manuals; written job descriptions for each level of nursing
personnel; coordination of nursing service with other services; recommending
number and levels of nursing personnel to be employed, and nursing staff
development. The Director of Nursing Services may work in conjunction with an
organized staff development department.
314
TREATMENT AND
MEDICATIONS
314.1 No
medication or treatment shall be given without the written order of the
physician or dentist. Drugs shall be administered in accordance with
orders.
314.2 If it is necessary to
take physician's or dentist's orders over the telephone or verbally, the order
shall be immediately written on the physician's order sheet in the medical
record and signed by the nurse who took the order. Documentation shall include
the name of the physician or dentist who gave the telephone or verbal order and
the date and time of the order. The order shall be countersigned by the
attending physician or dentist on his next regular visit or no more than seven
(7) days from the time the telephone or verbal order was given. There shall be
indication made by the nurse that the orders were transcribed (signature and
time).
314.3 Each resident shall be
identified prior to administration of medication.
314.4 Each resident shall have an individual
medication record.
314.5 The dose
of a drug administered to a resident shall be properly recorded by the person
who administered the drug except in established self-medication
programs.
314.6 Medications shall
be administered only by licensed nursing personnel except in established
self-administration programs.
314.7
Treatment of a lesion or open wound shall be done only by licensed nursing
personnel.
314.8 Medication setups
may be prepared one shift at a time. The medication must be administered on the
same shift on which they are prepared. Liquids and injectables shall not be set
up more than one hour in advance.
314.9 Medications shall be administered by
the same person who prepared the doses for administration, except under single
unit-dose package distribution systems.
314.10 The attending physician shall be
notified of an automatic stop-order prior to the last dose so that the
physician may decide if the administration of the medication is to be continued
or altered.
314.11 There shall be
written policies and procedures for the development of any self-administration
program. These policies must include qualifications of clients to participate
in the program and procedures for monitoring the program.
315
TUBERCULOSIS
SURVEILLANCE
Upon admission to the nursing home, physician orders shall be
obtained to administer a PPD (intermediate strength) tuberculin skin test to
the resident and to repeat in ten (10) to fourteen (14) days if necessary. If
this initial test reacts positively, the physician should be notified and a
chest X-ray obtained and read. The report of this X-ray should be placed on the
resident's chart.
If it is not possible to obtain a chest X-ray, a sputum sample
should be taken and forwarded for culture. If treatment is indicated, orders
are obtained from the attending physician.
If the result of the initial skin test is negative, the skin
test should be repeated in ten (10) to fourteen (14) days. If the result of
this test is positive, the physician should be notified and a chest X-ray or
sputum culture obtained. If treatment is indicated as a result of these tests,
orders are obtained from the attending physician. Once a resident has shown a
positive skin test (regardless of whether or not further testing indicated
treatment), he/she must be re-evaluated yearly. Either a chest X-ray or sputum
culture should be obtained. If neither of these is possible, the resident
should be evaluated for any visible signs of the disease such as productive
cough or weight loss. There should be evidence in the medical record of this
yearly re-evaluation.
If, however, the second skin test after admission is also
negative, there need be no further testing of this resident unless an active
case of tuberculosis is identified in the facility.
The medical record of all residents who have shown a positive
skin test should be flagged to note that this resident does need to be
re-evaluated yearly and that a sputum culture should be obtained following any
pulmonary infection.
316
PHARMACEUTICAL SERVICES
316.1
Responsibility for
Pharmacy Compliance
The Administrator shall be responsible for full compliance with
Federal and state laws governing procurement, control, and administration of
all drugs. Full compliance is expected with the comprehensive Drug Abuse
Prevention and Control Act of 1970, Public Law 91-513, and all amendments to
this set and all regulations and rulings passed down by the Federal Drug
Enforcement Agency (DEA), Arkansas Act No. 590 and all amendments to it and
these rules and regulations.
316.2
Administration of
Medication
316.2.1 No
medication shall be given without a written order by a physician or
dentist.
316.2.2 All medications
shall be given by licensed nursing personnel. The administrator or his
appointed assistant shall be responsible for ensuring that qualified nursing
personnel administer all medications order by a physician or dentist except in
established self-administration programs.
316.2.3 Caution shall be observed in
administering medication so that the exact dosage of the prescribed medication
is given as ordered by the doctor or dentist.
316.2.4 Each resident must have an individual
container, bin, compartment, or drawer for the storage of his medications in
the medication room, unless the unit dose system is employed.
316.2.5 Nursing personnel cannot transfer
more than one dose of medication from container to container. Loading narcotic
counters, preparing take-home supply of medications, incorporating supplies,
etc., by nursing personnel are not permitted.
316.3
Equipment for
Administering Medications
There shall be calibrated medicine containers to correctly
measure liquid medications. Disposable items shall not be reused. Disposable
syringes and needles must be disposed of by breaking and incineration.
316.4
Medicine
Cards
In administering medications, medication cards current with
physician order must be used.
Medicine cards (except in the case of established
self-administration programs) shall be provided to include:
* Name of client
* Location of client
* Medication and Dosage
* Hours to be given
316.5
Stop-Order
Policy
Medications not specifically limited as to time or number of
doses when ordered by the physician shall be controlled by the facility's
policy regarding automatic stop orders.
The facility's automatic stop-order policy, at a minimum, shall
cover the following categories of medications:
* Class II Narcotics
* Class II Non-narcotics
* Class III, Class IV, and Class V medications
* Anticoagulants
* Antibiotics
316.6
Storage of
Drugs
316.6.1 All drugs on
the premises of a nursing home except for the emergency tray as defined by the
Arkansas State Board of Health and the Arkansas State Board of Pharmacy shall
be in a properly labeled container as dispensed upon prescription by the
pharmacy.
316.6.2 All medications
shall be kept in a locked cabinet or locked room at all times. Only the nurse
responsible for administering the medication shall have the key.
316.6.3 All drugs for external use shall be
kept in a safe place accessible only to employees and kept in a special area
apart from other medications and prescriptions.
316.6.4 Medicines requiring cold storage
shall be refrigerated. A locked container placed below food level in a home
refrigerator is considered satisfactory storage space.
316.6.5 Labels should be affixed to the
immediate container. The immediate container is that which is in direct contact
with the drug at all times.
316.6.6
Drug rooms shall be supplied with adequate lighting so that medications can be
safely prepared for administration.
316.6.7 The drug room shall be properly
ventilated so that the temperature requirements set by the U.S.P. are met: 59
degrees F. to 86 degrees F.
316.7
Record of Controlled Drugs
A record shall be kept in a bound ledger book with
consecutively numbered pages of all controlled drugs procured and administered.
This record shall contain on each separate page:
* Name, strength, and quantity of drug received
* Date received
* Patient's name
* Prescribing physician
* Name of pharmacy
* Date and time of dosage given
* Quantity of drug remaining
* Signature of person administering the drug
The person responsible for entering the controlled drug into
the bound ledger should be the same person who signs for it in the drug
ordering and receiving record. This record shall be retained by the facility as
a permanent record and be readily available.
316.8
Controlled Drug
Accountability
There shall be a count of all C II controlled medications at
each change of shift. All C III, IV, and V controlled medication should be
counted at least once daily unless a true unit dose system is used. This
counting shall be made by the off-going charge nurse and the on-coming charge
nurse. If licensed personnel are not available on a shift, a non-licensed
employee can co-sign as a witness with the off-going nurse and co-sign as a
witness again with the on-coming nurse. This counting shall be documented. This
documentation shall include the date and time of the count, a statement as to
whether or not the count was correct, and if it was incorrect, an explanation
of the discrepancy.
This record shall be retained by the facility as a permanent
record and be readily retrievable.
When loss, suspected theft, or an error in the administration
of controlled drugs occurs, it must be reported to the Director of Nursing
Services and an incident report filled out; also, a copy of the form for
reporting theft or loss of controlled substances should be mailed to the
Arkansas Department of Health, Division of Drug Control. All documentation must
be retained in the facility as a permanent record.
316.9
Wasting of
Controlled Drugs
When a dose of a controlled drug is dropped or broken, two (2)
people should make a statement in the bound ledger as to what occurred, and
both must sign their names. These two people shall be licensed nursing
personnel whenever possible.
316.10
Cycle-Fill,
Pharmacy Notification and Disposition of Unused Drugs
Schedule II, III, IV, and V drugs dispensed by prescription for
a patient and no longer needed by the patient must be delivered in person or by
registered mail to: Drug Control Division, Arkansas Department of Health, 4815
West Markham Street, Little Rock, Arkansas 72201 along with Arkansas Department
of Health Form (PHA-DC-1) Report of Drugs Surrendered for Disposition According
to Law. When unused portions of controlled drugs go with a patient who leaves
the facility, the controlled drug record shall be signed by the person who
assumes responsibility for the patient and the person in charge of the
medication in the facility. This shall be done only on the written order of the
physician and at the time the patient is discharged, transferred, or visits
home.
All medications other than Schedule II, III, IV, and V not
taken out of the facility by the patient with the physician's consent when he
is discharged from the facility shall be destroyed. See Section 554.3, below,
on handling medication when a resident enters a hospital or is transferred. All
discontinued medications (except controlled drugs) shall be destroyed on the
premises of the facility. Destruction shall be made by the consultant
pharmacist and a nurse with a record made as to the date, quantity,
prescription number, patient's name, and strength of medications destroyed. The
destruction should be by means of incineration,
garbage disposal, or flushing down the commode. This record
shall be kept in a bound ledger with consecutively numbered pages. This record
shall be retained by the facility as a permanent record and be readily
retrievable.
316.10.1 Only oral solid
medications may be cycle-filled. Provided, however, that if an oral solid
medication meets one of the categories below, then that oral solid medication
may not be cycle-filled.
a. PRN or "as needed"
medications.
b. Controlled drugs
(CII - CV).
c. Refrigerated
medications.
d.
Antibiotics.
e.
Anti-infectives
316.10.2
A facility shall notify the pharmacy in writing of any change of condition that
affects the medication status of a resident. For purposes of this section,
change of condition includes death, discharge or transfer of a
resident, as well as medical changes of condition that necessitate a change to
the medication prescribed or the dosage given. The notification shall be made
within twenty-four (24) hours of the change of condition. If the notification
would occur after 4:30 p.m. Monday through Friday, or would occur on a weekend
or holiday, the facility shall notify the pharmacy by no later than 11:00 a.m.
the next business day. Documentation for drugs ordered, changed or discontinued
shall be retained by the facility for a period of no less than fifteen (15)
months.
316.10.3 When a resident is
transferred or enters a hospital, a facility shall hold all medication until
the return of the resident, unless otherwise directed by the authorized
prescriber. All continued or re-ordered medications will be placed in active
medication cycles upon the return of the resident. If the resident does not
return to the facility, any medications held by the facility shall be placed
with other medications or drugs for destruction or return as permitted by State
Board of Pharmacy regulations.
317
DIETETIC
SERVICES
317.1
Hygiene of Staff
All food service employees shall wear appropriate, light
colored clothing including hairnet and shall keep themselves and their clothing
clean. (Males may wear caps).
All persons working as food handlers in nursing homes shall
have in their possession, or on file in the home in which they are employed, a
currently approved health card.
Persons having symptoms of communicable or infectious diseases
or lesions shall not be allowed to work in the dietetic services. Food service
employees shall not be assigned duties outside dietetic services.
317.2
Frequency
of Meals
317.2.1 At least
three (3) meals are served daily.
317.2.2 The meals shall be served at
approximately the same hours each day.
317.2.3 There shall not be more than fourteen
(14) hours between the availability of a substantial supper and breakfast.
Supper shall include, as a minimum, two (2) ounces of a substantial protein
food, a starch (or substitute) or soup, vegetable or fruit, dessert and
beverage, preferably milk.
317.2.4
Bedtime snacks of nourishing quality shall be routinely offered to all clients
requesting such and whose diets do not prohibit the service of this night
feeding. Milk, juices, cookies, or crackers shall be offered.
317.3
Menus
317.3.1
Menus shall be planned and written two (2) weeks in advance and posted at least
one (1) week in advance. Menus for each level shall be written. Arrows, etc.,
are not acceptable.
317.3.2 Weekly
menus shall not be repeated more often than a three (3) week cycle.
Identical meals shall not be repeated more often than
once every three (3) weeks.
317.3.3
Changes shall be recorded on both the regular and therapeutic diet
menus.
317.3.4 Menus which have
been posted in the kitchen shall not be re-dated and re-used.
317.3.5 Meals served shall correspond
essentially with the posted menus and shall be served in sequential order as
planned and approved by the dietetic services consultant.
317.3.6 Records of menus as served shall be
on file and maintained for thirty (30) days.
317.4
Therapeutic
Diets
317.4.1 There shall
be a system of written communications between dietetic service and nursing
services, i.e., diet order forms. Nursing services should send a written
patient diet list monthly and diet change slips as diets are changed by the
physician.
317.4.2 Therapeutic
diets shall be served only to those patients for whom there is a physician's or
dentist's written order.
317.5
Preparation and
Storage of Food
317.5.1 An
adequately sized storage room shall be provided with adequate shelving.
Seamless containers with tight fitting lids, clearly labeled, shall be provided
for bulk storage of dry foods. (It is recommended that these containers be
placed on dollies for easy moving.) The storage room shall be of such
construction as to prevent the invasion of rodents and insects, the seepage of
dust, water leakage, or any other contamination. The room shall be clean,
orderly, well ventilated, and without condensation of moisture on the walls.
Food in any form shall not be stored on the floor. The bottom shelf shall be
twelve (12) inches above the floor.
317.5.2 All food prepared in the ICF/MR shall
be clean, wholesome, free from spoilage, and so prepared as to be safe for
human consumption. All food stored in the refrigerators shall be stored in
covered containers. Leftover foods shall be labeled and dated with the date of
preparation. Foods stored in freezers shall be wrapped in air-tight packages,
labeled and dated.
317.5.3 Fresh
fruits and vegetables shall be thoroughly washed in clean, safe water before
use. Vegetables subject to dehydration during storage shall be wrapped or
bagged in plastic.
317.5.4 All
readily perishable foods, including eggs or fluids, shall be stored at or below
forty-five (45) degrees F. A reliable and visible thermometer shall be kept in
the refrigerator.
317.5.5 All
frozen foods shall be stored at zero (0) degrees F. or below. A reliable and
visible thermometer shall be kept in the freezer. Frozen foods, which have been
thawed, shall not be refrozen.
317.5.6 Potentially hazardous frozen foods
shall be thawed at refrigerator temperatures of forty-five (45) degrees F. or
below.
317.5.7 Eggs shall be stored
below all other foods. Whole fresh eggs shall not be cracked more than two (2)
hours before use.
317.5.8 All toxic
compounds shall be used with extreme caution and shall be stored in an area
separate from food preparation storage, and service areas.
317.5.9 Work areas and equipment shall be
adequate for the efficient preparation and service of foods.
317.5.10 The use of tobacco in any form is
prohibited where food or drink is prepared, stored, cooked, or where dishes or
pots and pans are washed or stored.
317.5.11 Foods shall be cut, chopped, ground,
or pureed to meet the individual needs of the patient.
317.5.12 If a patient refuses foods served,
substitutes of similar nutritive value shall be prepared and
served.
317.6
Sanitary Conditions
317.6.1 Food shall be procured from sources
approved or considered satisfactory by Federal, State, and Local
authorities.
317.6.2 Floors shall
be cleaned after each meal.
317.6.3
Dishes, silverware, and glasses shall be free of breaks, tarnish, stain,
cracks, and chips. There shall be ample supply to serve all residents.
Residents will be furnished knives, forks, and spoons unless there is
documentation to indicate the resident is incapable of using these
implements.
317.6.4 Vessels used in
preparing, serving, or storing food shall be made of seamless metal or a
non-absorbent material, which can be easily cleaned and shall be used for no
other purpose. Enamelware shall not be used.
317.6.5 Rags from patient bedding, clothing,
or bath shall not be used in dietetic services for any purpose.
317.6.6 Dishes, knives, forks, spoons, and
other utensils used in the preparation and serving of foods must be stored in
such a manner as to be protected from rodents, flies or other insects, dust,
dirt, or other contamination. Silverware shall be stored in a clean container
that can be thoroughly washed and sanitized.
317.6.7 Paper or loose covering shall not be
used on shelves, cabinets, cabinet drawers, refrigerators, or stoves. Storage
cabinets shall be kept clean. Cardboard boxes shall not be saved and used for
the storage of food or articles which were not packed in that original
box.
317.6.8 Hand washing
facilities shall be equipped with blade-action controls and hot and cold water.
Soap and towel dispensers and a step-on trash can shall be located conveniently
to the lavatory. The kitchen lavatory shall be equipped with a goose-necked
spout.
317.7
Dietetic Services Staffing
317.7.1 Staffing will be correlated to the
size of the facility and the total patient meals served.
Facilities with fifty-nine (59) beds or less shall be staffed
at ten (10) minutes for each meal served.
Facility with sixty (60) to eighty (80) beds shall be staffed
at eight and one-half (8.5) minutes for each meal served.
Facilities with eighty-one (81) to one-hundred twenty (120)
beds shall be staffed at six (6) minutes for each meal served.
Facilities with one-hundred twenty-one (121) beds or more shall
be staffed at five and one half (5.5) minutes for each meal served.
317.8 Method for
determining dietary staffing:
# of minutes per meal x 3 = # of minutes per day, # of minutes
per day x # of patients divided by 60 = # of hours required per day.
317.9 Food Service Supervisors in
homes of eighty (80) beds or less may be assigned to duties in the department,
such as cooking, no more than fifty percent (50%) of their total work hours,
but must be allowed adequate time for supervisory tasks. In homes of more than
eighty (80) beds, the food service supervisor may be assigned to duties such as
cooking, no more than twenty-five percent (25%) of their total work hours, but
must be allowed adequate time from these assignments for supervisory
tasks.
317.10 The number of
employees will be rounded off to the nearest whole number.
317.11 If deficiencies are found that
directly relate to shortage of personnel, additional personnel will be
required.
400
INFORMAL DISPUTE RESOLUTIONS (IDR)
When a long term care facility does not agree with deficiencies
cited on a Statement of Deficiencies, the facility may request an IDR meeting
of the deficiencies in lieu of, or in addition to, a formal appeal. The
Informal Dispute Resolution (IDR) process is governed by Act 1108 of 2003,
codified at Ark. Code Ann. §
20-10-1901
etseq.
The request for an informal dispute resolution of deficiencies
does not stay the requirement for submission of an acceptable plan of
correction and allegation of compliance within the required time frame or the
implementation of any remedy, and does not substitute for an appeal.
401
REQUESTING
AN INFORMAL DISPUTE
RESOLUTION
A written request for an informal dispute
resolution must be made to the Arkansas Department of Health, Health Facility
Services, 5800 West 10th, Suite 400, Little Rock, AR 72204 within ten calendar
days of the receipt of the Statement of Deficiencies from the Office of Long
Term Care. The request must:
1. List
all deficiencies the facility wishes to challenge; and,
2. Contain a statement whether the facility
wishes the IDR meeting to be conducted by telephone conference, by record
review, or by a meeting in which the parties appear before the impartial
decision maker.
402
MATTERS WHICH MAY BE HEARD AT IDR
The IDR is limited to deficiencies cited on a Statement of
Deficiencies. Issues that may not be heard at an IDR include, but are not
limited to:
1. The scope and severity
assigned the deficiency by the Office of Long Term Care, unless the scope and
severity allege substandard quality of care or immediate jeopardy;
2. Any remedies imposed;
3. Any alleged failure of the survey team to
comply with a requirement of the survey process;
4. Any alleged inconsistency of the survey
team in citing deficiencies among facilities; and,
5. Any alleged inadequacy or inaccuracy of
the IDR process.
403
APPEALS
If a Medicaid certified facility is not satisfied with the
results of the informal dispute resolution, it may request a hearing before the
Long Term Care Facility Advisory Board within the 60 day time frame for appeal.
If the facility chooses, it may by-pass the informal dispute resolution process
and appeal directly to the board within the 60 day appeal period. Requests must
be submitted in writing to:
Chairman
Long Term Care Facility Advisory Board
P.O. Box 8059, Slot S409
Little Rock, AR 72203-8059
Medicare and Medicare/Medicaid certified facilities may request
a hearing by either the Associate Regional Administrator in the Dallas office
of the Centers for Medicare and Medicaid Services or the Departmental Appeals
Board at the addresses below at any point within the 60 day time frame for
appeals.
HCF-2
Associate Regional Administrator Division of Health Standards
and Quality Centers for Medicare and Medicaid Services 1200 Main Tower Building
Dallas, TX 75202
Department of Health and Human Services Departmental Appeals
Board, MS 6127 Civil Remedies Division 330 Independence Avenue, S.W. Cohen
Building - Room G-644 Washington, D.C. 20201
If the facility chooses to appeal to either of these agencies,
a copy of the appeal should also be forwarded to the OLTC.
500
REPORTING SUSPECTED
ABUSE, NEGLECT, EXPLOITATION, INCIDENTS, ACCIDENTS, DEATHS FROM VIOLENCE AND
MISAPPROPRIATION OF RESIDENT PROPERTY
Pursuant to federal regulation
42 CFR
483.13 (Resident Behavior and Facility
Practices) and state law Ark. Code Ann. §
5-28-101
et
seq. (Abuse of Adults) and 12-12-501et seq. (Child
Maltreatment Act), the facility must develop and implement written policies and
procedures to ensure incidents, including:
* alleged or suspected abuse or neglect of
residents;
* accidents, including accidents resulting in
death;
* unusual deaths or deaths from violence;
* unusual occurrences; and,
* exploitation of residents or any misappropriation of
resident property,
are prohibited, reported, investigated and documented as
required by these regulations.
A facility is not required under this regulation to report
death by natural causes. However, nothing in this regulation negates, waives or
alters the reporting requirements of a facility under other regulations or
statutes.
Facility policies and procedures regarding reporting, as
addressed in these regulations, must be included in orientation training for
all new employees, and must be addressed at least annually
during in-service training for all facility staff.
501
NEXT-BUSINESS-DAY REPORTING OF INCIDENTS
The following events shall be reported to the Office of Long
Term Care by facsimile transmission to telephone number 501-682-8551 of the
completed Incident & Accident Intake Form (Form DMS-7734) no later than
11:00 a.m. on the next business day following discovery by the facility.
a. Any alleged, suspected or witnessed
occurrences of abuse or neglect to residents.
b. Any alleged, suspected or witnessed
occurrence of misappropriation of resident property, or exploitation of a
resident.
c. Any alleged, suspected
or witnessed occurrences of verbal abuse. For purposes of this regulation,
"verbal abuse" means the use of oral, written, or gestured language that
willfully includes disparaging and derogatory terms to residents, or within
their hearing distance, regardless of their age, ability to comprehend, or
disability. Examples of verbal abuse include, but are not limited to: threats
of harm; saying things to frighten a resident, such as telling a resident that
he or she will never be able to see his or her family again.
d. Any alleged, suspected or witnessed
occurrences of sexual abuse to residents by any individual.
In addition to the requirement of a facsimile report by the
next business day on Form DMS-7734, the facility shall complete a Form DMS-762
in accordance with Section 505.
502
INCIDENTS OR
OCCURRENCES THAT REQUIRE INTERNAL REPORTING ONLY - FACSIMILE REPORT OR FORM
DMS-762 NOT REQUIRED.
The following incidents or occurrences shall require the
facility to prepare an internal report only and does not
require a facsimile report (DMS-7734) or form DMS-762 to be made to the
Office of Long Term Care. The internal report shall include all content
specified in Section 503, as applicable. Nursing facilities must maintain these
incident record files in a manner that allows verification of compliance with
this provision.
a. Incidents where a
resident attempts to cause physical injury to another resident without
resultant injury. The facility shall maintain written reports on these types of
incidents to document "patterns" of behavior for subsequent actions.
b. All cases of reportable disease, as
required by the Arkansas Department of Health.
c. Loss of heating, air conditioning or fire
alarm system of greater than two (2) hours duration.
503
INTERNAL-ONLY
REPORTING PROCEDURE
Written reports of all incidents and accidents included in
section 502 shall be completed within five (5) days after discovery. The
written incident and accident reports shall be comprised of all information
specified in forms DMS-7734 and 762 as applicable.
All written reports will be reviewed, initialed and dated by
the facility administrator or designee within five (5) days after discovery.
All reports involving accident or injury to residents will also be reviewed,
initialed and dated by the Director of Nursing Services or other facility
R.N.
Reports of incidents specified in Section 502 will be
maintained in the facility only and are not required to be
submitted to the Office of Long Term Care.
All written incident and accident reports shall be maintained
on file in the facility for a period of three (3) years.
504
OTHER REPORTING
REQUIREMENTS
The facility's administrator is also required to make any other
reports of incidents, accidents, suspected abuse or neglect, actual or
suspected criminal conduct, etc. as required by state and federal laws and
regulations.
505
ABUSE INVESTIGATION REPORT
The facility must ensure that all alleged or suspected
incidents involving resident abuse, exploitation, neglect or misappropriations
of resident property are thoroughly investigated. The facility's investigation
must be in conformance with the process and documentation requirements
specified on the form designated by the Office of Long Term Care, Form DMS-762,
and must prevent further potential incidents while the investigation is in
progress.
The results of all investigations must be reported to the
facility's administrator, or designated representative, and to other officials
in accordance with state law, including the Office of Long Term Care. Reports
to the Office of Long Term Care shall be made via facsimile transmission by
11:00 a.m. the next business day following discovery by the facility, on form
DMS-7734. The follow-up investigation report, made on form DMS-762, shall be
submitted to the Office of Long Term Care within 5 working days of
the date of the submission of the DMS-7734 to the Office of Long Term Care. If
the alleged violation is verified, appropriate corrective action must be
taken.
The DMS-762 may be amended and re-submitted at any time
circumstances require.
506
REPORTING SUSPECTED ABUSE OR NEGLECT
The facility's written policies and procedures shall include,
at a minimum, requirements specified in this section.
506.1 The requirement that the facility's
administrator or his or her designated agent immediately reports all cases of
suspected abuse or neglect of residents of a long-term care facility as
specified below:
a. Suspected abuse or neglect
of an adult (18 years old or older) shall be reported to the local law
enforcement agency in which the facility is located, as required by Arkansas
Code Annotated 5-28-203(b).
b.
Suspected abuse or neglect of a child (under 18 years of age) shall be reported
to the local law enforcement agency and to the central intake unit of the
Department of Human Services, as required by Act 1208 of 1991. Central intake
may be notified by telephone at 1-800-482 -5964.
506.2 The requirement that the facility's
administrator or his or her designated agent report suspected abuse or neglect
to the Office of Long Term Care as specified in this regulation.
506.3 The requirement that facility
personnel, including but not limited to, licensed nurses, nursing assistants,
physicians, social workers, mental health professionals and other employees in
the facility who have reasonable cause to suspect that a resident has been
subjected to conditions or circumstances which have or could have resulted in
abuse or neglect are required to immediately notify the facility administrator
or his or her designated agent.
506.4 The requirement that, upon hiring, each
facility employee be given a copy of the abuse or neglect reporting and
prevention policies and procedures and sign a statement that the policies and
procedures have been received and read. The statement shall be filed in the
employee's personnel file.
506.5
The requirement that all facility personnel receive annual, in-service training
in identifying, reporting and preventing suspected abuse/neglect, and that the
facility develops and maintains policies and procedures for the prevention of
abuse and neglect, and accidents. The policy shall also require that
documentation of training must be maintained by the facility.
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OLTC INCIDENT AND ACCIDENT REPORT (I&
A)
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Facility Investigation Report for Resident Abuse,
Neglect Misappropriation of Property, & Exploitation of Residents in Long
Term Care Facilities
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Section
I
l-Complete Description of Incident "See
Attached Is Not Acceptable! "
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Section
III - Findings and Actions Taken Please include Resident's current
medical condition
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Section
IV - Notification/ Status Administrator/Written Designee Must Be
Notified!
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Section
VI -Accused Party Information
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Facility Investigation Report for Resident Abuse.
Neglect. Misappropriation of Property. & Exploitation of Residents in Long
Term Care Facilities
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