Kan. Admin. Regs. § 28-39-163 - Administration
Each nursing facility shall be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
(a) Governing body.
(1) Each facility shall have a governing body
or shall designate a group of people to function as a governing body. The
governing body shall be legally responsible for establishing and implementing
policies regarding the management and operation of the facility.
(2) The governing body shall appoint an
administrator who meets the following criteria:
(A) Is licensed by the state; and
(B) has full authority and responsibility for
the operation of the facility and compliance with licensing requirements.
(3) The licensee shall
adopt a written position description for the administrator that includes
responsibility for the following:
(A)
Planning, organizing, and directing the operation of the facility;
(B) implementing operational policies and
procedures for the facility; and
(C) authorizing, in writing, a responsible
employee 18 years old or older to act on the administrator's behalf in the
administrator's absence.
(4) Each facility may request approval from
the department for an administrator to supervise more than one nursing
facility. Each request shall be submitted, in writing, by the governing bodies
of the facilities on a form approved by the department. Each facility shall
meet all of the following conditions:
(A) The
facilities are in a proximate location that would facilitate on-site
supervision daily, if needed.
(B)
The combined resident capacity does not exceed 120 residents.
(C) The administrator appointed to operate
the facilities has had at least two years of experience as an administrator of
a nursing facility and has demonstrated the ability to assure the health and
safety of residents.
(D) When a
change in administrator occurs, the facilities submit the credentials of the
proposed new administrator for approval by the department.
(b) Policies and
procedures.
(1) Each licensee shall adopt and
enforce written policies and procedures to ensure all of the following:
(A) Each resident attains or maintains the
highest practicable physical, mental, and psychosocial well-being.
(B) Each resident is protected from abuse,
neglect, and exploitation.
(C) The
rights of residents are proactively assured.
(2) The facility shall revise all policies
and procedures as necessary and shall review all policies and procedures at
least annually.
(3) Policies and
procedures shall be available to staff at all times. Policies and procedures
shall be available, on request, to any person during normal business hours. The
facility shall post a notice of availability in a readily accessible place for
residents.
(c) Power of
attorney and guardianship. Anyone employed by or having a financial interest in
the facility, unless the person is related by marriage or blood within the
second degree to the resident, shall not accept a power of attorney, a durable
power of attorney for health care decisions, guardianship, or conservatorship.
(d) Reports. Each administrator
shall submit to the licensing agency, not later than 10 days following the
period covered, a semiannual report of residents and employees. The
administrator shall submit the report on forms provided by the licensing
agency. The administrator shall submit any other reports as required by the
licensing agency.
(e) Telephone.
The facility shall maintain at least one non-coin-operated telephone accessible
to residents and employees on each nursing unit for use in emergencies. The
facility shall post adjacent to this telephone the names and telephone numbers
of persons or places commonly required in emergencies.
(f) Smoking. If smoking is permitted, there
shall be designated smoking areas.
(1) The
designated areas shall not infringe on the rights of nonsmokers to reside in a
smoke-free environment.
(2) The
facility shall provide areas designated as smoking areas both inside and
outside the building.
(g) Staff development and personnel policies.
The facility shall provide regular performance review and in-service education
of all employees to ensure that the services and procedures assist residents to
attain and maintain their highest practicable level of physical, mental, and
psychosocial functioning.
(1) The facility
shall regularly conduct and document an orientation program for all new
employees.
(2) Orientation of
direct care staff shall include review of the facility's policies and
procedures and evaluation of the competency of the direct care staff to perform
assigned procedures safely and competently.
(3) The facility shall provide regular,
planned in-service education for all staff.
(A) The in-service program shall provide all
employees with training in fire prevention and safety, disaster procedures,
accident prevention, resident rights, psychosocial needs of residents, and
infection control.
(B) The
facility shall provide direct care staff with in-service education in
techniques that assist residents to function at their highest practicable
physical, mental, and psychosocial level.
(C) Direct care staff shall participate in at
least 12 hours of in-service education each year. All other staff shall
participate in at least eight hours of in-service education each year.
(D) The facility shall maintain
documentation of in-service education offerings. Documentation shall include a
content outline, resume of the presenter, and record of staff in attendance.
(E) The facility shall record
attendance at in-service education in the employee record of each staff member.
(h)
Professional staff qualifications.
(1) The
facility shall employ on a full-time, part-time, or consultant basis any
professionals necessary to carry out the requirements of these regulations.
(2) The facility shall document
evidence of licensure, certification, or registration of full-time, part-time,
and consultant professional staff in employee records.
(3) The facility shall perform a health
screening, including tuberculosis testing, on each employee before employment
or not later than seven days after employment.
(i) Use of outside resources. Arrangements or
agreements pertaining to services furnished by outside resources shall specify
in writing that the facility assumes responsibility for the following:
(1) Obtaining services that meet professional
standards and principles that apply to professionals providing services; and
(2) assuring the timeliness of the
services.
(j) Medical
director.
(1) The facility shall designate a
physician to serve as medical director.
(2) The medical director shall be responsible
for the following:
(A) Implementation of
resident care policies reflecting accepted standards of practice;
(B) coordination of medical care in the
facility; and
(C) provision of
consultation to the facility staff on issues related to the medical care of
residents.
(k) Laboratory services. The facility shall
provide or obtain clinical laboratory services to meet the needs of its
residents. The facility shall be responsible for the quality and timeliness of
the services.
(1) If the facility provides
its own clinical laboratory services, it shall meet all of the following
requirements:
(A) The services shall meet
applicable statutory and regulatory requirements for a clinical laboratory.
(B) The facility staff shall
follow manufacturer's instructions for performance of the test.
(C) The facility shall maintain a record of
all controls performed and all results of tests performed on residents.
(D) The facility shall ensure that
staff who perform laboratory tests do so in a competent and accurate manner.
(2) If the facility
does not provide the laboratory services needed by its residents, the facility
shall have written arrangements for obtaining these services from a laboratory
as required in 42 CFR
483.75(j), as published on
October 1, 1993, and hereby adopted by reference.
(3) All laboratory services shall be provided
only on the order of a physician.
(4) The facility shall ensure that the
physician ordering the laboratory service is notified promptly of the findings.
(5) The facility shall ensure that
the signed and dated clinical reports of the laboratory findings are documented
in each resident's clinical record.
(6) The facility shall assist the resident,
if necessary, in arranging transportation to and from the source of laboratory
services.
(l) Radiology
and other diagnostic services. The facility shall provide or obtain radiology
and other diagnostic services to meet the needs of its residents.
(1) If the facility provides its own
radiology and diagnostic services, the services shall meet applicable statutory
and regulatory requirements for radiology and other diagnostic services.
(2) If the facility does not
provide the radiology and diagnostic services needed by its residents, the
facility shall have written arrangements for obtaining these services from a
licensed provider or supplier.
(3)
All radiology and diagnostic services shall be provided only on the order of a
physician.
(4) The facility shall
ensure that the physician ordering the radiology or diagnostic services is
notified promptly of the findings.
(5) The facility shall document signed and
dated clinical reports of the radiological or diagnostic findings in the
resident's clinical record.
(6)
The facility shall assist the resident, if necessary, in arranging
transportation to and from the source of radiology or diagnostic services.
(m) Clinical records.
(1) The facility shall maintain clinical
records on each resident in accordance with accepted professional standards and
practices. The records shall meet the following criteria:
(A) Be complete;
(B) be accurately documented; and
(C) be systematically organized.
(2) Clinical records shall be
retained according to the following schedule:
(A) At least five years following the
discharge or death of a resident; or
(B) for a minor, five years after the
resident reaches 18 years of age.
(3) Resident records shall be the property of
the facility.
(4) The facility
shall keep confidential all information in the resident's records, regardless
of the form or storage method of the records, except when release is required
by any of the following:
(A) Transfer to
another health care institution;
(B) law;
(C) third party payment contract;
(D) the resident or legal representative; or
(E) in the case of a deceased
resident, the executor of the resident's estate, or the resident's spouse,
adult child, parent, or adult brother or sister.
(5) The facility shall safeguard clinical
record information against loss, destruction, fire, theft, and unauthorized
use.
(6) The clinical record shall
contain the following:
(A) Sufficient
information to identify the resident;
(B) a record of the resident's assessments;
(C) admission information;
(D) the plan of care and services
provided;
(E) a discharge summary
or report from the attending physician and a transfer form after a resident is
hospitalized or transferred from another health care institution;
(F) physician's orders;
(G) medical history;
(H) reports of treatments and services
provided by facility staff and consultants;
(I) records of drugs, biologicals, and
treatments administered; and
(J)
documentation of all incidents, symptoms, and other indications of illness or
injury, including the date, the time of occurrence, the action taken, and the
results of action.
(7)
The physician shall sign all documentation entered or directed to be entered in
the clinical record by the physician.
(8) Documentation by direct care staff shall
meet the following criteria:
(A) List drugs,
biologicals, and treatments administered to each resident;
(B) be an accurate and functional
representation of the actual experience of the resident in the facility;
(C) be written in chronological
order and signed and dated by the staff person making the entry;
(D) include the resident's response to
changes in condition with follow-up documentation describing the resident's
response to the interventions provided;
(E) not include erasures or use of white-out.
Each error shall be lined through and the word "error" added. The staff person
making the correction shall sign and date the error. An entry shall not be
recopied; and
(F) in the case of
computerized resident records, include a system to ensure that when an error in
documentation occurs, the original entry is maintained and the person making
the correction enters the date and that person's electronic signature in the
record.
(9) Clinical
record staff.
(A) The facility shall assign
overall supervisory responsibility for maintaining the residents' clinical
records to a specific staff person.
(B) The facility shall maintain clinical
records in a manner consistent with current standards of practice.
(C) If the clinical record supervisor is not
a qualified medical record practitioner, the facility shall provide
consultation through a written agreement with a qualified medical record
practitioner.
(n) Disaster and emergency preparedness.
(1) The facility shall have a detailed
written emergency management plan to meet potential emergencies and disasters,
including, fire, flood, severe weather, tornado, explosion, natural gas leak,
lack of electrical or water service, and missing residents.
(2) The plan shall be coordinated with area
governmental agencies.
(3) The
plan shall include written agreements with agencies that will provide needed
services, including providing a fresh water supply, evacuation site, and
transportation of residents to an evacuation site.
(4) The facility shall ensure disaster and
emergency preparedness by the following means:
(A) Orienting new employees at the time of
employment to the facility's emergency management plan;
(B) periodically reviewing the plan with
employees; and
(C) annually
carrying out a tornado or disaster drill with staff and residents.
(5) The emergency management plan
shall be available to staff, residents, and visitors.
(o) Transfer agreement. The facility shall
have in effect a written transfer agreement with one or more hospitals that
reasonably assures both of the following:
(1)
Residents will be transferred from the facility to the hospital, and timely
admitted to the hospital, when transfer is medically appropriate, as determined
by the attending physician.
(2)
medical and other information needed for care and treatment of residents will
be exchanged between the institutions.
(p) Quality assessment and assurance.
(1) The facility shall maintain a quality
assessment and assurance committee consisting of these individuals:
(A) The director of nursing services;
(B) a physician designated by the
facility; and
(C) at least three
other members of the facility's staff.
(2) The quality assessment and assurance
committee shall perform the following:
(A)
Meet at least quarterly to identify issues with respect to what quality
assessment and assurance activities are necessary; and
(B) develop and implement appropriate plans
of action to correct identified quality deficiencies and prevent potential
quality deficiencies.
Notes
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No prior version found.