W. Va. Code R. § 64-75-7 - Health Care Standards

7.1. Admission

7.1.a. Only self-preservation individuals shall be admitted. The resident record shall include documented certification by a physician or psychologist that the resident is capable of self-preservation by virtue of his or her ability to follow directions and, with prompting if necessary, to take appropriate action for self-preservation under emergency conditions, except as provided in this section. The certification shall be updated as indicated by changes in the resident's physical or mental condition. (Class II)

7.1.b. Individuals admitted may be in need of personal assistance in activities of daily living, in need of supervision because of mental or physical impairment, or have limited and intermittent nursing care needs. (Class II)

7.1.c. Individuals requiring ongoing or extensive nursing services shall not be admitted. (Class II)

7.1.d. Individuals requiring a level of service for which the residential care community is not licensed or does not provide shall not be admitted. (Class I)

7.2. Retention of Residents Whose Condition and Functional Ability Declines After Admission.

7.2.a. In a residential care community, individuals who qualify for and are receiving services coordinated by a licensed hospice may receive these services, except that services utilizing equipment which requires auxiliary electrical power in the event of a power failure, such as suction apparatus, and intravenous or tube feeding pumps, shall not be used unless the residential care community has a backup power generator. In the event that a resident is receiving limited or intermittent nursing care or hospice services, the licensee shall assure that the resident has privacy in care and the ability to evacuate in an emergency. The provision of services to the resident receiving limited or intermittent nursing care or hospice care shall not interfere with the provision of services to other residents. (Class I)

7.2.b. If a resident exhibits symptoms of a mental or developmental disorder, and the resident is not receiving services to meet his or her current needs, is not a client of a behavioral health center or does not have a case manager, the licensee shall advise the resident's physician and on his or her advice notify the resident or his or her legal representative of the behavioral health service options within the local area. If the resident or his or her legal representative fails to meet the resident's needs in this area in a timely manner, then the licensee shall, after consultation with the resident's physician, refer the resident to a licensed behavioral health agency. (Class II)

7.2.c. The licensee shall seek immediate treatment for a resident or refuse to admit a prospective resident if the licensee has reason to believe that the resident may suffer serious harm or is likely to cause serious harm to himself or herself or to others if appropriate interventions are not provided in a timely manner. (Class I)

7.2.d. A resident who becomes incapable of self-preservation subsequent to admission may remain in the residential care community for ninety (90) days during a temporary illness or recovery from surgery if the resident does not require nursing care in excess of limited and intermittent nursing care, the resident is not incapable of self-preservation for more than ninety (90) days, and the following criteria are substantiated through resident interview:

7.2.d.1. The resident requests to remain in the residential care community; (Class II)

7.2.d.2. The resident is advised of the availability of other specialized health care facilities to treat his or her condition; (Class II)

7.2.d.3. The need for specialized health care is the result of a medical pathology or a result of the normal aging process. (Class II)

7.2.e. The licensee shall maintain a non-self-preserving resident's safety and meet their needs until such time as the resident's condition improves or he or she is discharged. (Class I)

7.3. Discharge and Transfer Procedures.

7.3.a. The licensee of a residential care community with a resident who needs more than limited and intermittent nursing care shall inform the resident or his or her legal representative of the need to move the resident to a health care facility with the capability of providing the needed level of nursing care. (Class III)

7.3.b. The licensee shall assist the resident and his or her legal representative to attempt on a weekly basis to secure placement in alternative care facilities. (Class III)

7.3.c. The licensee shall thoroughly document in the resident's record efforts made to obtain placement in alternative care facilities and refusals from the facilities in the event that the resident is unable to secure alternative placement and remains in the residential care community. (Class III)

7.3.d. The licensee shall give the resident a thirty-day notice prior to discharge unless an emergency situation which requires transfer to a hospital or other higher level of care exists or if the resident is a danger to himself or herself or others. A copy of the written discharge notice shall be filed in the resident's record. (Class III)

7.3.e. Prior to transfer or discharge the licensee shall prepare a summary to accompany the resident which shall include the residents functional needs assessment, individualized service plans, current physician's orders, any advanced directives, any allergies and pertinent progress notes. (Class II)

7.4. Records.

7.4.a. All resident records containing the information required by this rule shall be retained at the residential care community in a secure area and shall be made available for inspection by the secretary's duly authorized representative. (Class III)

7.4.b. The licensee shall begin at admission, maintain, and keep current, a record for each resident. (Class II)

7.4.c. The resident's record shall include:

7.4.c.1. The resident's name; social security number; birth date; sex; marital status; religious preference and affiliation, if any; (Class III)

7.4.c.2. The names, addresses and telephone numbers for the following relevant persons: physician; dentist; legal representative, if applicable; person, organization or agency responsible for payments for support of the resident, if applicable; next of kin or other interested relatives; persons to be notified in case of an emergency or death; any case management agency or organization; and any day care or other programs in which the resident regularly participates; (Class III)

7.4.c.3. All agreements or contracts entered into between the resident and the licensee; (Class III)

7.4.c.4. Admission, transfer and discharge data; (Class III)

7.4.c.5. Initial and subsequent physician health assessments, advanced directives, physician's orders, medication administration records; allergies; resident admission and monthly weight; the dates of physician, dentist and other health and behavioral health care providers and other professional appointments and visits (including those for accidents and illness requiring medical attention, coordinated by the licensee); all contact with the resident's physician by the residential care community staff; and observations by personnel, licensed nurses, physician, or others authorized to care for the resident;

(Class II)

7.4.c.6. Documentation of incidents and accidents involving the resident, including, at a minimum, the time, place, the action taken in response to the incident and the notification of the resident's physician (if applicable), family or legal representative; (Class III)

7.4.c.7. The resident's functional needs assessment, service plan, and updates annually and as indicated by significant changes in the resident's condition; (Class II)

7.4.c.8. A list of clothing and personal possessions of the resident if the resident so desires; (Class III) and

7.4.c.9. Documentation of death, including cause and disposition of the resident's body, medications, personal effects and any valuables safeguarded by the licensee. (Class III)

7.4.d. The licensee shall keep resident records in safe storage for at least five (5) years from the date of the death, discharge or transfer of the resident. If the residential care community ceases to operate, the licensee shall procure a holding area for the resident records that will ensure the confidentiality and safety of the records from loss, destruction or unauthorized use. (Class III)

7.4.e. Each licensee shall maintain a permanent resident register in a bound notebook in chronological order according to the date of the resident's admission. The register shall include the date of the resident's admission, his or her name, the date of his or her last day in the residential care residential care community and the name and address of the residence, health care facility or other place to which the resident (if living) has been discharged. (Class III)

7.5. Assessments and Service Plans

7.5.a. The licensee shall assure that each resident has a written, signed and dated health assessment by a licensed physician or other licensed health care professional authorized to perform such assessments by applicable State laws and rules not more than sixty (60) days prior to the those resident's admission, or no more than five (5) working days following admission, and at least annually thereafter. The admission and annual health assessment shall include screening for tuberculosis and other communicable diseases if indicated by exposure, prevalence or risk according to current medical practice in congregate living situations as indicated by the secretary. (Class II)

7.5.b. Within thirty (30) days of admission, every resident shall have an individualized functional needs assessment completed in writing by a licensed health care professional. At a minimum, the resident's assessment shall include a review of health status and functional, psychosocial, activity and dietary needs. (Class II)

7.5.c. Each resident shall have a service plan, based upon his or her functional needs assessment, developed within forty-five (45) days of admission. The service plan shall be developed in response to the individual resident's needs. (Class II)

7.5.d. The assessment and service plan shall reflect the resident's current needs and therefore shall be updated annually and as indicated by a significant change in the resident's condition. (Class II)

7.6. Services.

7.6.a. The licensee shall provide assistance to the resident and the resident's family in the resident's adjustment to the residential care community setting and to transfer when other levels of care become necessary. (Class II)

7.6.b. The licensee shall encourage and assist all residents in developing and maintaining independence, self-determination and the highest level of functioning possible. (Class II)

7.6.c. The licensee shall provide the resident with personal assistance to meet the needs identified on his or her functional needs assessment. Resident needs may include, but are not limited to, assistance from staff to supervise self-administration of medically prescribed drugs and treatments, to follow any planned diet, rest or activity regimen, to utilize functional equipment (i.e. hearing aides, glasses, canes, etc.), and to perform activities of daily living. (Class II)

7.6.d. The licensee shall assist the resident in making appointments for appropriate medical, dental, nursing or mental health services as needed by the resident. (Class II)

7.6.e. The licensee shall provide or arrange for appropriate transportation of the resident to receive medical appointments and social services. (Class III)

7.7. Medications and Treatments.

7.7.a. The licensee shall ensure that resident care is provided by appropriately licensed health care professionals when required by state law and rules, and that medications and treatments given to residents are administered as required by state and federal law, rules and regulations. (Class I)

7.7.b. The written order or prescription of an individual authorized by law to prescribe drugs in this State is required for obtaining, administering or self-administering of prescription and over-the counter medications. Copies of the prescriptions or written orders for drugs shall be retained in the resident's record. (Class I)

7.7.c. The prescribing health care professional shall determine whether or not the resident can self-administer medications in a safe manner and shall document this in the residents medical record. (Class I)

7.7.d. Verbal orders of physicians or other health care professionals shall be reviewed and signed by the individual responsible for the order within ten (10) working days from the original order date. (Class II)

7.7.e. The attending physician, or other health care professional, or a consulting pharmacist shall review the medication regimen of each resident as needed, but at least annually. The resident's record shall contain documentation of this review. (Class II)

7.7.f. The licensee shall keep a record of all drugs given to each resident indicating each dose given. The record shall include the resident's name; the name of the medication; the dosage to be administered and route of administration; the time or intervals at which the medication is to be administered; the date the medication is to begin and cease; the printed name, initials and signature of the individual who administered the medication; and any special instructions for handling or administering the medication, including instructions for maintaining aseptic conditions and appropriate storage. (Class I)

7.7.g. Medications shall be kept in a locked room, cabinet or other storage receptacle and accessible only to the staff responsible for medications unless residents are determined to be capable of self-medication. In those cases, the licensee shall provide the self-medicating resident with resources to store medications inaccessible to other residents. (Class I)

7.7.h. The container label of each prescription drug shall be legible, legally dispensed and labeled for the resident for whom it has been prescribed. When the prescriber's directions change, the container shall be relabeled by a licensed pharmacist or there shall be a written document signed and dated by the physician to verify the change in a medication prescription which is stored in the resident record. All medications shall be kept in their original labeled containers and shall be labeled in accordance with the rules of the West Virginia board of pharmacy and in a manner that the name and strength of medication, manufacturer name, lot number, and expiration date can be readily identified by the home. (Class I)

7.7.i. If refrigeration of medication is required, the licensee shall provide: a refrigerator in a locked room; a locked refrigerator; or a locked box within the refrigerator for storage. A thermometer is required in a refrigerator storing medications. The temperature within the refrigerator storing medications shall be maintained within the recommended temperature range on the medication package. (Class I)

7.7.j. If Schedule II drugs of the Uniform Controlled Substances Act W. Va. Code '60 A -1-101 et seq. are administered, a copy of the written prescription signed by the physician shall be in the resident's record and a proof of use record shall be maintained. Schedule II drugs shall be stored in a manner so that they are securely protected by two (2) locks. The key to the separately locked Schedule II drugs shall not be the same key that is used to gain access to non-scheduled drugs. (Class I)

7.7.k. The disposition of unused medications due to situations such as a change in drug therapy, the death of the resident, the resident leaving the residential care community, or the resident's inability to take the medication, shall be in accordance with the following:

7.7.k.1. Individual resident drugs supplied in unit dose or the manufacturer's originally sealed container shall be returned, if unopened, unless otherwise prohibited under applicable federal or State laws, to the issuing pharmacy, Provided, That:

7.7.k.1.A. No drug covered under the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 21 U.S.C. ' 801 et seq. shall be returned (Schedule II, III, IV, V); (Class III)

7.7.k.1.B. All returned drugs shall be identified as to lot or control number; (Class III) and

7.7.k.1.C. The signatures of the receiving pharmacist and the residential care community registered nurse shall be recorded in a separate log which lists the name of the patient, the name and strength of the drug with National Drug Code, the prescription number (if applicable), the amount of the drug returned and the date of return. The log shall be retained for at least two (2) years; (Class III) and

7.7.k.2. Resident drugs which are outdated, adulterated, deteriorated, or non-returnable shall be destroyed in the following manner:

7.7.k.2.A. Drugs listed in Schedules II, III, IV or V of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 21 U.S.C. ' 801 et seq. shall be destroyed by the residential care community in the presence of a pharmacist and the registered nurse. The following shall be retained for at least two years: the name of the resident, the name and strength of the drug, the prescription number, the amount destroyed, the date of destruction and the signatures of the witnesses required above. (Class III) and

7.7.k.2.B. All other non-scheduled legend drugs not in unit dose packaging or not in the manufacturer's originally sealed container shall be destroyed by the residential care community in the presence of a pharmacist or licensed nurse and one other witness. The patient's health record or a separate log shall contain the name of the patient, the name and strength of the drug, the prescription number, if applicable, the amount destroyed, the date of destruction and the signatures of the witnesses. The log shall be retained for at least two (2) years. (Class III)

7.7.l. When oxygen therapy is required, the residential care community shall have a portable source available for resident use for out-of-room activities and in the event of power failure. The licensee shall maintain any equipment electrically safe and shall arrange for service as needed; store the oxygen tubing in a sanitary manner when not in use and replace it as indicated by accepted infection control measures; prohibit smoking in any location when oxygen is in use; post no smoking signs conspicuously; and enforce the smoking prohibition. (Class I)

7.8. Accident, Illness and Major Incident Procedures.

7.8.a. A standard American Red Cross first-aid kit, or the equivalent, shall be readily available at all times to provide emergency aid for commonly occurring household injuries. (Class III)

7.8.b. When a resident experiences an illness or an incident that results in injury or resident complaint, the licensee shall arrange for an appropriately licensed health care professional to:

7.8.b.1. Assess the severity and cause of the accident or illness; (Class I)

7.8.b.2. Advise the staff as to the need to seek emergency assistance related to the accident or illness; (Class I) and

7.8.b.3. Record actions taken in the resident's record, and, recommend to the licensee, in writing, actions, if any, to take to avoid similar accidents or illnesses. The licensee shall keep a written documentation of the recommendations. (Class II)

7.8.c. If the resident has an obvious need for emergency assistance, the person on duty should first obtain emergency assistance, and then call the licensed health care professional. (Class I)

7.8.d. The staff of the residential care community shall monitor and document the resident's condition for a period of twenty-four (24) hours following the accident or the onset of the illness or as specified by the licensed health care professional. (Class II)

7.8.e. The residential care community shall report major incidents to the West Virginia office of health facility licensure and certification as soon as possible, but no later than the next business day. (Class III)

7.8.f. The residential care community staff shall promptly notify the resident's physician, responsible party and/or next of kin, when there is a major incident or any significant change in the resident's condition. (Class I)

7.8.g. The licensee shall take reasonable precautions to comply with recommendations by the local public health authority should an epidemic occur. (Class I)

7.9. Resident Death.

7.9.a. The residential care community shall immediately report the suspected death of a resident to the attending physician and report death to the resident's family or legal representative, as applicable. (Class III)

7.9.b. Upon the death of a resident, the following information shall be entered in the resident's record:

7.9.b.1. A record of the notification of the resident's physician, the designated individual for emergencies, and legal representative, if any; (Class III)

7.9.b.2. The date, time and circumstance of death, including the name of person to whom the body was released and any other details specific to the death; (Class III) and

7.9.b.3. A record of the disposition of the resident's personal belongings that were released, including funds. The resident's legal representative or next of kin shall sign a detailed receipt for these items. (Class III)

7.9.c. In the event of the death of a resident, a licensee shall deliver all property held in trust to the resident's estate administrator or executor. (Class III)

Notes

W. Va. Code R. § 64-75-7