Ala. Admin. Code r. 420-5-10-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-10-.03 - Administrative Management

(1) A facility must 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.

(2) A facility must be licensed under applicable State and local law

(3) The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

(4) Facilities must meet the applicable provisions of HHS regulations pertaining to nondiscrimination on the basis of race, color, or national origin; nondiscrimination on the basis of handicap; nondiscrimination on the basis of age; protection of human subjects of research and fraud and abuse. Although these regulations are not in themselves considered requirements under this part, their violation may result in the revocation of the facility license.

(5) Governing body. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and

(6) The governing body appoints the administrator who is:

(a) Licensed by the State where licensing is required, and;

(b) Responsible for the management of the facility.

(7) A current roster of the governing authority members shall be maintained in the nursing facility. At its discretion, the Alabama Department of Public Health may request that a copy of this roster be placed on file with the Division.

(a) The facility must supply full and complete information to the Alabama Department of Public Health as to the identity:

(1) of each officer and director of the corporation where the nursing facility is organized as a corporation and

(2) where a nursing facility is organized as a partnership.

(b) Of each person who has any direct or indirect ownership interest of 10 per centum or more in such nursing facility or who is the owner (in whole or in part) of any mortgage, deed of trust, note, or other obligation secured (in whole or in part) by such nursing facility or any of the property or assets of such nursing facility, and

(c) In case a nursing facility is organized as a corporation, of each officer and director of the corporation, and

(d) In case a nursing facility is organized as a partnership, the name of each partner.

(e) The governing authority shall submit to the state agency within 15 days any changes in the information herein required.

(f) There must be an individual authorized in writing to act for the administrator during absences.

(g) Written notification shall be made to the Alabama Department of Public Health, within 15 days of the Administrator's appointment.

(h) The accounting method and procedures shall be sufficient to permit an annual audit, accurate determination of the cost of operation, the cost per resident day, and accounting for resident's funds.

(i) Whenever there is found to be evidence of fraud or misrepresentation to secure money or property from residents, or applicants, or there is any evidence of misappropriation or conversion of money or property of residents or applicants, this must be reported to the proper authorities at the Alabama Department of Public Health.

(j) Unusual Occurrences. Occurrences such as catastrophes and unusual occurrences which threaten the welfare, safety or health of residents, personnel, or visitors shall be documented within 24 hours of the incident or occurrence. This documentation shall be retained in the facility for at least 2 years. All records required by this subsection shall be, upon request, made immediately available to surveyors employed by the Alabama Department of Public Health. Copies of such records shall be forwarded to the Alabama Department of Public Health promptly upon request. The term "Unusual occurrences" includes life threatening burns, and deaths under unusual circumstances.

(k) Fires shall be reported within 24 hours of the occurrence to the Technical Services Unit of the Alabama Department of Health.

(8) Required training of nursing aides - Definition Licensed health professional means a physician; physician assistant; nurse practitioner; physical, speech, or occupational therapist; physical or occupational therapy assistant; registered professional nurse; licensed practical nurse; licensed or certified social worker, or Dietitians. Nurse aide means any individual providing nursing related services to residents in a facility who is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay.

(9) General rule. A facility must not use any individual working in the facility as a nurse aide for more than four months, on a full-time basis, unless:

(a) That individual is competent to provide nursing related services; and

(b) That individual has completed a training and competency evaluation program; or

(c) That individual has been deemed or determined competent by the Alabama Nurse Aide Registry.

(10) Non-permanent employees. A facility must not use on a temporary, per diem, leased, any basis other than a permanent employee any individual who does not meet the requirements in paragraphs B & C above as a nurse aide.

(11) Competency A facility must not use any individual who has worked less than four months as a nurse aide in that facility unless the individual:

(a) Is a full-time employee in a State-approved training and competency evaluation program

(b) Has demonstrated competence through satisfactory participation in a State-approved nurse aide training and competency evaluation program; or

(c) Has been deemed or determined competent by the Alabama Nurse Aide Registry.

(12) Registry verification Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless:

(a) The individual is a full-time employee in a training and competency evaluation program approved by the State; or

(b) The individual can prove that he or she has recently successfully completed a training and competency evaluation program approved by the State and has not yet been included in the registry Facilities must follow up to ensure that such an individual actually becomes registered

(13) Multi-state registry verification. Before allowing an individual to serve as a nurse aide, a facility must contact the Alabama Nurse Aide Registry to seek information from every State registry the facility believes includes information on the individual.

(14) Required retraining. If, since an individuals most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program.

(15) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews The in-service training must:

(a) Be sufficient to ensure that continuing competence of nurse aides, but must be no less than 12 hours per year;

(b) Address areas of weakness as determined in nurse aides' performance reviews and may address the special needs of residents as determined by the facility staff; and

(c) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

(16) Proficiency of Nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

(17) Staff qualifications. The facility must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements.

(18) Professional staff must be licensed, certified, or registered in accordance with applicable State laws.

(19) Use of outside resources. If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Social Security Act as amended or an agreement described in paragraph (20) of this section.

(20) Arrangements as described in Section 1861(w) of the Social Security Act as amended or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for:

(a) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and

(b) The timeliness of the services

(21) Medical director. The facility must designate a physician to serve as medical director

(22) The medical director is responsible for:

(a) Implementation of resident care policies; and

(b) The coordination of medical care in the facility

(23) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.

(24) If the facility provides its own laboratory services, i.e., bedside testing including glucose or glucometer, the services must meet the applicable condition for coverage of the services furnished by laboratories specified in Part 493 of Title 42 Code of Federal Regulations revised 10/1/93.

(25) If the facility does not provide laboratory services on site, it must have an agreement to obtain these services only from a laboratory that meets the requirements of Part 493 of Title 42 Code of Federal Regulations revised 10/1/93.

(26) The facility must:

(a) Provide or obtain laboratory services only when ordered by the attending physician;

(b) Promptly notify the attending physician of the findings;

(c) Assist the resident in making transportation arrangement to and from the source of service if the resident needs assistance; and

(d) File in the resident's clinical record laboratory reports that are dated and contain the name and address of the testing laboratory

(27) If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and sub-specialties of services in accordance with the requirements of Part 493 of Title 42 Code of Federal Regulations revised 10/1/93.

(28) Radiology and other diagnostic services. The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.

(29) If the facility provides its own diagnostic services, the services must meet the applicable conditions of participation four hospitals contained in Section 482.26 of Title 42 Code of Federal Regulations revised 10/1/93.

(30) If the facility does not provide its own diagnostic services, it must have an agreement to obtain these services from a provider or supplier that is approved to provide these services under Medicare.

(31) The facility must:

(a) Provide or obtain radiology and other diagnostic services only when ordered by the attending physician;

(b) Promptly notify the attending physician of the finding;

(c) Assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance; and

(d) File in the resident's clinical record signed and dated reports of x-ray and other diagnostic services.

(32) Clinical records. The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are:

(a) Complete;

(b) Accurately documented;

(c) Readily accessible; and

(d) Systematically organized.

(33) Clinical records must be retained for:

(a) Five years from the date of discharge when there is no requirement in State law; or

(b) For a minor, three years after a resident reaches legal age under State law.

(34) The facility must safeguard clinical record information against loss, destruction, or unauthorized use.

(35) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is required by:

(a) Transfer to another health care institution;

(b) Law;

(c) Third party payment contract; or

(d) The resident.

(36) The clinical record must contain:

(a) Sufficient information to identify the resident;

(b) A record of the resident's assessments;

(c) The Plan of Care and services provided;

(d) The results of any pre-admission screening conducted by the State; and

(e) Progress notes.

(37) Disaster and emergency preparedness. The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.

(a) The facility must train all employees in emergency procedures when they begin to work in the facility;

(b) Periodically review the procedures with existing staff; and

(c) Carry out unannounced staff drills using those procedures.

(38) The facility must have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs that reasonably assures that:

(a) Residents will be transferred from the facility to the hospital, and ensured of timely admission to the hospital when transfer is medically appropriate, as determined by the attending physician; and

(b) Medical and other information needed for care and treatment of residents, and, when the transferring facility deems it appropriate, for determining whether such residents can be adequately cared for in a less expensive setting than either the facility or the hospital, will be exchanged between the institutions.

(39) The facility is considered to have a transfer agreement in effect if the facility has attempted in good faith to enter into an agreement with a hospital sufficiently close to the facility to make transfer feasible.

(40) Quality assessment and assurance. A facility must maintain a quality assessment and assurance committee consisting of:

(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.

(41) The quality assessment and assurance committee:

(a) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and

(b) Develops and implements appropriate plans of action to correct identified quality deficiencies.

(42) A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section.

(43) Disclosure of ownership. The facility must comply with the Disclosure requirements of Sections 420.206 and 455.104 of Title 42 Code of Federal Regulations revised 10/1/93.

(44) The facility must provide written notice to the Alabama Department of Public Health, if a change occurs in:

(a) Persons with an ownership or control interest, as defined by 420-5-10.02(6) (a) (i) - (x);

(b) The officers, directors, agents, or managing employees;

(c) The corporation, association, or other company responsible for the management of the facility; or

(d) The facility's administrator or director of nursing

(45) The notice specified in the paragraph (44) of this section must include the identity of each new individual or company.

(46) Any facility designated as a federal "Special Focus Facility" must place signage on their main entrance door informing the public of this designation. The signage must remain posted until the facility is taken off the Special Focus Facility listing or the provider agreement with CMS is terminated.

(a) The signage must state in bold print: This nursing home has been designated as a Special Focus Facility.

(b) The signage must further state: A Special Focus Facility is one with a noteworthy history of poor performance. A Special Focus Facility nursing home is required to have increased oversight and is subject to enhanced enforcement activity designed to stimulate improvement. Additional information about the federal Special Focus Facility program and process can be obtained from the administrator of this facility; by a search of the federal web site: www.cms.gov/sff; or by reviewing the information on the web site of the Alabama Department of Public Health: www.adph.org by searching keyword: sff.

(c) The signage lettering must be printed in block letters comparable to Times New Roman with font of at least 24 points. The notice must be on paper the size of at least 8 1/2'' by 11'' and of adequate size as to be readily noticed by all who enter.

Ala. Admin. Code r. 420-5-10-.03

Repealed and Replaced: Filed July 19, 1996; effective August 23, 1996. Amended: Filed November 18, 1999; effective December 23, 1999. Amended: Filed September 18, 2003; effective October 23, 2003. Amended: Filed June 23, 2004; effective July 28, 2004.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 09, June 30, 2016, eff. 7/30/2016.

Authors: Rick Harris, Walter T. Geary, Jr. M.D.

Statutory Authority:Code of Ala. 1975, §§ 22-21-20, et seq.