La. Admin. Code tit. 50 § II-10111

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10111 - Introduction

A. A 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. It shall be responsible for ensuring that all services provided to the residents by professional staff meet ethical and professional standards governing the profession.

B. Licensure. A facility must be licensed under applicable state and local laws.

C. Compliance with Federal, State, and Local Laws and Professional Standards. 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.

D. Relationship to Other HSS Regulations. In addition to compliance with the regulations set forth in this sub-part, facilities are obliged to meet the applicable provisions of other HSS regulations, including but not limited to those pertaining to:

1. nondiscrimination on the basis of race, color, or national origin (45 CFR page 80);

2. nondiscrimination on the basis of handicap (45 CFR page 84);

3. nondiscrimination on the basis of age ( 45 CFR Part 91);

4. protection of human subjects of research (45 CFR page 46); and

5. fraud and abuse ( 42 CFR Part 455).

E. Although these regulations are not in themselves considered requirements under this part their violation may result in termination or suspension of, or the refusal to grant or continue payment with federal funds.

F. Nursing facilities shall meet the following criteria.

1. Compliance. Facilities shall be in compliance with title VI of the Civil Rights Act of 1964 and shall not discriminate, separate, or make any distinction in housing, services, or activities based on race, color, or national origin.

2. Community Notification. Facilities shall notify the community that admission to the facility, resident care services, and other activities are provided without regard to race, color, or national origin. Notice to the community may be physicians, local health and welfare agencies, paramedical personnel, and public and private organizations having interest in equal opportunity or by notices in the local newspaper.

a. Residents shall not be asked if they are willing to share a room with a person of another race, color, or national origin.

b. Resident transfers shall not be used to evade compliance with title VI of the Civil Rights Act of 1964.

3. Open Admission Policy. An open admission policy and desegregation of facilities shall be required, particularly when the facility previously excluded or primarily served residents of a particular race, color, or national origin. Facilities which exclusively serve residents of one race have the responsibility for taking corrective action, unless documentation is provided that this pattern has not resulted from discriminatory practices.

4. Restricted Occupancy. A facility owned or operated by a private organization may restrict occupancy to members of the organization without violating Civil Rights compliance, provided membership in the organization and admission to the facility is not denied on the basis of race, color, or national origin.

5. Resident Services. All residents shall be provided medical, non-medical, and volunteer services without regard to race, color, or national origin. All administrative, medical and non-medical services are covered by this requirement.

6. Facility Personnel. Attending physicians shall be permitted to provide resident services without regard to race, color, or national origin.

a. Other medical, paramedical, or non-medical persons, whether engaged in contractual or consultative capacities, shall be selected and employed in a non-discriminatory manner.

b. Opportunity shall not be denied to qualified persons on the basis of race, color, or national origin.

c. Dismissal from employment shall not be based upon race, color, or national origin.

G. Facilities shall comply with section 504 of the Rehabilitation Act of 1973 which states the following: No qualified handicapped person shall, on the basis of handicap, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity which receives or benefits from federal financial assistance.

H. 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.

1. The governing body appoints the administrator who is:

a. licensed by the state where licensing is required; and

b. responsible for management of the facility.

I. Staffing. There are staff sufficient in number and qualifications on duty all hours of each day to carry out the policies, responsibilities, and program of the facility. The numbers and categories of personnel are determined by the number of residents and their particular needs in accordance with guidelines in this manual.

J. Policies and Procedures. There are written policies and procedures available to staff, residents, and the public which govern areas of service provided by the facility.

K. In-service Education Program. There is an orientation program for all new employees that includes review of all facility policies. Each employee receives appropriate orientation to the facility and its policies and to his position and duties. An in-service education program is planned and conducted for the development and improvement of skills of all the facility's personnel. In-service training includes at least prevention and control of infections, fire prevention and safety, accident prevention, confidentiality of resident information, and preservation of resident dignity, including protection of his privacy and his personal and privacy rights. Records are maintained which indicate the content of and attendance at such staff development programs.

1. Ongoing educations programs include orientation and in-service training appropriate for each employee.

2. Records indicate content and attendance at staff development programs.

L. Personnel Policies and Procedures. The governing body, through the administrator, is responsible for implementing and maintaining written personnel policies and procedures that support sound resident care and personnel practices. Personnel records are current and available for each employee and contain sufficient information to support placement in the position to which assigned. Written policies for control of communicable diseases are in effect to ensure that employees with symptoms or signs of communicable disease or infected skin lesions are not permitted to work and that a safe and sanitary environment for residents and personnel exists and incidents and accidents to residents and personnel are reviewed to identify health and safety hazards. Employees are provided or referred for annual health evaluations.

M. Development and Review of Resident Care Policies. The administrator or his designee is responsible, in writing, for the execution of such policies.

N. Quality Assurance. Each facility must have a quality assessment and assurance committee. Members must include:

1. director of nursing services;

2. physician designated by facility; and

3. at least three other members of the facility staff.

a. This committee meets at least quarterly to identify issues with respect to which quality assessments and assurance activities are necessary.

b. This committee develops and implements appropriate plans of action to correct identified quality deficiencies.

c. DHH or DHHS 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.

d. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions and/or citations on Form 2567.

La. Admin. Code tit. 50, § II-10111

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 22:34 (January 1996).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.