212 R.I. Code R. 212-RICR-10-05-1.11

Current through December 3, 2024

Section 212-RICR-10-05-1.11 - Residential Settings Subject to Licensing

The DDO ensures that there is a legally enforceable written agreement that includes, at minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant laws of the state, county, city or other designated entity.

1.11.1Health Care Services

A. DDOs shall maintain written health care and nursing policies and procedures in a "DDO Health Care Manual," that addresses all the areas indicated and outlined in this Part.

1. Each agency shall ensure that the DDO Health Care Manual is reviewed and approved by a Professional Nurse on an annual basis and when any changes are made to it.

2. Each agency shall maintain documentation to support the annual, and as needed, approvals of the DDO Health Care Manual by a Professional Nurse.

B. Influenza, pneumococcal, and other adult vaccination policies and protocols shall be developed and implemented by the DDO in accordance with the most current recommendations of The Advisory Council on Immunization Practices (ACIP) Guidelines for these vaccinations, and as recommended and ordered by the person's physician or other licensed health care provider.

C. The DDO shall have written policies to be followed for health care communication with family members and/or legal guardians regarding significant changes in medication and/or medical status of the person with developmental disabilities.

1.11.2 Medical Care

A. The DDO shall ensure that each participant has the opportunity for an annual physical examination. Components of the physical exam shall include a review of prescribed medication, over-the-counter medication and herbal/homeopathic supplements, completion of accepted primary care screenings. If routine screening is deferred by the participant, or their physician or other licensed health care provider, documentation as to the reason for the deferral must be included in the participant's health care record.

B. Any physician, dietician, or other licensed health care provider's prescribed diet order shall be implemented and a copy of the diet is kept the person's health care record.

C. Dental examinations and cleanings shall be performed as recommended by the American Dental Association, unless otherwise determined by the participant or their licensed health care provider.

D. Vision, Audiology, or Speech consults, orthopedic, physical therapy, occupational therapy examinations, and/or other medical referrals shall be performed if indicated.

E. The DDO shall assist in obtaining adaptive or assistive equipment as needed and is kept in good repair. Regular assessment for proper fit and usage shall also be completed. The individual shall receive support to utilize and maintain assistive equipment.

F. The DDO shall document an individual's refusal of tests, exams, procedures or other health care recommendations in the individual's plan. Necessity of said procedures will be periodically reviewed and ongoing efforts shall be made to achieve the desired health care goals. Documentation will be maintained in the individual's health care record.

1.11.3Documentation Standards and Maintenance of Health Care Records

A. Health care records shall include all pertinent health care related documents including physician or health care provider assessments and orders.

B. Documentation and corrections in health care information shall be made in accordance with standard nursing practice.

C. All health care information shall be placed in the individual's record in reverse chronological order.

D. Health care records shall be kept for a minimum of ten (10) years following the cessation of services.

E. The Professional Nurse shall complete and document the findings of a nursing assessment on a minimum of an annual basis.

1. The nursing assessment shall include, but not be limited to, a deliberate and systematic collection of data to determine a person's current health status; including physical assessment, data analyses, problem identification, and development of a plan of care.

2. The Professional Nurse will complete a nursing assessment when nursing services are deemed appropriate and per the individual plan as determined by the Professional Nurse based on the person's health care needs.

3. An assessment shall be completed and documented whenever there is a significant change in the individual's health status.

4. The professional nurse shall complete nursing progress notes as determined by the nature and scope of the individual's health care needs, and the DDO's policy and procedure for documentation.

1.11.4Medication Administration and Treatment

A. The DDO shall have written policies and procedures for medication administration, including protocols for documentation and contact with the DDO professional nurse and/or licensed health care provider in the event of a medication error and/or medication reaction.

1. The DDO shall have a written policy and procedure describing medication safeguards and support protocols for participants who self-administer their medications.

B. Medications shall only be administered by support staff who have:

1. Received documented training in medication administration by a professional nurse;

2. Displayed appropriate competency to carry out said procedure and has been documented by the professional nurse;

3. Received annual training and competency assessment by the professional nurse with appropriate documentation retained in the personnel file.

C. Medications and treatments shall be stored safely, securely and properly, following manufacturer's recommendations and the DDO's written policy.

1. The dispensing pharmacy shall dispense medications in containers that meet legal requirements. Medications shall be kept stored in those containers. An exemption from storage in original containers is permitted if using a pre-poured packaging distribution system packaged by a pharmacy or professional nurse.

2. A corrected label shall be provided by the pharmacist or noted to indicate change by the professional nurse, correspond to the medication administration sheet, and shall be completed for any medication change orders.

3. Unless otherwise outlined in the individual's health care plan, medications:

a. shall be stored in a locked area;

b. shall be stored separately from non-medical items;

c. shall be stored under proper conditions of temperature, light, humidity, and ventilation;

d. requiring refrigeration shall be stored in a locked container within the refrigerator; and

e. internal and external medications shall be stored separately;

f. Potentially harmful substances shall be clearly labeled and stored in an area separate and apart from medications.

D. A licensed health care provider and/or nurse shall review the medication sheets monthly and shall sign and date the medication sheets at the time of the review. The medication record shall have a signature sheet of all staff authorized to administer medications, which includes the staff's signature and the initials he/she will be using on the medication sheet.

E. Medication sheets shall be maintained by the DDO for all persons who do not self-administer their medications. Medication sheets will include:

1. name of the person to whom the medication is being administered;

2. medication(s) name;

3. dosage;

4. frequency;

5. route of administration;

6. date of administration;

7. time of administration;

8. any known medication allergies or other undesirable reaction;

9. any special consideration in taking the medication;

10. the signature and initials of the person(s) administering the medication.

F. All prescriptions shall be reviewed and renewed annually at the time of the annual physical or as indicated by a physician or other licensed health care provider. All medication changes require a new prescription.

G. "PRN" medications are medications administered on an "as needed" basis and shall be specifically prescribed by a physician or other licensed health care prescriber and include specific parameters and rationale for use.

H. All PRN medications shall be documented on medication administration sheets. The documentation shall include:

1. the name of the person to whom the medication is being administered;

2. the name, dosage, and route of the medication;

3. the date, time(s) and reason for administration;

4. the effect of the medication; and

5. the initials of the person(s) administering the medication.

I. The name and dosages of PRN medications administered for behavioral intervention shall be documented per the written policy and procedures of the DDO and as part of an approved plan in accordance with this Part.

J. Medication checks for anyone taking psychotropic medications shall include contact on a regular basis between the person for whom the medications are prescribed and the physician, psychiatrist, or other licensed health care prescriber. The effectiveness of the medication shall be assessed on a regular basis by the multi-disciplinary clinical team.

1.11.5Monitoring of Controlled Medications

A. Medications listed in Schedules II, III, IV, and V pursuant to R.I. Gen. Laws Chapter 21-28, shall be appropriately stored, documented, and accurately reconciled.

B. Schedule II medications shall be stored separately from other medications in a double locked drawer or compartment, or in a separate storage location which is locked, has additional security restrictions such as a combination lock, and has been designated solely for that purpose.

C. A controlled medication accountability record shall be completed when receiving a Schedule II, III, IV, or V medication.

1. The following information shall be included:

a. name of the person for whom the medication is prescribed;

b. name, dosage, and route of medication;

c. dispensing pharmacy;

d. date received from pharmacy;

e. quantity received; and

f. name of person receiving delivery of the medication.

2. All controlled medications shall be counted and signed for at the end of each shift, or in accordance with the DDO's written policy and procedure.

3. The DDO shall maintain signed controlled medication accountability records for all persons to whom medications are administered by DDO personnel.

D. When a controlled medication is administered, the person administering the medication shall immediately verify and/or enter all the following information on the accountability record and/or the medication sheet:

1. name of the person to whom the medication is being administered;

2. name of the medication, dosage, and route of administration;

3. amount used;

4. amount remaining;

5. date and time of administration; and,

6. signature of the person administering the medication.

1.11.6Disposal of Medications

A. DDOs shall have a written policy and procedure for the disposal of damaged, excess, discontinued and/or expired controlled substances. The policy and procedure shall outline the DDO's protocol for the inventory and disposal of all such controlled medications in accordance with federal Drug Enforcement Administration (DEA) regulations and all other applicable federal, state, and local regulations.

B. Agencies shall have a written policy and procedure for the disposal of all non-controlled medications.

1.11.7Transcription of Medication Orders

A. The DDO shall have a written policy and procedure describing the conditions under which the support staff may copy a new written medication order from the pharmacy prescription label onto the appropriate documentation form. At a minimum, the procedure shall require the following:

1. Identification of and training requirements for DDO personnel who shall be permitted to copy the medication order from the pharmacy prescription label onto the appropriate documentation form.

2. Safeguards for ensuring that the information has been accurately copied.

3. Protocols for verification by a Professional Nurse per DDO policy.

1.11.8Individualized Procedures

A. The DDO, in conjunction with the physician, the professional nurse, the individual and his or her family/advocate, shall develop the plan for supporting the individual if they require an individualized procedure to maintain or improve their health status. This procedure is necessary for the health maintenance of the participant and one that the individual is unable to do for themselves. Appropriate training and documentation of competency in performing an individualized procedure shall be specific to the needs, risks and individual characteristics of the person and shall be completed before a support staff performs said task. The fact that a support staff may have been approved to perform an individualized procedure for one person does not create or imply approval for that support staff to perform similar procedures for another individual. When such a procedure is required the following standard for delegation of nursing activities shall apply.

1. Prior to the implementation of an individualized procedure, the RN shall assess the individual's condition as to whether or not it is of a stable and predictable nature.

2. All training of support staff on the individualized procedure shall be completed by a professional nurse or licensed health care provider.

3. The professional nurse shall assess support staff for their knowledge and demonstrated competency prior to delegating the task for that person to that support staff and communicate and document approval.

4. The professional nurse shall reassess support staff's competency on an annual basis at a minimum or as the individualized procedures change.

5. The professional nurse shall provide ongoing monitoring of the individual's health care needs and of the support staff's skills.

B. If a professional nurse determines that a task or individualized procedure cannot be safely delegated, she/he shall follow DDO policy for communication and resolution while ensuring the health and safety of the individual.

1.11.9Support Staff Training

A. DDOs shall have written policies and procedures for ongoing health care training as outlined in the DDO Health Care Manual for all support staff.

1. Specific health care related training shall be conducted or supervised by a licensed nurse or a qualified instructor as specified in the DDO's policies.

2. Professional nursing staff shall delegate tasks only to support staff that have received training commensurate with the DDO's protocols and have demonstrated competencies in each area of training.

3. Support staff shall be deemed competent upon documentation of satisfactory completion of training. Satisfactory completion and documentation of training shall include knowledge and demonstration of the delegated task.

4. A competency training checklist shall be completed by a professional nurse prior to the delegation of any health care task, including medication administration. The intent of the competency check is to ensure for the delegating nurse that the staff person has satisfactorily completed all required elements of the training program and has satisfactorily demonstrated skills and competencies in the designated areas.

B. Support staff shall receive annual training and a competency evaluation in health care/health and life education areas. Support staff shall demonstrate a working knowledge of comprehensive health care principles and procedures and shall demonstrate the ability to assist individuals to understand their health care needs more fully. The following Core Curriculum is the standardized guideline of minimum expectations for staff training and shall be followed by DDO specific policies, procedures and protocols.

1. Universal Precautions: The support staff shall demonstrate the ability to apply measures to prevent communicable diseases, to recognize and report the presence or onset of communicable disease, and to carry out the recommended procedures.

a. Communicable Diseases;

b. Infection Control; and

c. Exposure Control Plan (OSHA).

2. Wellness & Prevention of Illness: The support staff shall demonstrate an understanding of a comprehensive, holistic approach to health care and positive, healthy behaviors which will enhance the individuals' overall physical and mental health.

a. Nutrition/Food Handling;

b. Personal Hygiene;

c. Sexual & Reproductive Health; and

d. Healthy Lifestyle

3. Signs & Symptoms of Illness & Injury: The support staff shall be able to recognize the signs and symptoms of illness and injury and take appropriate action.

4. Emergency Care: The support staff shall demonstrate an understanding of how to identify and respond to emergency situations and when to seek outside help

a. Basic First Aid; and

b. Cardio-Pulmonary Resuscitation. All staff who work with individuals supported shall maintain current CPR Certification and documentation of such shall be maintained in the employee's personnel file.

5. Communication: The support staff shall understand and demonstrate the importance of clear communication and the compliance with DDO policy regarding health care issues.

6. Medication Administration: The support staff shall safely administer, completely document and communicate appropriately on issues related to medication administration per acceptable standards in accordance with this Part.

7. Agency Specific Policy, Procedures and Protocols: The support staff shall demonstrate a working knowledge of the DDO's specific policies, procedures and protocols regarding healthcare.

8. Individualized Procedures: The support staff shall demonstrate competency in the provision of any individualized procedure as detailed in this Part prior to implementing the procedure.

1.11.10Professional Nursing

A. The Professional Nurse shall maintain compliance with the RI Department of Health's "Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs" (216-RICR- 40-05-3) regarding delegation to unlicensed assistive personnel, including the criteria for appropriate delegation to support staff.

B. The DDO shall have written policy and procedures regarding nursing support protocols for evening, weekend, and holiday coverage.

212 R.I. Code R. 212-RICR-10-05-1.11

Adopted effective 1/7/2019