CHAPTER 211. PROGRAM STANDARDS FOR LONG-TERM
CARE NURSING FACILITIES

 (a)  When a resident develops a reportable disease, the administrator shall report the information to the appropriate health agencies and appropriate Division of Nursing Care Facilities field office. Reportable diseases, infections and conditions are listed in §  27.21a (relating to reporting of cases by health care practitioners and health care facilities).

 (b)  Cases of scabies and lice shall be reported to the appropriate Division of Nursing Care Facilities field office.

 (c)  Significant nosocomial outbreaks, as determined by the facility’s medical director, Methicillin Resistant Stapylococcus Aureus (MRSA), Vancomycin-Resistant Staphylococcus Aureus (VRSA), Vancomycin-Resistant Enterocci (VRE) and Vancomycin-Resistant Stapylococcus Epidermidis (VRSE) shall be reported to the appropriate Division of Nursing Care Facilities field office.

   The provisions of this §  211.1 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)); amended under the Disease Prevention and Control Law of 1955 (35 P. S. § §  521.1—521.21).

 (a)  The attending physician shall be responsible for the medical evaluation of the resident and shall prescribe a planned regimen of total resident care.

 (b)  The facility shall have available, prior to or at the time of admission, resident information which includes current medical findings, diagnoses and orders from a physician for immediate care of the resident. The resident’s initial medical assessment shall be conducted no later than 14 days after admission and include a summary of the prior treatment as well as the resident’s rehabilitation potential.

 (c)  A facility shall have a medical director who is licensed as a physician in this Commonwealth and who is responsible for the overall coordination of the medical care in the facility to ensure the adequacy and appropriateness of the medical services provided to the residents. The medical director may serve on a full- or part-time basis depending on the needs of the residents and the facility and may be designated for single or multiple facilities. There shall be a written agreement between the physician and the facility.

 (d)  The medical director’s responsibilities shall include at least the following:

   (1)  Review of incidents and accidents that occur on the premises and addressing the health and safety hazards of the facility. The administrator shall be given appropriate information from the medical director to help insure a safe and sanitary environment for residents and personnel.

   (2)  Development of written policies which are approved by the governing body that delineate the responsibilities of attending physicians.

   The provisions of this §  211.2 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

 (a)  A physician’s oral and telephone orders shall be given to a registered nurse, physician or other individual authorized by appropriate statutes and the State Boards in the Bureau of Professional and Occupational Affairs and shall immediately be recorded on the resident’s clinical record by the person receiving the order. The entry shall be signed and dated by the person receiving the order. Written orders may be by fax.

 (b)  A physician’s oral and telephone orders for care and treatments, shall be dated and countersigned with the original signature of the physician within 7 days of receipt of the order. If the physician is not the attending physician, he shall be authorized and the facility so informed by the attending physician and shall be knowledgeable about the resident’s condition.

 (c)  A physician’s telephone and oral orders for medications shall be dated and countersigned by the prescribing practitioner within 48 hours. Oral orders for Schedule II drugs are permitted only in a bona fide emergency.

 (d)  Oral orders for medication or treatment shall be accepted only under circumstances where it is impractical for the orders to be given in a written manner by the responsible practitioner. An initial written order as well as a countersignature may be received by a fax which includes the practitioner’s signature.

 (e)  The facility shall establish policies identifying the types of situations for which oral orders may be accepted and the appropriate protocols for the taking and transcribing of oral orders in these situations, which shall include:

   (1)  Identification of all treatments or medications which may not be prescribed or dispensed by way of an oral order, but which instead require written orders.

   (2)  A requirement that all oral orders be stated clearly, repeated by the issuing practitioner, and be read back in their entirety by personnel authorized to take the oral order.

   (3)  Identification of all personnel authorized to take and transcribe oral orders.

   (4)  The policy on fax transmissions.

   The provisions of this §  211.3 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

   The provisions of this §  211.3 adopted August 29, 1975, effective September 1, 1975, 5 Pa.B. 2233; amended February 11, 1977, effective February 12, 1977, 7 Pa.B. 437; amended May 26, 1978, effective May 27, 1978, 8 Pa.B. 1466; amended April 23, 1982, effective April 24, 1982, 12 Pa.B. 1316; amended January 31, 1987, effective July 1, 1987, 17 Pa.B. 514; amended July 23, 1999, effective July 24, 1999, 29 Pa.B. 3999. Immediately preceding text appears at serial pages (240324) to (240325).

 (a)  Written postmortem procedures shall be available at each nursing station.

 (b)  Documentation shall be on the resident’s clinical record that the next of kin, guardian or responsible party has been notified of the resident’s death. The name of the notified party shall be written on the resident’s clinical record.

   The provisions of this §  211.4 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

 (a)  Clinical records shall be available to, but not be limited to, representatives of the Department of Aging Ombudsman Program.

 (b)  Information contained in the resident’s record shall be privileged and confidential. Written consent of the resident, or of a designated responsible agent acting on the resident’s behalf, is required for release of information. Written consent is not necessary for authorized representatives of the State and Federal government during the conduct of their official duties.

 (c)  Records shall be retained for a minimum of 7 years following a resident’s discharge or death.

 (d)  Records of discharged residents shall be completed within 30 days of discharge. Clinical information pertaining to a resident’s stay shall be centralized in the resident’s record.

 (e)  When a facility closes, resident clinical records may be transferred with the resident if the resident is transferred to another health care facility. Otherwise, the owners of the facility shall make provisions for the safekeeping and confidentiality of clinical records and shall notify the Department of how the records may be obtained.

 (f)  At a minimum, the resident’s clinical record shall include physicians’ orders, observation and progress notes, nurses’ notes, medical and nursing history and physical examination reports; identification information, admission data, documented evidence of assessment of a resident’s needs, establishment of an appropriate treatment plan and plans of care and services provided; hospital diagnoses authentication—discharge summary, report from attending physician or transfer form—diagnostic and therapeutic orders, reports of treatments, clinical findings, medication records and discharge summary including final diagnosis and prognosis or cause of death. The information contained in the record shall be sufficient to justify the diagnosis and treatment, identify the resident and show accurately documented information.

 (g)  Symptoms and other indications of illness or injury, including the date, time and action taken shall be recorded.

 (h)  Each professional discipline shall enter the appropriate historical and progress notes in a timely fashion in accordance with the individual needs of a resident.

 (i)  The facility shall assign overall supervisory responsibility for the clinical record service to a medical records practitioner. Consultative services may be utilized, however, the facility shall employ sufficient personnel competent to carry out the functions of the medical record service.

   The provisions of this §  211.5 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

   The provisions of this §  211.5 adopted August 29, 1975, effective September 1, 1975, 5 Pa.B. 2233; amended January 31, 1987, effective July 1, 1987, 17 Pa.B. 514; amended July 23, 1999, effective July 24, 1999, 29 Pa.B. 3999. Immediately preceding text appears at serial pages (240325) to (240327).

 (a)  Menus shall be planned at least 2 weeks in advance. Records of menus of foods actually served shall be retained for 30 days. When changes in the menu are necessary, substitutions shall provide equal nutritive value.

 (b)  Sufficient food to meet the nutritional needs of residents shall be prepared as planned for each meal. There shall be at least 3 days’ supply of food available in storage in the facility at all times.

 (c)  Overall supervisory responsibility for the dietary services shall be assigned to a full-time qualified dietary services supervisor.

 (d)  If consultant dietary services are used, the consultant’s visits shall be at appropriate times and of sufficient duration and frequency to provide continuing liaison with medical and nursing staff, advice to the administrator, resident counseling, guidance to the supervisor and staff of the dietary services, approval of menus, and participation in development or revision of dietary policies and procedures and in planning and conducting inservice education and programs.

 (e)  A current therapeutic diet manual approved jointly by the dietitian and medical director shall be readily available to attending physicians and nursing and dietetic service personnel.

 (f)  Dietary personnel shall practice hygienic food handling techniques. An employe shall wear clean outer garments, maintain a high degree of personal cleanliness and conform to hygienic practices while on duty. Employes shall wash their hands thoroughly with soap and water before starting work, after visiting the toilet room and as often as necessary to remove soil and contamination.

   The provisions of this §  211.6 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

   The provisions of this §  211.6 adopted August 29, 1975, effective September 1, 1975, 5 Pa.B. 2233; amended April 23, 1982, effective April 24, 1982, 12 Pa.B. 1316; amended January 31, 1987, effective July 1, 1987, 17 Pa.B. 514; amended July 23, 1999, effective July 24, 1999, 29 Pa.B. 3999. Immediately preceding text appears at serial pages (240327) to (240329).

 (a)  Physician assistants and certified registered nurse practitioners may be utilized in facilities, in accordance with their training and experience and the requirements in statutes and regulations governing their respective practice.

 (b)  If the facility utilizes the services of physician assistants or certified registered nurse practitioners, the following apply:

   (1)  There shall be written policies indicating the manner in which the physician assistants and certified registered nurse practitioners shall be used and the responsibilities of the supervising physician.

   (2)  There shall be a list posted at each nursing station of the names of the supervising physician and the persons, and titles, whom they supervise.

   (3)  A copy of the supervising physician’s registration from the State Board of Medicine or State Board of Osteopathic Medicine and the physician assistant’s or certified registered nurse practitioner’s certificate shall be available in the facility.

   (4)  A notice plainly visible to residents shall be posted in prominent places in the institution explaining the meaning of the terms ‘‘physician assistant’’ and ‘‘certified registered nurse practitioner.’’

 (c)  Physician assistants’ and certified registered nurse practitioners’ documentation on the resident’s record shall be countersigned by the supervising physician within 7 days with an original signature and date by the licensed physician. This includes progress notes, physical examination reports, treatments, medications and any other notation made by the physician assistant or certified registered nurse practitioner.

 (d)  Physicians shall countersign and date their verbal orders to physician assistants or certified registered nurse practitioners within 7 days.

 (e)  This section may not be construed to relieve the individual physician, group of physicians, physician assistant or certified registered nurse practitioner of responsibility imposed by statute or regulation.

   The provisions of this §  211.7 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

 (a)  Restraints may not be used in lieu of staff effort. Locked restraints may not be used.

 (b)  Restraints may not be used or applied in a manner which causes injury to the resident.

 (c)  Physical restraints shall be removed at least 10 minutes out of every 2 hours during the normal waking hours to allow the resident an opportunity to move and exercise. Except during the usual sleeping hours, the resident’s position shall be changed at least every 2 hours. During sleeping hours, the position shall be changed as indicated by the resident’s needs.

 (d)  A signed, dated, written physician order shall be required for a restraint. This includes the use of chest, waist, wrist, ankle, drug or other form of restraint. The order shall include the type of restraint to be used.

 (e)  The physician shall document the reason for the initial restraint order and shall review the continued need for the use of the restraint order by evaluating the resident. If the order is to be continued, the order shall be renewed by the physician in accordance with the resident’s total program of care.

 (f)  Every 30 days, or sooner if necessary, the interdisciplinary team shall review and reevaluate the use of all restraints ordered by physicians.

   The provisions of this §  211.8 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

 (a)  Facility policies shall ensure that:

   (1)  Facility staff involved in the administration of resident care shall be knowledgeable of the policies and procedures regarding pharmacy services including medication administration.

   (2)  Only licensed pharmacists shall dispense medications for residents. Licensed physicians may dispense medications to the residents who are in their care.

 (b)  Medications shall be administered by authorized persons as indicated in §  201.3 (relating to definitions).

 (c)  Medications and biologicals shall be administered by the same licensed person who prepared the dose for administration and shall be given as soon as possible after the dose is prepared.

 (d)  Medications shall be administered under the written orders of the attending physician.

 (e)  Each resident shall have a written physician’s order for each medication received. This includes both proprietary and nonproprietary medications.

 (f)  Residents shall be permitted to purchase prescribed medications from the pharmacy of their choice. If the resident does not use the pharmacy that usually services the facility, the resident is responsible for securing the medications and for assuring that applicable pharmacy regulations and facility policies are met. The facility:

   (1)  Shall notify the resident or the resident’s responsible person, at admission and as necessary throughout the resident’s stay in the facility, of the right to purchase medications from a pharmacy of the resident’s choice as well as the resident’s and pharmacy’s responsibility to comply with the facility’s policies and State and Federal laws regarding packaging and labeling requirements.

   (2)  Shall have procedures for receipt of medications from outside pharmacies including requirements for ensuring accuracy and accountability. Procedures shall include the review of medications for labeling requirements, dosage and instructions for use by licensed individuals who are authorized to administer medications.

   (3)  Shall ensure that the pharmacist or pharmacy consultant will receive a monthly resident medication profile from the selected pharmacy provider.

   (4)  Shall have a policy regarding the procurement of medications in urgent situations. Facilities may order a 7-day supply from a contract pharmacy if the resident’s selected pharmacy is not able to comply with these provisions.

 (g)  If over-the-counter drugs are maintained in the facility, they shall bear the original label and shall have the name of the resident on the label of the container. The charge nurse may record the resident’s name on the nonprescription label. The use of nonprescription drugs shall be limited by quantity and category according to the needs of the resident. Facility policies shall indicate the procedure for handling and billing of nonprescription drugs.

 (h)  If a unit of use or multiuse systems are used, applicable statutes shall be met. Unit of use dispensing containers or multiuse cards shall be properly labeled. Individually wrapped doses shall be stored in the original container from which they were dispensed.

 (i)  At least quarterly, outdated, deteriorated or recalled medications shall be identified and returned to the dispensing pharmacy for disposal in accordance with acceptable professional practices. Written documentation shall be made regarding the disposition of these medications.

 (j)  Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident’s chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.

 (k)  The oversight of pharmaceutical services shall be the responsibility of the quality assurance committee. Arrangements shall be made for the pharmacist responsible for the adequacy and accuracy of the services to have committee input. The quality assurance committee, with input from the pharmacist, shall develop written policies and procedures for drug therapy, distribution, administration, control, accountability and use.

 (l)  A facility shall have at least one emergency medication kit. The kit used in the facility shall be governed by the following:

   (1)  The facility shall have written policies and procedures pertaining to the use, content, storage and refill of the kits.

   (2)  The quantity and categories of medications and equipment in the kits shall be kept to a minimum and shall be based on the immediate needs of the facility.

   (3)  The emergency medication kits shall be under the control of a practitioner authorized to dispense or pre-scribe medications under the Pharmacy Act (63 P. S. § §  390.1—390.13).

   (4)  The kits shall be kept readily available to staff and shall have a breakaway lock which shall be replaced after each use.

   The provisions of this §  211.9 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

 (a)  Resident care policies shall be available to admitting physicians, sponsoring agencies, residents and the public, shall reflect an awareness of, and provision for, meeting the total medical and psychosocial needs of residents. The needs include admission, transfer and discharge planning.

 (b)  The policies shall be reviewed at least annually and updated as necessary.

 (c)  The policies shall be designed and implemented to ensure that each resident receives treatments, medications, diets and rehabilitative nursing care as prescribed.

 (d)  The policies shall be designed and implemented to ensure that the resident receives proper care to prevent pressure sores and deformities; that the resident is kept comfortable, clean and well-groomed; that the resident is protected from accident, injury and infection; and that the resident is encouraged, assisted and trained in self-care and group activities.

   The provisions of this §  211.10 amended under section 803 of Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

   The provisions of this §  211.10 adopted August 29, 1975, effective September 1, 1975, 5 Pa.B. 2233; amended January 31, 1987, effective July 1, 1987, 17 Pa.B. 514; amended July 23, 1999, effective July 24, 1999, 29 Pa.B. 3999. Immediately preceding text appears at serial pages (240335) to (240336).

   Transfer

 (a)  The facility shall designate an individual to be responsible for the coordination and implementation of a written resident care plan. This responsibility shall be included as part of the individual’s job description.

 (b)  The individual responsible for the coordination and implementation of the resident care plan shall be part of the interdisciplinary team.

 (c)  A registered nurse shall be responsible for developing the nursing assessment portion of the resident care plan.

 (d)  The resident care plan shall be available for use by personnel caring for the resident.

 (e)  The resident, when able, shall participate in the development and review of the care plan.

   The provisions of this §  211.11 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

 (a)  The facility shall provide services by sufficient numbers of personnel on a 24-hour basis to provide nursing care to meet the needs of all residents.

 (b)  There shall be a full-time director of nursing services who shall be a qualified licensed registered nurse.

 (c)  The director of nursing services shall have, in writing, administrative authority, responsibility and accountability for the functions and activities of the nursing services staff, and shall serve only one facility in this capacity.

 (d)  The director of nursing services shall be responsible for:

   (1)  Standards of accepted nursing practice.

   (2)  Nursing policy and procedure manuals.

   (3)  Methods for coordination of nursing services with other resident services.

   (4)  Recommendations for the number and levels of nursing personnel to be employed.

   (5)  General supervision, guidance and assistance for a resident in implementing the resident’s personal health program to assure that preventive measures, treatments, medications, diet and other health services prescribed are properly carried out and recorded.

 (e)  The facility shall designate a registered nurse who is responsible for overseeing total nursing activities within the facility on each tour of duty each day of the week.

 (f)  In addition to the director of nursing services, the following daily professional staff shall be available.

   (1)  The following minimum nursing staff ratios are required:

   (2)  When the facility designates an LPN as a nurse who is responsible for overseeing total nursing activities within the facility on the night tour of duty in facilities with a census of 59 or under, a registered nurse shall be on call and located within a 30-minute drive of the facility.

 (g)  There shall be at least one nursing staff employe on duty per 20 residents.

 (h)  At least two nursing service personnel shall be on duty.

 (i)  A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.

 (j)  Nursing personnel shall be provided on each resident floor.

 (k)  Weekly time schedules shall be maintained and shall indicate the number and classification of nursing personnel, including relief personnel, who worked on each tour of duty on each nursing unit.

 (l)  The Department may require an increase in the number of nursing personnel from the minimum requirements if specific situations in the facility—including, but not limited to, the physical or mental condition of residents, quality of nursing care administered, the location of residents, the location of the nursing station and location of the facility—indicate the departures as necessary for the welfare, health and safety of the residents.

   The provisions of this §  211.12 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

 (a)  The facility shall assist residents in obtaining routine and 24-hour emergency dental care.

 (b)  The facility shall make provisions to assure that resident dentures are retained by the resident. Dentures shall be marked for each resident.

 (a)  The facility shall provide social services designed to promote preservation of the resident’s physical and mental health and to prevent the occurrence or progression of personal and social problems. Facilities with a resident census of more than 120 residents shall employ a qualified social worker on a full-time basis.

 (b)  In facilities with 120 beds or less that do not employ a full-time social worker, social work consultation by a qualified social worker shall be provided and documented on a regular basis.

   The provisions of this §  211.16 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

 If pet therapy is utilized, the following standards apply:

   (1)  Animals are not permitted in the kitchen or other food service areas, dining rooms when meals are being served, utility rooms and rooms of residents who do not want animals in their rooms.

   (2)  Careful selection of types of animals shall be made so they are not harmful or annoying to residents.

   (3)  The number and types of pets shall be restricted according to the layout of the building, type of residents, staff and animals.

   (4)  Pets shall be carefully selected to meet the needs of the residents involved in the pet therapy program.

   (5)  The facility shall have written procedures established which will address the physical and health needs of the animals. Rabies shots shall be given to animals who are potential victims of the disease. Care of the pets may not be imposed on anyone who does not wish to be involved.

   (6)  Pets and places where they reside shall be kept clean and sanitary.

   The provisions of this §  211.17 amended under section 803 of the Health Care Facilities Act (35 P. S. §  448.803); and section 2102(g) of The Administrative Code of 1929 (71 P. S. §  532(g)).

   The provisions of this §  211.22 adopted April 23, 1982, effective April 24, 1982, 12 Pa.B. 1316; reserved January 30, 1987, effective July 1, 1987, 17 Pa.B. 514. Immediately preceding text appears at serial pages (70700) to (70704).