6.1 General Services. Any nursing facility not providing skilled services shall implement each resident’s physician’s
orders obtained on the day of admission and renewed or revised every 60 days thereafter.
6.2 Medical Services
6.2.1 All persons admitted to a nursing facility shall be under the care of a physician licensed to
practice in Delaware.6.2.2 All nursing facilities shall arrange for one or more licensed physicians to be called in an emergency.
Names, telephone and fax numbers of these physicians shall be posted at all nurses’ stations.
6.2.3 For a resident admitted or readmitted from the hospital with orders for nine or more medications (excluding
over-the-counter medications), the attending physician or designee or medical director shall conduct a
comprehensive medication review and reconciliation of past and present medications within 5 days.
6.2.4 All written or verbal physician orders shall be signed by the attending physician or prescriber within 10 days.
6.2.5 After the initial physician visit, an advanced practice nurse or physician’s assistant, affiliated with the
physician, may alternate with the physician, making every other required visit.
6.2.6 A progress note shall be written and signed by the physician or designee (an advanced practice nurse or
physician’s assistant) after examining the resident at each visit
6.3 Nursing Administration
6.3.1 The facility’s director of nursing shall:
6.3.1.1 Develop and/or maintain nursing policy and procedure manuals
6.3.1.2 Assign duties to and supervise all levels of nursing services direct caregivers
6.3.1.3 Coordinate nursing services with medical, therapy, dietary, pharmaceutical,
recreational, and other ancillary services
6.3.1.4 Coordinate orientation programs for new nursing services direct caregivers (including temporary
staff) and in-service education, as appropriate, for such staff. Written records of the content of
each in-service program and the attendance records shall be maintained for two years
6.3.1.5 Participate in the selection of prospective residents by evaluating the nursing services required
and the facility’s ability to competently provide those required services or ensure that such an
evaluation is conducted by a designated registered nurse
6.3.2 Treatments and medications ordered by a physician shall be administered using
professionally accepted techniques in accordance with 24 Delaware Code, Chapter 19.
6.3.3 Within 14 days of admission, the facility shall make a comprehensive assessment of each
resident’s needs. This assessment shall include, at a minimum, the following information:
6.3.3.1 Identification, background and demographic information
6.3.3.2 Customary routine
6.3.3.3 Cognitive patterns
6.3.3.4 Communication
6.3.3.5 Vision
6.3.3.6 Mood and behavior patterns
6.3.3.7 Psychosocial well-being
6.3.3.8 Physical functioning and structural problems
6.3.3.9 Continence
6.3.3.10 Disease diagnoses and health conditions
6.3.3.11 Dental and nutritional status
6.3.3.12 Skin condition
6.3.3.13 Activity pursuits
6.3.3.14 Medications
6.3.3.15 Special treatments and procedures
6.3.3.16 Discharge potential
6.3.4 The resident assessment shall include a screening instrument for mental illness, mental retardation, and
developmental disabilities to assess if an individual has an active treatment need for one of these
conditions.
6.3.5 Based on the physician’s admission orders and the admission information for each resident, an interim
individual nursing care plan shall be developed within 24 hours of admission pending the completion of a
comprehensive resident assessment.
6.3.6 A comprehensive care plan shall be developed to address medical, nursing, nutritional and psychosocial
needs within 7 days of completion of the comprehensive assessment. Care plan development shall include
the interdisciplinary team that includes the attending physician, an RN/LPN and other appropriate staff as
determined by the resident’s needs. With the resident’s consent, the resident, the resident’s family or the
resident’s legal representative may attend care plan meetings.
6.3.7 The assessment and care plan for each resident shall be reviewed/revised as needed when a significant
change in physical or mental condition occurs, and at least quarterly. A complete comprehensive
assessment shall be conducted and a comprehensive care plan shall be developed at least yearly from the
date of the last full assessment.
6.3.8 The resident has the right to be free from any physical or chemical restraints imposed for purposes of
discipline or convenience, and not required to treat the resident’s medical symptoms.
6.3.8.1 The resident’s comprehensive assessment shall document the medical symptom(s) potentially
requiring the use of restraints.
6.3.8.2 The facility shall follow a comprehensive, systematic process of evaluation and care planning to
ameliorate medical and psychosocial indicators prior to restraint use.
6.3.8.3 The resident’s care plan shall document the facility’s use of interventions, such as modifying the
resident’s environment to increase safety, and use of assistive devices to enhance monitoring in
order to avoid the use of restraints.
6.3.8.4 Should such interventions and assistive devices fail to provide for the resident’s safety, a
physician’s written order permitting the use of restraints shall be required and shall specify the type
of restraint ordered.
6.3.8.5 The facility shall be accountable for the safe and effective implementation of the physician’s order
permitting the use of restraints.
6.3.8.6 When the use of restraints has been implemented, the facility shall initiate a systematic process,
on an ongoing basis, documented in the care plan, in an effort to employ the least restrictive
restraint.
6.3.8.7 In an emergency, when the resident’s unanticipated violent or aggressive behavior places him/her
or others in imminent danger, restraints may be used as a last resort to protect the safety of the
resident or others, and such use shall not extend beyond the immediate episode.
6.3.9 The facility shall ensure that each nursing and ancillary staff member providing care to a resident under 18
years of age meets the standards as defined in regulations for nursing facilities admitting pediatric
residents.
6.3.10 The facility shall ensure that all licensed or certified direct care staff receive CPR certification and shall
ensure that at least one staff person with current CPR certification is present in the facility during all shifts.
6.4 Social Services
6.4.1 The facility shall identify each resident’s need for social services to attain or maintain the highest
practicable physical, mental and psychosocial well-being of each resident; and shall assist each resident to
obtain all required services to meet the individual resident’s needs. These social services shall include, but
not be limited to:
6.4.1.1 Making arrangements for obtaining needed adaptive equipment, clothing and personal items
6.4.1.2 Making referrals and obtaining services from outside entities
6.4.1.3 Assisting residents with financial and legal matters, according to facility policy
6.4.1.4 Discharge planning services
6.4.1.5 Assisting residents to determine how they would like to make decisions about their health care,
and whether or not they would like anyone else to be involved in those decisions
6.4.1.6 Meeting the needs of residents who are grieving
6.5 Food Service
6.5.1 Meals. Therapeutic diets, mechanical alterations and changes in either must be prescribed by an attending
physician within 72 hours of implementation. All meals and snacks shall be served in accordance with the
therapeutic diet, if prescribed.
6.5.2 Menus
6.5.2.1 Menus shall be planned in advance and a copy of the current week’s menu shall be posted in the
kitchen and in a public area. Portion sizes shall be listed on a menu in the food service area.
6.5.2.2 Menus showing food actually served each day shall be kept on file for at least 3 months. When
changes in the menu are necessary, substitutions of similar nutritive value shall be provided.
6.5.2.3 A 3-day supply of food shall be kept on the premises at all times.
6.5.2.4 A copy of a recent dietary manual shall be available for planning therapeutic menus and as a
resource for staff.
6.5.3 Nutritional Assessment
6.5.3.1 The immediate nutritional needs of each resident shall be addressed upon admission.
6.5.3.2 A comprehensive nutritional assessment which includes an evaluation of each resident’s caloric,
protein, and fluid requirements shall be completed within 14 days of admission in consultation with
a dietitian.
6.5.3.3 The facility shall have an ongoing evaluation and assessment program to meet the nutritional
needs of all residents.
6.5.3.4 The facility shall obtain and document each resident’s weight at least monthly.
6.6 Housekeeping and Laundry Services
6.6.1 The facility shall maintain a safe, clean, and orderly environment, free from offensive odors, for the interior
and exterior of the facility.
6.6.2 A full-time employee shall be designated responsible for housekeeping services and for
supervision and training of personnel.
6.6.3 The facility shall have written policies and procedures and schedules for cleaning all areas of the facility.
6.6.4 The facility shall maintain a supply, in the amount of 3 sets per resident, of towels, washcloths, sheets and
pillowcases changed weekly or whenever soiled.
6.6.5 The facility’s handling, storage, processing and transporting of linens shall comply with facility infection
control policies and procedures.
6.6.6 The facility shall contract with a licensed pest control vendor to ensure that the entire facility is free of live
insects and other vermin.
6.7 Pharmacy Services
6.7.1 Each nursing facility shall have a consultant pharmacist who shall be responsible for the general
supervision of the nursing facility’s pharmaceutical services.
6.7.2 For a resident admitted or readmitted from the hospital with orders for nine or more medications (excluding
over-the-counter medications), the facility shall complete an on-site or off-site pharmacy review within 10
days of admission or readmission.
6.8 Medications
6.8.1 Medication Administration
6.8.1.1 All medications (prescription and over-the-counter) shall be administered to residents in
accordance with orders which are signed and dated by the ordering physician or prescriber. Each
medication shall have a documented supporting diagnosis. Verbal or telephone orders shall be
written by the nurse receiving the order and then signed by the ordering physician or prescriber
within 10 days.
6.8.1.2 Standing orders may be established for over-the-counter medications that have been approved by
the resident’s attending physician.
6.8.1.3 Standing orders shall be initiated by licensed nurses, but shall not be used for more than 72 hours
6.8.1.4 When any standing order is initiated, it shall be written as a complete order on the
MAR for the specified time period and charted when administered.
6.8.1.5 Medications shall be given only to the individual resident for whom the prescription or order was
issued, and shall be given in accordance with the prescriber’s instructions.
6.8.1.6 An individual resident may self-administer medications upon the written order of the physician,
following determination by the interdisciplinary team that this practice is safe. The facility shall
establish policies and procedures pertaining to the security of self-administered medication.
6.8.1.7 The facility’s policies and procedures shall not prohibit or restrict a resident from receiving
medications from the pharmacy of the resident’s choice. However, the
resident and/or his representative shall be informed of any ramifications of ordering medications
from other than the facility’s pharmacy, such as cost differences, responsibility for delivery of
medication to the facility and length of ordering time.
6.8.1.8 Only licensed nurses shall administer medications and then record the administration on the
resident’s Medication Administration Record (MAR) immediately after administration to that
resident.
6.8.1.9 The facility shall ensure that licensed nurses administering medications count
controlled substances at the beginning and end of each shift. The on-coming
medication nurse shall conduct, verify, and document the controlled substance count in the
presence of the off-going medication nurse.
6.8.1.10 Any medications removed but not administered to the resident shall not be returned to the original
container. In circumstances such as refusal of drugs by the resident, the drugs shall be discarded
and the refusal recorded on the resident’s Medication Administration Record (MAR). If the
medication is a controlled substance, the signature of the administering nurse is required on the
record of the controlled substance count.
6.8.1.11 Each nursing home shall have available a current edition of at least one drug reference text for the
nursing staff.
6.8.1.12 Medication shall be released to residents on discharge or transfer only by the written authorization
of the resident’s physician. A resident who leaves the nursing facility on a short leave may be
issued a quantity of medication to meet his/her needs, with the approval of the resident’s
physician.
6.8.1.13 The barrel, plunger, needle and contents of disposable hypodermic syringes shall be properly
discarded in accordance with OSHA regulations immediately after use.
6.8.1.14 The administrator or designee shall notify the Office of Controlled Substances in the Division of
Professional Regulation and the Division of Long Term Care Residents Protection of any
unexplained loss of controlled substances, syringes, needles, or prescription pads within 8 hours
of discovery of such loss or theft.
6.8.2 Medication Storage and Stocks
6.8.2.1 Stock supplies of drugs available without a prescription (over-the-counter drugs such as antacids,
aspirin, laxatives) may be kept in the facility. These over-the-counter drugs shall be labeled “house
stock”.
6.8.2.2 All medications shall be stored in a locked cabinet. The key to the cabinet shall be kept in the
control of the licensed nurse responsible for the administration of medications.
6.8.2.3 Prescription medications for emergency or interim use may be stocked by the facility subject to
Board of Pharmacy regulations.
6.8.3 Medication Labeling
6.8.3.1 Medications shall be labeled in accordance with 24 Delaware Code, §2522 and the regulations of
the Board of Pharmacy.
6.8.3.2 Medications dispensed using a unit dose system shall be pharmacy-prepared or
manufacturer-prepared in individually packaged and sealed doses that are identifiable and
properly labeled. The label shall include, at a minimum, the brand and/or generic name of the
medication, strength, and lot number and expiration date.
6.9 Communicable Diseases
6.9.1 General Requirements
6.9.1.1 The facility shall follow Division of Public Health regulations for the Control of
Communicable and Other Disease Conditions and Centers for Disease Control
guidelines for communicable diseases.
6.9.1.2 The facility shall establish written policies and procedures implementing the Division of Public
Health regulations and Centers for Disease Control guidelines for communicable diseases.
6.9.1.3 The nursing facility shall ensure that the necessary precautions stated in the policies and
procedures are followed.
6.9.1.4 A resident, when suspected or diagnosed as having a communicable disease, shall be placed on
the appropriate precautions as recommended for that disease by the Centers for Disease Control.
Residents infected or colonized with the same organism may share a room based on current
standard of practice.
6.9.1.5 The admission of a resident with or the occurrence of a disease or condition on the Division of
Public Health List of Notifiable Diseases/Conditions within a nursing facility shall be reported to the
resident’s physician and the facility’s medical director. The facility shall also report such an
admission or occurrence to the Division of Public Health’s Health Information and Epidemiology
office.
6.9.2 Specific Requirements for Tuberculosis
6.9.2.1 A resident diagnosed with active tuberculosis in an infectious stage shall not continue to reside in a
nursing facility unless that facility has a room with negative pressure ventilation and staff trained to
care for residents requiring respiratory isolation.
6.9.2.2 A resident of any facility unable to provide care as described above who is diagnosed with active
tuberculosis in an infectious stage shall be transferred to an acute care hospital, and the facility
shall notify the Division of Public Health’s Health Information and Epidemiology office immediately.
6.9.2.3 The facility shall have on file the results of tuberculin testing performed on all newly placed
residents.
6.9.2.4 Minimum requirements for pre-employment tuberculosis (TB) testing require all employees to have
a base line two step tuberculin skin test (TST) or single Interferon Gamma Release Assay (IGRA
or TB blood test) such as QuantiFeron. Any required subsequent testing according to risk category
shall be in accordance with the recommendations of the Centers for Disease Control and
Prevention of the U.S. Department of Health and Human Services. Should the category of risk
change, which is determined by the Division of Public Health, the facility shall comply with the
recommendations of the Center for Disease Control for the appropriate risk category.
6.9.2.4.1 No person, including volunteers, found to have active tuberculosis in an infectious stage shall
be permitted to give care or service to residents.
6.9.2.4.2 Any person having a positive skin test but a negative X-ray shall receive an annual evaluation
for signs and symptoms of active TB if they can not provide documentation of completion of
treatment for LTBI (latent TB infection).
6.9.2.4.3 Persons with a prior BCG vaccination are required to be tested as set forth in 6.9.2.4.
6.9.3 Immunizations
6.9.3.1 All facilities shall have on file evidence of annual vaccination against influenza for all residents, as
recommended by the Immunization Practice Advisory Committee of the Centers for Disease
Control, unless medically contraindicated.
6.9.3.2 All facilities shall have on file evidence of vaccination against pneumococcal
pneumonia for all residents older than 65 and as recommended by the Immunization Practice
Advisory Committee of the Centers for Disease Control unless medically contraindicated.
6.9.3.3 A resident who refuses to be vaccinated against influenza or pneumococcal pneumonia shall be
informed by the facility of the health risks involved. The reason for the refusal(s) shall be
documented in the resident’s medical record annually.
6.9.4 Employee Health
6.9.4.1 All employees shall receive education and training on standard precautions, use of personal
protective equipment, the importance of hand hygiene, the facility’s infection control policies and
reporting of exposures to blood or other potentially infectious materials.
6.9.4.2 Personal protective equipment, as required by Centers for Disease Control guidelines, shall be
made available by the facility for employee use.
6.9.4.3 If an accidental exposure to blood or other potentially infectious materials occurs (specifically to
eye, mouth, other mucous membrane or non-intact skin), appropriate first aid treatment shall be
given immediately and follow-up testing and counsel inginitiated. A copy of the exposure incident
and follow-up treatment shall be maintained in the employee’s personnel file.
6.9.4.4 Facilities shall establish procedures in accordance with Division of Public Health requirements and
Centers for Disease Control guidelines for exclusion from work and authorization to return to work
for staff with communicable diseases.
6.10 Infection Control
6.10.1 Infection Control Committee
6.10.1.1 The nursing facility shall establish an infection control committee (or a subcommittee of an overall
quality control program) of professional staff whose responsibility shall be to manage the infection
control program in the facility. One member of the committee shall be designated the infection
control coordinator.
6.10.1.2 The infection control committee shall consist of members of the medical and nursing staffs,
administration, dietetic department, pharmacy, housekeeping, maintenance, and therapy services.
6.10.1.3 The infection control committee shall establish written policies and procedures that describe the
role and scope of each department/service in infection prevention and control activities.
6.10.1.4 The committee is responsible for the development and coordination of policies and procedures to
accomplish the following:
6.10.1.4.1 Prevent the spread of infections and communicable diseases
6.10.1.4.2 Promote early detection of outbreaks of infection
6.10.1.4.3 Ensure a sanitary environment for residents, staff and visitors
6.10.1.4.4 Establish guidelines for the implementation of isolation/precautionary measures
6.10.1.4.5 Monitor the rate of nosocomial infection
6.10.1.5 The infection control coordinator shall maintain records of all nosocomial infections and corrective
actions related to those infections to enable the committee to analyze clusters or significant
increases in the rate of infection and to make recommendations for the prevention and control of
additional cases.
6.10.1.6 The infection control committee shall establish the infection control training of staff and volunteers,
and disseminate current information on health practices.
6.10.2 Infectious Waste
6.10.2.1 The facility shall establish and implement policies and procedures for the collection, storage,
handling and disposition of all pathological and infectious wastes within the facility as well as for
those to be removed from the facility including the following:
6.10.2.1.1 Needles, syringes and other solid, sharp, or rigid items shall be placed in a puncture resistant
container prior to disposal by an infectious waste hauler approved by the Department of
Natural Resources and Environmental Control (DNREC).
6.10.2.1.2 Non-rigid items, such as blood tubing and disposable equipment and supplies, shall be placed
in double, heavy duty, impervious plastic bags prior to disposal by an infectious waste hauler
approved by DNREC.