An assisted living facility shall provide, make available, coordinate, or contract for services that meet the care needs identified in the direct care services and health care services plan portions of residents’ occupancy admission agreements, to meet unscheduled care needs of residents, and to make emergency assistance available 24 hours a day, all in a manner that does not pose an undue hardship on
residents. An assisted living facility shall respond to changes in residents’ needs for services by revising the direct care services or health care services plan portions of residents’ occupancy admission agreements, or both, and, if necessary, by adjusting its staffing plan or contracting for services from other providers. If non-residents utilize services of the assisted living facility, it must occur in a
manner that does not unduly disturb residents or deprive residents of timely access to services.
Services are provided according to the direct care services or health care services plan portions of residents’ occupancy admission agreements, or both, and may include, but are not limited to, homemaker, attendant care, and medication oversight to the extent permitted under State law. Services include 24-hour available staff to respond to residents’ needs in a way that promotes maximum
dignity and independence and provides supervision, safety and security. Other individuals or agencies may furnish care directly or under arrangements with the assisted living facility. Such care shall be supplemental to the services provided by the assisted living facility and does not supplant, nor may be substituted for, the requirements of service provisions by the facility.
Services are furnished to a person who resides in his or her own apartment or unit that may include dually occupied units when both occupants consent to the arrangement. Each apartment or unit shall be of adequate size and configuration to permit residents to perform, with or without assistance, all the functions necessary for independent living, including sleeping; sitting; dressing; personal
hygiene; storing, preparing, serving and eating food; storage of clothing and other personal possessions; doing personal correspondence and paperwork and entertaining visitors. Care provision and service delivery must be resident-driven to the maximum extent possible and treat each person with dignity and respect. Care must be furnished in a way that fosters the independence of each resident. Occasional or intermittent guidance, direction or monitoring, or assistance with activities of daily living and social activities and transportation or travel, as defined in these regulations, for residents to keep appointments for medical, dental, social, political or other services or activities shall be made available to residents. The resident may be assisted in making arrangements to secure community based health or other professional services, examinations and reports needed to maintain or document the maintenance of the resident’s health, safety and welfare.
700.1 Housekeeping and Maintenance
700.1.1 Each assisted living facility shall establish and conduct a housekeeping and maintenance program, to ensure the continued maintenance of the facility in good repair, to promote good housekeeping procedures, and to
ensure sanitary practices throughout the facility.
700.1.2 The facility shall have full responsibility to clean and maintain all common areas and shall make no additional charge to the resident or third parties, including Medicaid, for such services. The facility shall ensure that each resident or staff person maintains the residents’ living quarters in a safe and sanitary condition. If the resident declines housekeeping
services, the resident’s apartment or unit shall not impact negatively on other apartments or units or common areas (e.g., odors, pests).
700.1.3 For those residents who do not wish to clean their own apartment or unit, the facility shall include this service as part of the service package either for free, or for an additional fee basis and indicate such in the occupancy admission agreement.
700.1.4 Each assisted living facility, in addition to meeting applicable fire and building codes, shall meet the following housekeeping and maintenance requirements:
a. All areas of the facility shall be kept clean and free of lingering odors, insects, rodents and trash;
b. Each resident’s apartment or unit shall be cleaned before use by another resident;
c. Corridors shall not be used for storage;
d. Attics, cellars, basements, below stairways, and similar areas shall be kept clean of refuse, old newspapers and discarded furniture;
e. Polish used on floors shall provide a non-slip finish;
f. The building(s) and grounds shall be maintained in a clean, orderly condition and in good repair;
g. The interior walls, ceilings and floors shall be clean. Cracked plaster, peeling wallpaper or paint, missing or damaged tiles and
torn or split floor coverings shall be promptly and adequately repaired or replaced;
h. Electric systems, including appliance, cords, and switches, shall be maintained in compliance with state and local codes;
i. Plumbing and plumbing fixtures shall be maintained in compliance with state plumbing and gas codes governing them at the time of
construction or as applicable due to renovations;
j. Ventilation, heating, air conditioning and air changing systems shall be properly maintained. All HVAC and gas systems shall be
inspected at least every 12 months to ensure safe operation.
Inspection certificates, where applicable, shall be maintained for review;
k. The building(s), grounds and support structures shall be free of breeding areas for flies, other insects and rodents;
l. Entrances, exits, steps, and outside walkways shall be maintained in safe condition, including removing or treating snow and ice
within a reasonable amount of time of its accumulation;
m. Repairs or additions shall meet current codes.
700.2 Linen and Laundry Services
700.2.1 Each assisted living facility shall offer laundry facilities or services to its residents.
700.2.2 Each assisted living facility shall meet the following laundry service requirements:
a. Each assisted living facility shall have laundering facilities unless commercial laundries are used. The laundry shall be located in a
specifically designed area that is physically separate and distinct from residents’ rooms and from areas used for dining and food
preparation and service. There shall be adequate rooms and spaces for sorting, processing and storage of soiled material. Laundry
rooms shall not open directly into resident care area or food service area. Domestic washers and dryers that are for the use of residents
may be provided in resident areas, provided they are installed in such a manner that they do not cause a sanitation problem or
offensive odors.
b. Laundry dryers shall be properly vented to the outside;
c. The laundry room shall be cleaned after each day’s use to prevent lint accumulation and to remove clutter;
d. Portable heaters or stoves, or either of them, shall not be used in the laundry area;
e. The laundry room shall be well lighted and vented to the outside by either power vents, gravity vents or by outside windows;
f. When facility staff is performing laundry duties for the entire facility, resident’s clothing, kitchen linens, and bed linens shall be
washed separately. If linens, including washable blankets, are not washed at a minimum temperature of 150 degrees Fahrenheit, a
disinfecting agent shall be used.
g. The facility shall be responsible, as part of the services required under the basic charge, for providing laundry services on all linens
and supplies owned by the facility.
700.2.3 For those residents who do not wish to launder their own personal items, the facility shall include this service as part of the service package. The facility may provide this service for free, or for an additional fee basis, and
indicate as such in the occupancy admission agreement.
700.3 Dietary Services
700.3.1 Required Facility Dietary Services
700.3.2 As part of the basic charge, each assisted living facility must make available food for three (3) balanced meals, as specified in Section 601.3
(a)(6), and make between-meal snacks available. Potable water and other drinking fluids shall be available at all times. Meals shall be served at approximately the same time each day. There shall be no more than five
(5) hours between breakfast and lunch and no more than seven (7) hours between lunch and the evening meal. Variations from these stated parameters may be permitted at the written request of the resident or his or
her responsible party or as directed by the resident’s personal physician or advance practice nurse in writing. The facility shall retain documentation stating the reason for the variance.
700.3.3 For those residents who wish to have meals served in his or her apartment or unit, the facility shall include this service as part of the service package, either for free, or for an additional fee basis, and indicate as such in the
occupancy admission agreement.
700.3.4 In the event that a resident is unable or unwilling to consume regular meals served to him or her for more than two (2) consecutive days, the facility shall immediately notify the resident’s personal physician or advance practice nurse and take appropriate action to ensure the physician or advance practice nurse’s instructions are implemented. If a resident
chooses not to consume regular meals, this must be documented in the resident’s service plan portion of the occupancy admission agreement. In the event that the resident refuses to provide a written statement, the facility shall document the refusal, as well as all contact with the resident’s personal physician or advance practice nurse regarding the resident’s refusal to eat.
700.3.5 A supply of food shall be maintained on the premises at all times. This hall include at least a 24-hour supply of perishable food and a three (3)- day supply of non-perishable food. The food supply shall come from a source approved by the State Department of Health. Assisted living facilities attached to other licensed long term care facilities may utilize the kitchen facilities of the attached long term care facility, however, the assisted living facility shall ensure that the kitchen facilities so utilized are adequate to meet the needs of the residents of the assisted living facility.
700.3.6 Dietary personnel and universal workers shall wear clean clothing and hair coverings while in the kitchen preparing or handling food.
700.3.7 Each facility shall comply with all applicable regulations relating to food service for sanitation, safety, and health as set forth by state, county, and local health departments.
700.3.8 Food service personnel and universal workers shall ensure that all food is prepared, cooked, served, and stored in such a manner that protects against contamination and spoilage.
700.3.9 The kitchen and dining area must be cleaned after each meal.
700.3.10 An adequate supply of eating utensils (e.g., cups, saucers, plates, glasses, bowls, and flatware) will be maintained in the facility’s kitchen to meet the needs of the communal dining program. An adequate number of pots and pans shall be provided for preparing meals. Eating utensils shall be free of chips or cracks.
700.3.11 Each assisted living facility shall have adequate refrigeration and storage space. An adequately sized storage room shall be provided with adequate shelving. The storage room shall be constructed to prevent the invasion of rodents, insects, sewage, water leakage or any other contamination. The bottom shelf shall be of sufficient height from the floor to allow cleaning of the area underneath the bottom shelf.
700.3.12 Refrigerator temperature shall be maintained at 41 degrees Fahrenheit or below, and freezer temperatures shall be maintained at degrees
700.3.13 Raw meat and eggs shall be separated from cooked foods and other foods when refrigerated. Raw meat is to be stored in such a way that juices do not drip on other foods.
700.3.14 Fresh whole eggs shall not be cracked more than 2 hours before use.
700.3.15 Hot foods should leave the kitchen (or steam table) above 140 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit.
700.3.16 Containers of food shall not be stored on the floor of a walk-in refrigerator, freezer, or storage rooms. Containers shall be seamless with tight-fitting lids and shall be clearly labeled as to content.
700.3.17 In facilities that have a residential type kitchen, a five (5)-lb. ABC fire extinguisher is required in the kitchen. In facilities that have commercial kitchens with automatic extinguishers in the range hood, the portable five
(5)-lb. fire extinguisher must be compatible with the chemicals used in the range hood extinguisher. The manufacturer recommendations shall be followed.
700.3.18 Food scraps shall be placed in garbage cans with airtight fitting lids and bag liners. Garbage cans shall be emptied as necessary, but no less than daily.
700.3.19 Leftover foods placed in the refrigerator shall be sealed, dated, and used or disposed of within 48 hours.
700.3.20 Personnel/staff/employees shall not use tobacco, in any form while engaged in food preparation or service, nor while in areas used for equipment or utensil washing, or for food preparation.
700.3.21 Menus shall be posted on a weekly basis. The facility shall retain a copy of the last month’s menus.
700.3.22 A therapeutic diet shall be planned by a licensed dietician. The dietician should review any therapeutic dietetic changes.
700.3.23 Each assisted living facility shall make available a dietary manager, who is certified as required by law or regulation, to prepare nutritionally balanced meal plans in consultation with staff and residents or their responsible parties. A chef that has documentation of graduation from a culinary school may also function as a certified dietary manager.
700.4 Ancillary Services
All ancillary services (both core services [Section 601.3(a)] and any other ancillary services identified as wanted by the resident or his or her responsible party to be provided by the facility at additional cost to the resident or his or her responsible party [Section 700.1.3, Section 700.2.3 and Section 700.3.3]) that are identified in the resident’s needs assessment or evaluation and shall be included in
the resident’s occupancy admission agreement.
701 DIRECT CARE SERVICES
701.1 (a) Direct care services directly help a resident with certain activities of daily living such as assistance with mobility and transfers; hands-on or cuing assistance to a resident to eat meals or food, grooming, shaving, trimming or shaping fingernails and toenails, bathing, dressing, personal hygiene, bladder and bowel requirements, including incontinence; and assistance with medication only to the extent permitted by the state Nurse Practice Act and interpretations thereto by the Arkansas State Board of Nursing.
701.1 (b) The assisted living facility shall ensure the resident receives direct care services in accordance with the services plan portion of the occupancy admission agreement. Direct care services needs of all residents in the facility shall be reviewed at least annually, and the services plan portion of the occupancy admission agreement revised, if necessary.
701.1 (c) Revision of the services plan portion of the occupancy admission agreement shall be revised within fourteen (14) days upon any significant enduring change to the resident.
701.1.2 An initial needs assessment or evaluation is to be completed for each resident to identify all needed direct care
701.1.3 If the needs assessment or evaluation indicates that the resident has general service needs, a resident direct care services plan portion of the occupancy admission agreement shall be developed. The resident’s direct care services plan portion of the occupancy admission agreement shall include, but not be limited to, the resident’s needs for assisted living facility services, including but not limited to, assistance with activities of daily living (ADL).
701.1.4 If the resident does not have any direct care service needs, a resident direct care services plan portion of the occupancy admission agreement is not needed. However, the facility must document how and where the evaluation was performed and that the resident does not have any direct care service needs.
701.1.5 If the needs assessment or evaluation indicates that the resident will need assistance with emergency evacuation, arrangements for staff to provide this assistance shall be included in the direct care services plan portion of
the occupancy admission agreement.
701.1.6 The resident or his or her responsible party shall participate in and, if the resident or his or her responsible party agrees, family members shall be invited to participate in, the development of the resident direct care services plan portion of the occupancy admission agreement. Participation shall be documented in the resident’s record.
701.1.7 Direct care staff may perform emergency or first-aid procedures as
specified below:
1. Emergencies are defined as those measures necessary to prevent death or trauma until such time that the resident can be transported
to the appropriate medical facility or treated by appropriate medical personnel;
2. First-aid measures will be defined as temporary procedures necessary to relieve trauma or injury;
3. First-aid supplies shall be available in the facility.
702 HEALTH CARE SERVICES and HEALTH CARE SERVICES PLAN
702.1 The assisted living facility shall ensure that the resident receives health care services under the direction of a registered nurse in accordance with the health care services plan portion of the occupancy admission agreement.
a. Each resident shall be examined by a physician or by an advance practice nurse or by a nurse practitioner or by a physician assistant within 60 days of admission that shall be documented in the resident’s record.
b. The facility shall have at least one registered nurse available at all times. Available, in this instance, shall mean on call, capable of being reached by telephone or pager and capable of appearing at the facility as required to
meet residents’ needs.
c. A registered nurse shall be responsible for developing nursing policies and procedures and the coordination of all health care services required in the resident’s health care services plan portion of the occupancy admission
agreement.
d. The facility shall ensure, at a minimum, the following:
1. Assessment of the health care services needs of all residents in the facility shall be performed annually, except that those residents
who have a health care services plan portion of the occupancy admission agreement shall be reassessed quarterly and revisions
made as needed. The health care services plan portion of the occupancy admission agreement shall be revised within fourteen
(14) days upon any significant enduring change to the resident;
2. Monitoring of the conditions of the residents on a periodic basis;
3. Notification of the registered nurse if there are significant changes in a resident’s condition;
4. Assessment of the resident’s need for referral to a physician or advance practice nurse or community agencies as appropriate; and
5. Maintenance of records as required.
e. In the planning of health care services:
1. The assisted living facility shall arrange for health care services to be provided to residents as needed or ordered by the resident’s
physician or advance practice nurse and documented in the health care services plan portion of the occupancy admission agreement.
2. At the time of admission, arrangements shall be made between the assisted living facility and the resident or his or her responsible
party regarding the physician or advance practice nurse and dentist to be called in case of illness or the person to be called for a
resident who, because of religious affiliation or personal choice, is opposed to medical treatment, if any.
3. The initial health care assessment shall be documented by the facility and shall be updated as required, in accordance with
professional standards of practice or upon a significant change of condition. In no event shall the health care assessment be updated
less frequently than annually. The resident’s physician or advance practice nurse shall be notified
of any significant change in the resident’s physical or psychological condition and any intervention by the physician or
advance practice nurse shall be recorded. Intervention includes, but is not limited to, orders given by the physician or advance
practice nurse or documentation that the physician or advance practice nurse did not issue an order after notice of the significant
change of condition. For purposes of documentation, the facility
shall document:
A. The name and address of the physician or advance practice nurse whom the facility contacted;
B. The date and time of the notice to the physician or advance practice nurse whom the facility contacted;
C. The information provided to the physician or advance practice nurse whom the facility contacted, regarding the
significant change of condition; and,
D. The response of the physician or advance practice nurse whom the facility contacted.
f. Residents or their responsible parties shall be permitted free choice of physician or advance practice nurse and of pharmacy. A facility may make a selection of a treating physician or advance practice nurse or pharmacy only when the resident or his or her responsible party is fully informed of his or her right of choice and waives that right in writing. The
facility shall maintain any written waives in the resident’s file.
702.2 Health Care Services
702.2.1 If the resident needs assessment or evaluation indicates that the resident requires health care services, a written health care service plan shall be completed and become a part of the resident’s occupancy admission agreement within 30 days of the date of admission by a registered nurse using an assessment instrument that meets the requirement of Section
702.3 Based on the health care assessment, a written health care service plan shall be developed as part of the resident’s occupancy admission agreement. The health care service plan shall include, but not be limited
to, the following:
1. Orders for treatment or services, medications and diet, if needed;
2. The resident’s needs and preferences;
3. The specific goals of treatment or services, if appropriate;
4. The time intervals at which the resident’s response to treatment
will be reviewed;
5. The measures to be used to assess the effects of treatment.
702.2.2 Each resident health care assessment shall include, at a minimum, evaluation of the following:
1. Physical health, status and abilities, including but not limited to:
a. Functional limitations and capacities;
b. Ability to self-administer medication;
c. Strengths, abilities and capacity for self-care;
d. Disease diagnosis;
e. Oral and dental status;
f. Nutritional status and needs;
g. Skin conditions;
h. Continence;
2. Mental and emotional health, including but not limited to:
a. Mood and behavior patterns;
b. Ability to self-administer medications;
c. Cognitive patterns;
d. Strengths, abilities and capacity for self-care;
3. Medications;
4. Social and leisure needs and preferences;
5. Communication and hearing patterns;
6. Visual patterns;
7. Situations or conditions that could put the resident at risk of harm or injury;
8. Frequency of monitoring that the resident’s condition requires;
9. Special treatment and procedures.
702.2.3 If the resident does not need a health care service, a health care service plan does not have to be included in the resident’s occupancy admission agreement. However, the facility must document that the health care assessment was performed and that the resident does not have any health care service needs.
702.2.4 Assessment of the health care services needs of all residents in the facility shall be performed at least annually, except that those residents who have a health care services plan portion of the occupancy admission agreement shall be reassessed quarterly and revisions made as needed. The health care services plan portion of the occupancy admission agreement shall be revised within fourteen (14) days upon any significant change to the resident.
703 Medications
703.1 Administration
703.1.1 Each assisted living facility must have written policies and procedures to ensure that residents receive medications as ordered. In-service training on facility medications policies and procedures (see Sections 504.4(b)(1) and 504.4.1) shall be provided at least annually for all facility personnel supervising or administering medications.
703.1.2 Facilities must comply with applicable state laws and regulations governing the administration of medications and restrictions applicable to non-licensed personnel/staff/employees. However, licensed nursing personnel (RN, LPN) may administer medication in accordance with Sections 504.2.2 and 504.2.3 of these regulations in cases in which the resident is assessed as being unable to self-administer his or her medication. In such cases, the facility shall document, and shall be responsible to ensure, that medications are administered by licensed nursing personnel/staff/employees, and are administered without an error rate greater than 5% (see 703.1.2.1).
703.1.2.1 Medication Errors
a. The facility must ensure that:
1. It is free of medication error rates of five percent (5%) or greater; and
2. Residents are free of any significant medication errors.
b. Medication error means the observed preparation or administration of drugs or biologicals which is not in accordance with:
1. Physician’s orders;
2. Manufacturer’s specifications (not recommendations) regarding the preparation and administration of the drug or biological; or,
3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards
and principles include the various practice regulations in Arkansas, and current commonly accepted health standards established by
national organizations, boards, and councils. Medication error rate means the percentage of both significant and nonsignificant medication errors. Significant medication error means one which causes the resident discomfort or jeopardizes his or her health and
safety. Whether a medication error is significant is determined by consideration of the resident’s condition, the drug category, and the
frequency of the error. Non-significant medication error means a medication error that does not meet the definition of a significant
medication error.
c. Determining medication error rate The medication error rate is determined by dividing the number of errors by the opportunities for errors and multiplying the result by 100, and is expressed as Medication Error Rate = (Number of Errors Observed / the
Opportunities for Errors) X 100. The Number of Errors Observed is the total number of errors that the survey team observes, both significant and non-significant. The Opportunities for Errors includes all the doses the observed being administered plus the doses ordered but not administered.
703.1.3 The facility shall document in the resident’s record whether the resident or the facility is responsible for storing the resident’s medication.
703.1.4 The facility shall document in the resident’s record whether the resident will self-administer medication or the facility will administer medication to the resident.
703.1.5 Residents who have been assessed to manage their medications must be familiar with their medications and comprehend administration instructions.
703.1.6 Facility staff shall provide assistance to enable residents to manage their medications. For clarification, examples for acceptable practices are listed below:
1. The medication regimen on the container label may be read to the resident;
2. A larger sterile or disposable container may be provided to the resident if needed to prevent spillage. The containers shall not be
shared by residents.
3. The resident may be reminded of the time to take the medication and be observed to ensure that the resident follows the directions
on the container;
4. Facility staff may assist residents in the management of their medications by:
a. taking the medication in its container from the area where it is stored and handing the container with the medication in it to the resident.
b. In the presence of the resident, facility staff may remove the container cap or loosen the packaging. If the resident is physically
impaired but cognitively able (has awareness with perception, reasoning, intuition and memory), facility staff, upon request by or
with the consent of the resident, may assist the resident in removing oral medication from the container and in taking the
medication.
c. If the resident is physically unable to place a dose of oral medication in his or her mouth without spilling or dropping it,
facility staff may place the dose of medication in another container and place that container to the mouth of the resident;
703.1.7 Changes in dosage or schedule of the medication shall be made only upon the authorization of the resident’s physician or advance practice nurse. This regulation is not applicable to residents who manage their own medications.
703.2 Medication Storage
703.2.1 All medications stored for residents by the facility must be stored in a locked area or a locked medication cart labeled with the resident’s name. Provided, however, that if the resident administers his or her own medication, the resident shall have access to his or her medication.
703.2.2 Medications may be kept in the residents’ apartments or units. Prior to a resident being permitted to keep medications in his or her apartment or unit, the facility shall:
a. Assess the resident to determine the resident’s understanding of, and ability to follow, the instructions on the prescription or label,
and the understanding of and ability to follow storage requirements or recommendations on the prescription or label, or as made by the
pharmacist or facility employees;
b. Document the assessment in the resident’s records. The assessment shall include at a minimum:
1. Date of assessment;
2. Name of person performing assessment; and,
3. The information obtained by the assessment that indicated the resident’s ability to understand and follow prescription
or label directions and instructions;
c. Assess all residents to determine whether any resident may be at risk of taking, or introducing into their system, medications kept in
the room of another resident. In the event that any resident is found to be at risk due to medications being kept in an unsecured
room, the facility shall take actions to protect the resident, including but not limited to, requiring that medications be kept in a
locked container in residents’ rooms or that the rooms of residents keeping medication in their rooms be locked.
d. Residents who have been assessed and are able to manage their own medications may determine which medications they will keep
in their rooms to self-administer and which if any, they will request the facility to store. The assessment shall be documented in the
residents occupancy admission agreement. After the initial assessment, facilities shall perform reassessments as needed, including upon changes of conditions of residents, and shall perform the steps outlined in subsections (a) through (c), above. Failure to
assess or reassess, or to identify residents at risk of harm from medications in unsecured locations or rooms, shall constitute a deficient facility practice. Resulting harm from a failure to assess or reassess, or to identify residents at risk of harm from medications in unsecured locations or rooms, shall constitute a deficient facility practice.
703.2.3 Medications must be stored in an environment that is clean, dry and not exposed to extreme temperature ranges. Medications requiring cold storage shall be refrigerated. A locked container placed below food level in a facility’s refrigerator is acceptable storage.
703.2.4 All drugs on the premises of the facility shall be labeled in accordance with accepted professional principles and practices.
703.2.5 Prescriptive medications must be properly labeled in accordance with current applicable laws and regulations pertaining to the practice of pharmacy.
7032.6 All medications in the control or care of the facility shall have an expiration date that is not expired.
703.2.7 Medications must be individually labeled with the resident’s name and kept in the original container unless the resident or responsible party transfers the medication into individual dosage containers. Under no circumstances may an owner or personnel of the facility repackage medication.
703.2.8 Any medication that is stored by the facility that has been prescribed for but is no longer in use by a resident must be destroyed or disposed of in accordance with state law or may be given to the resident’s family in accordance with this section. Any medication stored by the facility that has been placed on hold status by the resident’s physician or advance practice nurse may be transferred to a locked medication cabinet in a locked office for future use by the resident. Upon physician notice to resume the mediation, all current medication labeling must be in accordance with 703.2.5
Scheduled II, III, IV and V drugs dispensed by prescription for a resident and no longer needed by the resident must be delivered in person or by registered mail to: Drug Control Division, Arkansas Department of Health, along with the Arkansas Department of Health’s Form (PHA-DC1) Report of Drugs surrendered for Disposition According to Law. When unused portions of controlled drugs go with a resident who leaves the facility, the person who assumes responsibility for the resident and the person in charge of the medications for the facility shall sign the Controlled Drug Record in the facility. This shall be done only on the written order of the physician or advance practice nurse and at the time that the resident is discharged, transferred or visits home. All other medications not taken out of the facility when the resident leaves the facility shall be destroyed or returned in accordance with law and applicable regulations.
703.2.9 Under no circumstance will one resident’s medication that is under the facility’s control be shared with another resident.
703.2.10 For all medication that is stored by the facility, the facility must remove from use:
1. Outdated or expired medication or drugs;
2. Drug containers with illegible or missing labels;
3. Drugs and biologicals discontinued by the physician or advance practice nurse.
All such medications shall be destroyed or returned in accordance with law and applicable regulations.
703.2.11 All controlled drugs or substances stored by the facility shall be stored in a locked, permanently affixed, substantially constructed cabinet within a locked room designed for the storage of drugs. When mobile medication carts for unit-dose or multiple day card systems are used, the cart must be:
1. In a locked room when the cart is not in use and the unit contains controlled drugs;
2. When the cart is in use, the facility shall ensure that the cart remains in the observation of staff utilizing the cart, and that
residents are not able to access the cart or obtain medications from the cart. Controlled substances of less than minimal quantity shall be stored in a separately locked compartment within the cart. Minimal quantity means a twenty-four (24) hour or less supply.
703.2.12 In all cases in which the facility destroys drugs, destruction shall be made by a nurse, and witnessed by a non-licensed employee. A record shall be made of the date, quantity, prescription number and name, resident’s name, and strength of the medication. Destruction shall comply with state laws and regulations governing the destruction of drugs. The record of the destruction shall be recorded in a bound ledger, in ink, with consecutively numbered pages, and retained by the facility as a permanent, retrievable
record.
703.2.13 Reporting Misappropriation of controlled Substances. Reporting misappropriation of controlled substances shall be in accordance with theArkansas Department of Health Pharmacy Services Branch rules and regulations.
703.3 Medication Charting
703.3.1 If a facility stores a resident’s medications, the facility shall maintain a list
of those medications.
703.3.2 If the facility stores and supervises a resident’s medication, a notation must be made on the individual record for each resident who refuses, either through affirmative act, omission, or silence, or is unable, to self administer his or her medications. The notation shall include the date, time and dosage of medication that was not taken or administered to or by the resident, including a notation that the resident’s attending physician or advance practice nurse was notified, as required by physician or advance
practice nurse’s orders.
703.3.3 If medications are prescribed to be taken as needed (PRN) by the resident, documentation in the resident’s file should list the medication, the date and time received by the resident and the reason given.
703.3.4 A record shall be maintained in a bound ledger book, in ink, with consecutively numbered pages, of all controlled drugs procured or administered. The record shall contain:
1. Name, strength and quantity of drug;
2. Date received and date, time and dosage administered;
3. Name of the resident for whom the drug was prescribed, or received the drug;
4. Name of the prescribing physician or advance practice nurse;
5. Name of the dispensing pharmacy;
6. Quantity of drug remaining after each administrated dosage;
7. Signature of the individual administering the drug.
703.3.5 When a dose of a controlled drug, managed by the facility, is dropped, broken or lost, two (2) employees shall record in the record the facts of the event, and sign or otherwise identify themselves for the record.
703.3.6 For all medications stored by the facility, there shall be a weekly count of all Scheduled II, III, IV and V controlled medications. The count shall be made by the person responsible for medications in the facility, and shall be witnessed by a non-licensed employee. The count shall be documented by both employees, and shall include the date and time of the event, a statement as to whether the count was correct, and if incorrect, an explanation of the discrepancy. When the count is incorrect, the facility shall document as required under Section 703.3.4 above.
703.3.7 Medication administered by the facility shall be recorded in each resident’s medical record no less than once each shift in which the medication is administered. The notation shall be in ink, and shall state, at a minimum:
a. The name of the medication;
b. The dosage prescribed and the dosage taken or administered;
c. The method of administration; and,
d. The date and time of the administration.
703.3.8 Cycle Fill and Change of Condition
Only oral solid medications may be cycle-filled. Provided, however, that if an oral solid medication meets one of the categories below, then that oral solid medication may not be cycle-filled.
a. PRN or “as needed” medications
b. Controlled drugs (CII – CV)
c. Refrigerated medications
d. Antibiotics
e. Anti-infectives
An assisted living facility shall notify the pharmacy in writing of any change of condition or circumstance that affects the medication status of a resident. For purposes of this section, change of condition or circumstance includes death, discharge or transfer of a resident, change of pharmacy, as well as medical changes of condition or circumstance that necessitate a change to the medication prescribed or the dosage given. The notification shall be made within twenty-four (24) hours of the change of condition or circumstance. If the notification would occur after 4:30 p.m. Monday through Friday, or would occur on a weekend or holiday, the facility shall notify the pharmacy by no later than 11:00 a.m. the next business day. Documentation for drugs ordered, changed or discontinued shall be
retained by the facility for a period of no less than fifteen (15) months. When a resident is transferred or enters a hospital, the assisted living facility shall hold all medication until the return of the resident, unless otherwise directed by the authorized prescriber. All continued or reordered medications will be placed in active medication cycles upon the return of the resident. If the resident does not return to the assisted living facility, any medications held by the assisted living facility shall be placed with other medications or drugs for destruction as described in Section
703.2.10 or return as permitted by State Board of Pharmacy regulations.
703.4 PHARMACEUTICAL SERVICES
703.4.1 Responsibility for Pharmacy Compliance
The administrator shall be responsible for full compliance with Federal and State laws governing procurement, control and administration of all drugs. Full compliance is expected with the Comprehensive Drug Abuse Prevention and Control Act of 1970, Public Law 91-513 and all amendments of this set and all regulations and rulings passed down by the Federal Drug Enforcement Agency (DEA), Arkansas Act No. 590 and all amendments to it and these rules and regulations. Each facility shall contract with, or otherwise employ, a consultant pharmacist. For purposes of these regulations, consultant pharmacist means an individual licensed or certified by the Arkansas State Board of Pharmacy as a Consultant Pharmacist in Charge.
The consultant pharmacist shall, at least quarterly per year:
1. Review the methods employed by the facility to store, label, distribute, administer and safeguard all medication. The consultant
pharmacy shall prepare a written report to the facility detailing:
a. Any areas in which the consultant pharmacist determines that the methods employed by the facility are deficient, or
have the potential to adversely affect the health, safety or welfare of residents; and
b. The recommended alterations to the methods, or additions to the methods, to correct any methods determined by the
consultant pharmacist to have the potential to adversely affect the health, safety or welfare of residents.
2. Review all orders for medication prescribed since the last review and prepare a report to the facility detailing:
a. All instances in which medication has been improperly prescribed or administered; and
b. Instances in which, in the opinion of the consultant pharmacist, the facility should seek physician review of the
number or types of prescribed medications for residents. The facility shall retain the consultant pharmacist’s reports for a period of
eighteen (18) months or until the facility review, whichever is the longer period.
703.4.2 Prescriptions On Individual Basis
All drugs prescribed for each resident shall be on an individual prescription basis. Medications prescribed for one resident shall not be
administered to another resident.
703.5 Influenza Immunization of Residents
a. The facility shall ensure that all Medicare-eligible residents receive annual influenza immunizations except when:
1. Objection is made on religious grounds; or,
2. Immunization is medically contra-indicated.
b. The facility shall record the following information:
1. The name of the resident;
2. The date that the immunization occurred;
3. The exception applicable to each resident who was not immunized.
c. The facility shall place the documentation in each resident’s medical chart and retain the record in the same manner, and for the
same time period, as medical records.
704 COMPLIANCE AGREEMENTS
The Level II licensed assisted living facility shall not admit any resident whose needs are greater than the facility is licensed to provide. The assisted living facility shall not provide services to residents who:
a. need 24-hour nursing services;
b. are bedridden;
c. has a temporary (more than fourteen (14) consecutive days) or terminal condition unless a physician or advance practice nurse certifies the resident’s needs may be safely met by a service agreement developed by the assisted living facility, the attending physician or advance practice nurse, a registered nurse, the resident or his or her responsible party if the resident is incapable of making decisions, and other appropriate health care professionals as determined by the resident’s needs;
d. have transfer assistance needs that the facility cannot meet with current staffing;
e. present a danger to self or others or engages in criminal activities.
The choice and independence of action of a resident may need to be limited when a resident’s individual choice, preference, or actions, are identified as placing the resident or others at risk, lead to adverse outcomes, or violate the norms of the facility or program or the majority of the residents, or any combination of these events.
No resident shall be permitted to remain in an assisted living facility if his or her condition requires twenty-four (24) hour nursing care or other services that a Level II assisted living facility is not authorized by law or these regulations to provide. This prohibition applies even if the resident is willing to execute an agreement relieving the facility of responsibility attendant to the resident’s continued placement. When the resident evaluation indicates that there is a high probability that a choice or action of the resident has resulted or will result in any of the outcomes of placing the resident or others at risk, leading to adverse outcomes, violating the norms of the facility or program or the majority of the residents, or any combination of the events, the assisted living facility shall:
1. Identify the specific concern(s);
2. Provide the resident or his or her responsible party (and if the resident agrees, the resident’s family) with clear, understandable
information about the possible consequences of his or her choice or action;
3. Negotiate a compliance agreement with the resident or his or her responsible party that will minimize the possible risk and adverse
consequences while still respecting the resident’s preferences. Nothing in this provision requires a facility to successfully
negotiate a compliance agreement;
4. Document the process of negotiation and, if no agreement can be reached, the lack of agreement and the decisions of the parties
involved. Any compliance agreements negotiated, or attempted to be negotiated, with the resident or his or her responsible party shall address the following areas in writing:
1. Consequence to resident – any situation or condition that is or should be known to the facility that involves a course of action
taken or desired to be taken by the resident contrary to the practice or advice of the facility and could put the resident at risk of harm
or injury;
2. The probable consequences if the resident continues the choice or action identified as a cause for concern;
3. The resident or his or her responsible party’s preference concerning how the situation is to be handled and the possible
consequences of action on that preference;
4. What the facility will and will not do to meet the resident’s needs and comply with the resident’s preference to the identified course
of action;
5. Alternatives offered by the assisted living facility or resident or his or her responsible party to reduce the risk or mitigate the
consequences relating to the situation or condition;
6. The agreed-upon course of action, including responsibilities of both the resident or his or her responsible party and the facility;
7. The resident or his or her responsible party’s understanding and acceptance of responsibility for the outcome from the agreed-upon
course of action and written proof that the resident or his or her responsible party is making an informed decision, free from
coercion, and that the refusal of the resident or his or her responsible party to enter into a compliance agreement with the
facility, or to revise the compliance agreement or to comply with the terms of the compliance agreement may result in discharge
from the facility;
8. The date the agreement is executed and, if needed, the timeframes in which the agreement will be reviewed.
A copy of the compliance agreement shall be provided to the resident or his or her responsible party, and the original shall be placed in the resident’s record at the time it is implemented.