0086 Administration and Management -Deficiency
(a) The licensee:
(1) is responsible for compliance with all applicable laws; and
(2) has full authority and responsibility for the:
(C) operation; and
(D) control of the licensed facility.
The delegation of any authority by the licensee does not
diminish the responsibilities of the licensee.
0087 Administration and Management -Noncompliance
(b) The licensee shall provide the number of staff as required
to carry out all the functions of the facility, including the
(1) Initial orientation of all employees.
(2) A continuing in-service education and training program
for all employees.
(3) Provision of supervision for all employees.
0088 Administration and Management -Noncompliance
(c) The licensee shall:
(1) appoint an administrator with either a:
(A) comprehensive care facility administrator license as
required by IC 25-19-1-5(c); or
(B) residential care facility administrator license as required
by IC 25-19-1-5(d); and
(2) delegate to that administrator the authority to organize and
implement the day-to-day operations of the facility.
(d) The licensee shall notify the director:
(1) within three (3) working days of a vacancy in the
administrator’s position; and
(2) of the name and license number of the replacement administrator..
0089 Administration and Management -Noncompliance
(e) An administrator shall be employed to work in each
licensed health facility. For purposes of this subsection, an
individual can only be employed as an administrator in one (1):
(1) health facility; or
(2) hospital-based long-term care unit at a time.
(f) In the administrator’s absence, an individual shall be
authorized, in writing, to act on the administrator’s behalf.
0090 Administration and Management -Deficiency
(g) The administrator is responsible for the overall
management of the facility. The responsibilities of the
administrator shall include, but are not limited to, the
(1) Informing the division within twenty-four (24) hours of
becoming aware of an unusual occurrence that directly
threatens the welfare, safety, or health of a resident. Notice of
unusual occurrence may be made by telephone, followed by a
written report, or by a written report only that is faxed or sent
by electronic mail to the division within the twenty-four (24)
hour time period. Unusual occurrences include, but are not
(A) epidemic outbreaks;
(C) fires; or
(D) major accidents.
If the division cannot be reached, a call shall be made to the
emergency telephone number published by the division.
(2) Promptly arranging for or assisting with the provision of
medical, dental, podiatry, or nursing care or other health care
services as requested by the resident or
resident’s legal representative.
(3) Obtaining director approval prior to the admission of an
individual under eighteen (18) years of age to an adult
(4) Ensuring the facility maintains, on the premises, an
accurate record of actual time worked that indicates the:
(A) employee’s full name; and
(B) dates and hours worked during the past twelve (12)
(5) Posting the results of the most recent annual survey of the
facility conducted by state surveyors, any plan of correction
in effect with respect to the facility, and any subsequent
surveys. The results must be available for examination in the
facility in a place readily accessible to residents and a notice
posted of their availability.
(6) Maintaining reports of surveys conducted by the division
in each facility for a period of two (2) years and making the
reports available for inspection to any member of the public
0091 Administration and Management – Noncompliance
410 IAC 16.2-5-1.3(h)(1-4)
(h) The facility shall establish and implement a written policy
manual to ensure that resident care and facility objectives are
attained, to include the following:
(1) The range of services offered.
(2) Residents’ rights.
(3) Personnel administration.
(4) Facility operations.
The policies shall be made available to residents upon
0092 Administration and Management -Noncompliance
(i) The facility must maintain a written fire and disaster
preparedness plan to assure continuity of care of residents in
cases of emergency as follows:
(1) Fire exit drills in facilities shall include the transmission of
a fire alarm signal and simulation of emergency fire
conditions, except that the movement of nonambulatory
residents to safe areas or to the exterior of the building is not
required. Drills shall be conducted quarterly on each shift to
familiarize all facility personnel with signals and emergency
action required under varied conditions. At least twelve (12)
drills shall be held every year. When drills are conducted
between 9 p.m. and 6 a.m., a coded announcement may be
used instead of audible alarms.
(2) At least every six (6) months, a facility shall attempt to
hold the fire and disaster drill in conjunction with the local
fire department. A record of all training and drills shall be
documented with the names and signatures of the personnel
0093 Administration and Management -Noncompliance
(j) If professional or diagnostic services are to be provided to
the facility by an outside resource, either individual or
institutional, an arrangement shall be developed between the
licensee and the outside resource for the provision of the
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services. If a written agreement is used, it shall specify the
(1) the responsibilities of both the facility and the outside
(2) the qualifications of the outside resource staff;
(3) a description of the type of services to be provided,
including action taken and reports of findings; and
(4) the duration of the agreement
0094 Administration and Management-Nonconformance
410 IAC 16.2-5-1.3(k)
(k) The facility shall conspicuously post the license or a true
copy thereof within the facility in a location accessible to public view.
0095 Administration and Management-Noncompliance
(l) In facilities that are required under IC 12-10-5.5 to submit
an Alzheimer’s and dementia special care unit disclosure
form, the facility must designate a director for the Alzheimer’s
and dementia special care unit. The director shall have an
earned degree from an educational institution in a health care,
mental health, or social service profession or be a licensed
health facility administrator. The director shall have a
minimum of one (1) year work experience with dementia or
Alzheimer’s residents, or both, within the past five (5) years.
Persons serving as a director for an existing Alzheimer’s and
dementia special care unit at the time of adoption of this rule
are exempt from the degree and experience requirements. The
director shall have a minimum of twelve (12) hours of
dementia-specific training within three (3) months of initial
employment as the director of the Alzheimer’s and dementia
special care unit and six (6) hours annually thereafter to:
(1) meet the needs or preferences, or both, of cognitively
impaired residents; and
(2) gain understanding of the current standards of care for
residents with dementia.
0096 Administration and Management -Deficiency
(m) The director of the Alzheimer’s and dementia special care
unit shall do the following:
(1) Oversee the operation of the unit.
(2) Ensure that:
(A) personnel assigned to the unit receive required in-service
(B) care provided to Alzheimer’s and dementia care unit
residents is consistent with:
(i) in-service training;
(ii) current Alzheimer’s and dementia care practices; and
(iii) regulatory standards.