RESIDENT CARE AND RELATED SERVICES | VA

22VAC40-73-440. Uniform assessment instrument (UAI).

 

1. All residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.

 

1. For private pay individuals, the UAI shall be completed by one of the following qualified assessors:

 

1. An assisted living facility staff person who has successfully completed state-approved training on the uniform assessment instrument and level of care criteria foreither public or private pay assessments, provided the administrator or the administrator’s designated representative has successfully completed such training and approves and then signs the completed UAI, and the facility maintains documentation of completed training;

    

   2. An independent physician; or

    

   3. A qualified public human services agency assessor.

    

   1. For a private pay individual, if the UAI is completed by an independent physician or a qualified human services agency assessor, the assisted living facility shall be responsible for coordinating with the physician or the agency assessor to ensure that the UAI is completed as required.

    

   110. For private pay individuals, the assisted living facility shall ensure that the uniform assessment instrument is completed as required by 22VAC30-110.

    

   110. For public pay individuals, the UAI shall be completed by a case manager or qualified assessor as specified in 22VAC30-110.

    

   1. The UAI shall be completed within 90 days prior to admission to the assisted living facility, except that if there has been a change in the resident’s condition since the completion of the UAI that would affect the admission, a new UAI shall be completed.

    

   1. When a resident moves to an assisted living facility from another assisted living facility or other long-term care setting that uses the UAI, if there is a completed UAI on record, another UAI does not have to be completed except that a new UAI shall be completed whenever:

    

   1. There is a significant change in the resident’s condition; or

    

   2. The previous assessment is more than 12 months old.

    

   1. Annual reassessments and reassessments due to a significant change in the resident’s condition, using the UAI, shall be utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.

    

   1. During an inspection or review, staff from the department, the Department of Medical Assistance Services, or the local department of social services may initiate a change in level of care for any assisted living facility resident for whom it is determined that the resident’s UAI is not reflective of the resident’s current status.

    

   1. At the request of the assisted living facility, the resident’s legal representative, the resident’s physician, the department, or the local department of social services an

22VAC40-73-440. Uniform assessment instrument (UAI).

 

independent assessment using the UAI shall be completed to determine whether the resident’s care needs are being met in the assisted living facility. The assisted living facility shall assist in obtaining the independent assessment as requested. An independent assessment is one that is completed by a qualified entity other than the original assessor.

 

110. The assisted living facility shall be in compliance with the requirements set forth in 22VAC30-110.

 

1. The facility shall maintain the completed UAI in the resident’s record.

 

22VAC40-73-450. Individualized service plans.

 

1. On or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. The preliminary plan shall be developed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident, and, as appropriate, other individuals noted in subdivision B 1 of this section. The preliminary plan shall be identified as such and be signed and dated by the licensee, administrator, or his designee (i.e., the person who has developed the plan), and by the resident or his legal representative.

 

EXCEPTION: A preliminary plan of care is not necessary if a comprehensive individualized service plan is developed, in conformance with this section, on the day of admission.

 

1. The licensee, administrator, or his designee who has successfully completed the department-approved individualized service plan (ISP) training, provided by a licensed health care professional practicing within the scope of his profession, shall develop a comprehensive ISP to meet the resident’s service needs. State approved private pay UAI training must be completed as a prerequisite to ISP training. An individualized service plan is not required for those residents who are assessed as capable of maintaining themselves in an independent living status.

 

1. The licensee, administrator, or designee shall develop the ISP in conjunction with the resident and, as appropriate, with the resident’s family, legal representative, direct care staff members, case manager, health care providers, qualified mental health professionals, or other persons.

 

2. The plan shall support the principles of individuality, personal dignity, freedom of choice, and home-like environment and shall include other formal and informal supports in addition to those included in subdivision C 2 of this section that may participate in the delivery of services. Whenever possible, residents shall be given a choice of options regarding the type and delivery of services.

 

3. The plan shall be designed to maximize the resident’s level of functional ability.

 

22VAC40-73-450. Individualized service plans.

 

1. The comprehensive individualized service plan shall be completed within 30 days after admission and shall include the following:

 

1. Description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources;

 

2. A written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them;

 

3. When and where the services will be provided;

 

4. The expected outcome and time frame for expected outcome;

 

5. Date outcome achieved; and

 

6. For a facility licensed for residential living care only, if a resident lives in a building housing 19 or fewer residents, a statement that specifies whether the resident does or does not need to have a staff member awake and on duty at night.

 

1. When hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan.

 

1. The individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person who was involved in the development of the plan shall be included. These requirements shall also apply to reviews and updates of the plan.

 

1. Individualized service plans shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident’s family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.

 

1. The master service plan shall be filed in the resident’s record. A current copy shall be provided to the resident and shall also be maintained in a location accessible at all times to direct care staff, but that protects the confidentiality of the contents of the service plan. Extracts from the plan may be filed in locations specifically identified for their retention.

22VAC40-73-450. Individualized service plans.

 

1. The facility shall ensure that the care and services specified in the individualized service plan are provided to each resident, except that:

 

1. There may be a deviation from the plan when mutually agreed upon between the facility and the resident or the resident’s legal representative at the time the care or services are scheduled or when there is an emergency that prevents the care or services from being provided.

 

2. Deviation from the plan shall be documented in writing, including a description of the circumstances, the date it occurred, and the signatures of the parties involved, and the documentation shall be retained in the resident’s record.

 

3. The facility may not start, change, or discontinue medications, dietary supplements, diets, medical procedures, or treatments without an order from a physician or other prescriber.

 

22VAC40-73-460. Personal care services and general supervision and care.

 

1. The facility shall assume general responsibility for the health, safety, and well-being of the residents.

 

1. Care provision and service delivery shall be resident-centered to the maximum extent possible and include:

 

1. Resident participation in decisions regarding the care and services provided to him;

 

2. Personalization of care and services tailored to the resident’s circumstances and preferences; and

 

3. Prompt response by staff to resident needs as reasonable to the circumstances.

 

1. Care shall be furnished in a way that fosters the independence of each resident and enables him to fulfill his potential.

 

1. The facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.

 

1. The facility shall regularly observe each resident for changes in physical, mental, emotional, and social functioning.

 

1. Any notable change in a resident’s condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident’s record.

22VAC40-73-460. Personal care services and general supervision and care.

 

2. The facility shall provide appropriate assistance when observation reveals unmet needs.

 

1. The facility shall notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling or wandering from the premises, whether or not it results in injury. This notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident. The resident’s record shall include documentation of the notification, including date, time, caller, and person or agency notified.

 

EXCEPTION: If the whereabouts of a resident are unknown and there is reason to be concerned about his safety, the facility shall immediately notify the appropriate law-enforcement agency. The facility shall also immediately notify the resident’s next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency.

 

1. The facility shall provide care and services to each resident by staff who are able to communicate with the resident in a language the resident understands or shall make provisions for communications between staff and residents to ensure an accurate exchange of information.

 

1. The facility shall ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with:

 

1. The activities of daily living:

 

1. Bathing – at least twice a week, but more often if needed or desired;

 

1. Dressing;

 

1. Toileting;

 

1. Transferring;

 

1. Bowel control;

 

1. Bladder control; and

 

1. Eating/feeding;

 

2. The instrumental activities of daily living:

 

1. Meal preparation;

 

1. Housekeeping;

22VAC40-73-460. Personal care services and general supervision and care.

 

1. Laundry; and

 

1. Managing money;

 

3. Ambulation;

 

4. Hygiene and grooming:

 

1. Shampooing, combing, and brushing hair;

 

1. Shaving;

 

1. Trimming fingernails and toenails (certain medical conditions necessitate that this be done by a licensed health care professional);

 

1. Daily tooth brushing and denture care; and

 

1. Skin care at least twice daily for those with limited mobility; and

 

5. Functions and tasks:

 

1. Arrangements for transportation;

 

1. Arrangements for shopping;

 

1. Use of the telephone; and

 

 

1. Each resident shall be dressed in clean clothing and be free of odors related to hygiene. Each resident shall be encouraged to wear day clothing when out of bed.

 

1. Residents who are incontinent shall have a full or partial bath and clean clothing and linens each time their clothing or bed linen is soiled or wet.

 

1. The facility shall ensure each resident is able to obtain individually preferred personal care items when:

 

1. The preferred personal care items are reasonably available; and

 

2. The resident is willing and able to pay for the preferred items.

22VAC40-73-470. Health care services.

 

1. The facility shall ensure, either directly or indirectly, that the health care service needs of residents are met. The ways in which the needs may be met include:

 

1. Staff of the facility providing health care services;

 

2. Persons employed by a resident providing health care services; or

 

3. The facility assisting residents in making appropriate arrangements for health care services.

 

1. When a resident is unable to participate in making appropriate arrangements, the resident’s family, legal representative, designated contact person, cooperating social agency, or personal physician shall be notified of the need.

 

1. When mental health care is needed or desired by a resident, this assistance shall include securing the services of the local community services board, behavioral health authority, state or federal mental health clinic, or similar facility or agent in the private sector.

 

1. A resident’s need for skilled nursing treatments within the facility shall be met by the facility’s employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse.

 

1. Services shall be provided to prevent clinically avoidable complications, including:

 

1. Pressure ulcer development or worsening of an ulcer;

 

2. Contracture;

 

3. Loss of continence;

 

4. Dehydration; and

 

 

1. The facility shall develop and implement a written policy to ensure that staff are made aware of allergies and allergic reactions and any life-threatening conditions of residents, and actions that staff may need to take.

 

1. When care for gastric tubes is provided to a resident by unlicensed direct care facility staff as allowed in clause (ii) of 22VAC40-73-310 K, the following criteria shall be met:

 

1. Prior to the care being provided, the facility shall obtain an informed consent, signed by the resident or his legal representative, that includes at a minimum acknowledgment that:

22VAC40-73-470. Health care services.

 

1. An unlicensed person will routinely be providing the gastric tube care and feedings under the delegation of a registered nurse (RN) who has assessed the resident’s care needs and the unlicensed person’s ability to safely and adequately meet those needs;

 

1. Delegation means the RN need not be present in the facility during routine gastric tube care and feedings;

 

1. Registered medication aides are prohibited from administering medications via gastric tubes and medications may only be administered by licensed personnel (e.g., a licensed practical nurse (LPN) or RN);

 

1. The tube care and feedings provided to the resident and the supervisory oversight provided by the delegating RN will be reflected on the individualized service plan as required in 22VAC40-73-450; and

 

1. The signed consent shall be maintained in the resident’s record.

 

2. Only those direct care staff with written approval from the delegating RN may provide the tube care and feedings. In addition to the approval, the RN shall document:

 

1. The general and resident-specific instructions he provided to the staff person; and

 

1. The staff person’s successful demonstration of competency in tube care.

 

3. The delegating RN shall be employed by or under contract with the licensed assisted living facility and shall have supervisory authority over the direct care staff being approved to provide gastric tube care and feedings.

 

4. The supervisory responsibilities of the delegating RN include:

 

1. Monitoring the direct care staff performance related to the delegated tasks;

 

1. Evaluating the outcomes for the resident;

 

1. Ensuring appropriate documentation; and

 

1. Documenting relevant findings and recommendations.

 

5. The delegating RN shall schedule supervisory oversight based upon the following criteria:

 

1. The stability and condition of the resident;

22VAC40-73-470. Health care services.

 

1. The experience and competency of the unlicensed direct care staff person;

 

1. The nature of the tasks or procedures being delegated; and

 

1. The proximity and availability of the delegating RN to the unlicensed direct care staff person when the nursing tasks will be performed.

 

6. Prior to allowing direct care staff to independently perform care for gastric tubes as provided for in this subsection, such staff must be able to successfully demonstrate performance of the entire procedure correctly while under direct observation of the delegating RN. Subsequently, each direct care staff shall be directly observed no less than monthly for at least three consecutive months, after which direct observation shall be conducted no less than every six months or more often if indicated. The delegating RN shall retain documentation at the facility of all supervisory activities and direct observations of staff.

 

7. Contact information for the delegating RN shall be readily available to all staff responsible for tube feedings when an RN or LPN is not present in the facility.

 

8. Written protocols that encompass the basic policies and procedures for the performance of gastric tube feedings, as well as any resident-specific instructions, shall be available to any direct care staff member responsible for tube feedings.

 

9. The facility shall have a written back-up plan to ensure that an RN, LPN, or person who is qualified as specified in this subsection is available if the direct care staff member who usually provides the care is absent.

 

1. When the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The circumstances involved and the medical attention received or refused shall be documented in the resident’s record. The date and time of occurrence, as well as the personnel involved shall be included in the documentation.

 

1. The resident’s physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident’s refusal of medical attention. If a resident refuses medical attention, the resident’s physician shall be notified immediately.

 

2. A notation shall be made in the resident’s record of such notice, including the date, time, caller, and person notified.

22VAC40-73-470. Health care services.

 

1. If a resident refuses medical attention, the facility shall assess whether it can continue to meet the resident’s needs.

 

22VAC40-73-480. Restorative, habilitative, and rehabilitative services.

 

1. Facilities shall ensure that all restorative care and habilitative service needs of the residents are met. Facilities shall coordinate with appropriate professional service providers and ensure that any facility staff who assist with support for these service needs are trained by and receive direction from qualified professionals. Restorative and habilitative care includes range of motion, assistance with ambulation, positioning, assistance and instruction in the activities of daily living, psychosocial skills training, and reorientation and reality orientation.

 

1. In the provision of restorative and habilitative care, staff shall emphasize services such as the following:

 

1. Making every effort to keep residents active, within the limitations set by physicians’ or other prescribers’ orders;

 

2. Encouraging residents to achieve independence in the activities of daily living;

 

3. Assisting residents to adjust to their disabilities, to use their prosthetic devices,

 

and to redirect their interests if they are no longer able to maintain past involvement in particular activities;

 

4. Assisting residents to carry out prescribed physical therapy exercises between appointments with the physical therapist; and

 

5. Maintaining a bowel and bladder training program.

 

1. Facilities shall arrange for specialized rehabilitative services by qualified personnel as needed by the resident. Rehabilitative services include physical therapy, occupational therapy, and speech-language pathology services. Rehabilitative services may be indicated when the resident has lost or has shown a change in his ability to respond to or perform a given task and requires professional rehabilitative services in an effort to regain lost function. Rehabilitative services may also be indicated to evaluate the appropriateness and individual response to the use of assistive technology.

 

1. All rehabilitative services rendered by a rehabilitative professional shall be performed only upon written medical referral by a physician or other qualified health care professional.

 

1. The physician’s or other prescriber’s orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services shall be recorded in the resident’s record.

22VAC40-73-480. Restorative, habilitative, and rehabilitative services.

 

1. Direct care staff who are involved in the care of residents using assistive devices shall know how to operate and utilize the devices.

 

22VAC40-73-490. Health care oversight.

 

1. Each assisted living facility shall retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight.

 

1. For residents who meet the criteria for residential living care:

 

1. The licensed health care professional, practicing within the scope of his profession, shall provide health care oversight at least every six months, or more often if indicated, based on his professional judgment of the seriousness of a resident’s needs or the stability of a resident’s condition; or

 

1. If the facility employs a licensed health care professional who is on site on a full-time basis, a licensed health care professional, practicing within the scope of his profession, shall provide health care oversight at least annually, or more often if indicated, based on his professional judgment of the seriousness of a resident’s needs or stability of a resident’s condition.

 

2. For residents who meet the criteria for assisted living care:

 

1. The licensed health care professional, practicing within the scope of his profession, shall provide health care oversight at least every three months, or more often if indicated, based on his professional judgment of the seriousness of

• resident’s needs or stability of a resident’s condition; or

 

1. If the facility employs a licensed health care professional who is on site on a full-time basis, a licensed health care professional, practicing within the scope of his profession, shall provide health care oversight at least every six months, or more often if indicated, based on his professional judgment of the seriousness of

• resident’s needs or stability of a resident’s condition.

 

3. All residents shall be included at least annually in health care oversight.

 

1. While on site, as specified in subsection A of this section, the licensed health care professional shall provide health care oversight of the following and make recommendations for change as needed:

 

1. Ascertain whether a resident’s service plan appropriately addresses the current health care needs of the resident.

22VAC40-73-490. Health care oversight.

 

2. Monitor direct care staff performance of health-related activities.

 

3. Evaluate the need for staff training.

 

4. Provide consultation and technical assistance to staff as needed.

 

5. Review documentation regarding health care services, including medication and treatment records, to assess that services are being provided in accordance with physicians’ or other prescribers’ orders.

 

6. Monitor conformance to the facility’s medication management plan and the maintenance of required medication reference materials.

 

7. Evaluate the ability of residents who self-administer medications to continue to safely do so.

 

8. Observe infection control measures and consistency with the infection control program of the facility.

 

1. For all restrained residents, on-site health care oversight shall be provided by a licensed health care professional at least every three months and include the following:

 

1. The licensed health care professional shall be at a minimum a registered nurse who meets the experience requirements in subdivision A of this section.

 

2. The licensed health care professional shall review the current condition and the records of restrained residents to assess the appropriateness of the restraint and progress toward its reduction or elimination.

 

3. The licensed health care professional providing the oversight for this subdivision shall also provide the oversight for subdivisions B 1 through B 8 of this section for restrained residents.

 

4. The oversight provided shall be a holistic review of the physical, emotional, and mental health of the resident and identification of any unmet needs.

 

5. The oversight shall include review of physician’s orders for restraints to determine whether orders are no older than three months, as required by 22VAC40-73-710 E

 

6. The oversight shall include an evaluation of whether direct care staff have received the restraint training required by 22VAC40-73-270 and whether the facility is meeting the requirements of 22VAC40-73-710 regarding the use of restraints.

22VAC40-73-490. Health care oversight.

 

7. The licensed health care professional shall make recommendations for change as needed.

 

1. The licensed health care professional who provided the health care oversight shall certify that the requirements of subsection B and, if applicable, C of this section were met, including the dates of the health care oversight. The specific residents for whom the oversight was provided must be identified. The administrator shall be advised of the findings of the health care oversight and any recommendations. All of the requirements of this subsection shall be (i) in writing, (ii) signed and dated by the health care professional, (iii) provided to the administrator within 10 days of the completion of the oversight, and (iv) maintained in the facility files for at least two years, with any specific recommendations regarding a particular resident also maintained in the resident’s record.

 

1. Action taken in response to the recommendations noted in subsection D of this section shall be documented in the resident’s record if resident specific, and if otherwise, in the facility files.

 

22VAC40-73-500. Access by community services boards, certain local government departments, and behavioral health authorities.

 

All assisted living facilities shall provide reasonable access to staff or contractual agents of community services boards, local government departments with policy-advisory community services boards, or behavioral health authorities as defined in § 37.2-100 of the Code of Virginia for the purposes of:

 

1. Assessing or evaluating clients residing in the facility;

 

2. Providing case management or other services or assistance to clients residing in the facility; or

 

3. Monitoring the care of clients residing in the facility.

 

Such staff or contractual agents also shall be given reasonable access to other facility residents who have previously requested their services.

 

22VAC40-73-510. Mental health services coordination and support.

 

1. For each resident requiring mental health services, the services of the local community services board, behavioral health authority, or a public or private mental health clinic, rehabilitative services agency, treatment facility or agent, or qualified health care professional shall be secured as appropriate based on the resident’s current evaluation and to the extent possible, the resident’s preference for service provider. The assisted living facility shall assist the resident in obtaining the services. If the services are not able to be secured, the facility shall document the reason for such and the efforts made to obtain the

22VAC40-73-510. Mental health services coordination and support.

 

services. If the resident has a legal representative, the representative shall be notified of failure to obtain services and the notification shall be documented.

 

1. Written procedures to ensure communication and coordination between the assisted living facility and the mental health service provider shall be established to ensure that the mental health needs of the resident are addressed.

 

1. Efforts, which must be documented, shall be made by the assisted living facility to assist in ensuring that prescribed interventions are implemented, monitored, and evaluated for their effectiveness in addressing the resident’s mental health needs.

 

1. If efforts to obtain the recommended services are unsuccessful, the facility must document:

 

1. Whether it can continue to meet all other needs of the resident.

 

2. How it plans to ensure that the failure to obtain the recommended services will not compromise the health, safety, or rights of the resident and others who come in contact with the resident.

 

3. Details of additional steps the facility will take to find alternative providers to meet the resident’s needs.

 

1. Any contracts for mental health services between the facility and the mental health services provider:

 

1. Shall not contain terms that conflict with the regulations; and

 

2. Shall be provided to the regional licensing office within 10 days of entering into the contract.

 

22VAC40-73-520. Activity and recreational requirements.

 

1. Activities for residents shall:

 

1. Support the skills and abilities of residents in order to promote or maintain their highest level of independence or functioning;

 

2. Accommodate individual differences by providing a variety of types of activities and levels of involvement; and

 

3. Offer residents a varied mix of weekly activities including those that are physical; social; cognitive, intellectual, or creative; productive; sensory; reflective or contemplative; involve nature or the natural world; and weather permitting, outdoor

 

22VAC40-73-520. Activity and recreational requirements.

 

activity. Any given activity may involve more than one of these. Community resources as well as facility resources may be used to provide activities.

 

1. Resident participation in activities.

 

1. Residents shall be encouraged but not forced to participate in activity programs offered by the facility and the community.

 

2. During an activity, each resident shall be encouraged but not coerced to join in at his level of functioning, to include observing.

 

3. Any restrictions on participation imposed by a physician shall be documented in the resident’s record.

 

1. Activities shall be planned under the supervision of the administrator or other qualified staff person who shall encourage involvement of residents and staff in the planning.

 

1. In a facility licensed for residential living care only, there shall be at least 11 hours of scheduled activities available to the residents each week for no less than one hour each day.

 

1. In a facility licensed for both residential and assisted living care, there shall be at least 14 hours of scheduled activities available to the residents each week for no less than one hour each day.

 

1. During an activity, when needed to ensure that each of the following is adequately accomplished, there shall be staff persons or volunteers to:

 

1. Lead the activity;

 

2. Assist the residents with the activity;

 

3. Supervise the general area;

 

4. Redirect any residents who require different activities; and

 

5. Protect the health, safety, and welfare of the residents participating in the activity.

 

1. The staff person or volunteer leading the activity shall have a general understanding of the following:

 

1. Attention spans and functional levels of the residents;

 

2. Methods to adapt the activity to meet the needs and abilities of the residents;

22VAC40-73-520. Activity and recreational requirements.

 

3. Various methods of engaging and motivating residents to participate; and

 

4. The importance of providing appropriate instruction, education, and guidance throughout the activity.

 

1. Adequate supplies and equipment appropriate for the program activities shall be available in the facility.

 

1. There shall be a written schedule of activities that meets the following criteria:

 

1. The schedule of activities shall be developed at least monthly.

 

2. The schedule shall include:

 

 

1. Group activities for all residents or small groups of residents; and

 

1. The name, if any, and the type, date, and hour of the activity.

 

3. If one activity is substituted for another, the change shall be noted on the schedule.

 

4. The current month’s schedule shall be posted in a conspicuous location in the facility or otherwise be made available to residents and their families.

 

5. The schedule of activities for the past two years shall be kept at the facility.

 

6. If a resident requires an individual schedule of activities, that schedule shall be a part of the individualized service plan.

 

1. The facility shall promote access to the outdoors.

 

1. In addition to the required scheduled activities, there shall be unscheduled staff and resident interaction throughout the day that fosters an environment that promotes socialization opportunities for residents.

 

22VAC40-73-530. Freedom of movement.

 

1. Any resident who does not have a serious cognitive impairment shall be allowed to freely leave the facility. A resident who has a serious cognitive impairment shall be subject to the provisions set forth in 22VAC40-73-1040 A or 22VAC40-73-1150 A.

 

1. Doors leading to the outside shall not be locked from the inside or secured from the inside in any manner that amounts to a lock, except that doors may be locked or secured in a manner that amounts to a lock in special care units as provided in 22VAC40-73-1150 A.

22VAC40-73-530. Freedom of movement.

 

Any devices used to lock or secure doors in any manner must be in accordance with applicable building and fire codes.

 

1. The facility shall provide freedom of movement for the residents to common areas and to their personal spaces. The facility shall not lock residents out of or inside their rooms.

 

22VAC40-73-540. Visiting in the facility.

 

1. Daily visits to residents in the facility shall be permitted.

 

1. Visiting hours shall not be restricted, except by a resident when it is the resident’s choice.

 

1. The facility may establish a policy or guidelines so that visiting is not disruptive to other residents and facility security is not compromised. However, daily visits and visiting hours shall not be restricted as provided in subsections A and B of this section.

 

1. The facility shall encourage regular family involvement with the resident and shall provide ample opportunities for family participation in activities at the facility.

 

22VAC40-73-550. Resident rights.

 

1. The resident shall be encouraged and informed of appropriate means as necessary to exercise his rights as a resident and a citizen throughout the period of his stay at the facility.

 

1. The resident has the right to voice or file grievances, or both, with the facility and to make recommendations for changes in the policies and services of the facility. The residents shall be protected by the licensee or administrator, or both, from any form of coercion, discrimination, threats, or reprisal for having voiced or filed such grievances.

 

63. Any resident of an assisted living facility has the rights and responsibilities as provided in § 63.2-1808 of the Code of Virginia and this chapter.

 

63. The operator or administrator of an assisted living facility shall establish written policies and procedures for implementing § 63.2-1808 of the Code of Virginia.

 

63. The facility shall make its policies and procedures for implementing § 63.2-1808 of the Code of Virginia available and accessible to residents, relatives, agencies, and the general public.

 

1. The rights and responsibilities of residents shall be printed in at least 14-point type and posted conspicuously in a public place in all assisted living facilities. The facility shall also post the name and telephone number of the appropriate regional licensing supervisor of the department, the Adult Protective Services’ toll-free telephone number, the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any substate

22VAC40-73-550. Resident rights.

 

(i.e., local) ombudsman program serving the area, and the toll-free telephone number of the disAbility Law Center of Virginia.

 

1. The rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence of this review shall be the resident’s, his legal representative’s or responsible individual’s, or staff person’s written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident’s or staff person’s record.

 

63. If a resident is unable to fully understand and exercise the rights and responsibilities contained in § 63.2-1808 of the Code of Virginia and does not have a legal representative, the facility shall require that a responsible individual, of the resident’s choice when possible, designated in writing in the resident’s record annually be made aware of each item in

 

• 2-1808 and the decisions that affect the resident or relate to specific items in § 63.2-1808. The responsible individual shall not be the facility licensee, administrator, or staff person or family members of the licensee, administrator, or staff person.

 

1. A resident shall be assumed capable of understanding and exercising these rights unless a physician determines otherwise and documents the reasons for such determination in the resident’s record.

 

2. The facility shall seek a determination and reasons for the determination from a resident’s physician regarding the resident’s capability to understand and exercise these rights when there is reason to believe that the resident may not be capable of such.

 

22VAC40-73-560. Resident records.

 

1. The facility shall establish written policy and procedures for documentation and recordkeeping to ensure that the information in resident records is accurate and clear and that the records are well-organized.

 

1. Resident records shall be identified and easily located by resident name, including when a resident’s record is kept in more than one place. This shall apply to both electronic and hard copy material.

 

1. Any physician’s notes and progress reports in the possession of the facility shall be retained in the resident’s record.

 

1. Copies of all agreements between the facility and the resident and official acknowledgment of required notifications, signed by all parties involved, shall be retained in the resident’s record. Copies shall be provided to the resident and to persons whose signatures appear on the document.

22VAC40-73-560. Resident records.

 

1. All resident records shall be kept current, retained at the facility, and kept in a locked area, except that information shall be made available as noted in subsection F of this section.

 

1. The licensee shall ensure that all records are treated confidentially and that information shall be made available only when needed for care of the resident. All records shall be made available for inspection by the department’s representative.

 

1. Residents shall be allowed access to their own records. A legal representative of a resident shall be provided access to the resident’s record or part of the record as allowed by the scope of his legal authority.

 

1. The complete resident record shall be retained for at least two years after the resident leaves the facility.

 

1. For at least the first year, the record shall be retained at the facility.

 

2. After the first year, the record may be retained off site in a safe, secure area. The record must be available at the facility within 48 hours.

 

1. A current picture of each resident shall be readily available for identification purposes or, if the resident refuses to consent to a picture, there shall be a narrative physical description, which is annually updated, maintained in his file.

 

22VAC40-73-570. Release of information regarding resident’s personal affairs and records.

 

1. The resident or the appropriate legal representative has the right to release information from the resident’s record to persons or agencies outside the facility.

 

1. The licensee is responsible for making available to residents and legal representatives a form which they may use to grant their written permission for the facility to release information to persons or agencies outside the facility. The facility shall retain a copy of any signed release of information form in the resident’s record.

 

1. Only under the following circumstances is a facility permitted to release information from the resident’s records or information regarding the resident’s personal affairs without the written permission of the resident or his legal representative, where appropriate:

 

1. When records have been properly subpoenaed;

 

2. When the resident is in need of emergency medical care and is unable or unwilling to grant permission to release information or his legal representative is not available to grant permission;

22VAC40-73-570. Release of information regarding resident’s personal affairs and records.

 

3. When the resident moves to another caregiving facility;

 

4. To representatives of the department; or

 

5. As otherwise required by law.

 

1. When a resident is hospitalized or transported by emergency medical personnel, information necessary to the care of the resident shall be furnished by the facility to the hospital or emergency medical personnel. Examples of such information include a copy of the current medication administration record (MAR), a Do Not Resuscitate (DNR) Order, advance directives, and organ donation information. The facility shall also provide the name, address, and telephone number of the resident’s designated contact person to the hospital or emergency medical personnel.

 

22VAC40-73-580. Food service and nutrition.

 

1. When any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years.

 

1. All meals shall be served in the dining area as designated by the facility, except that:

 

1. If the facility, through its policies and procedures, offers routine or regular room service, residents shall be given the option of having meals in the dining area or in their rooms, provided that:

 

1. There is a written agreement to this effect, signed and dated by both the resident and the licensee or administrator and filed in the resident’s record.

 

1. If a resident’s individualized service plan, physical examination report, mental health status report, or any other document indicates that the resident has a psychiatric condition that contributes to self-isolation, a qualified mental health professional shall make a determination in writing whether the resident should have the option of having meals in his room. If the determination is made that the resident should not have this option, then the resident shall have his meals in the dining area.

 

2. Under special circumstances, such as temporary illness, temporary incapacity, temporary agitation of a resident with cognitive impairment, or occasional, infrequent requests due to a resident’s personal preference, meals may be served in a resident’s room.

 

When meals are served in a resident’s room, a sturdy table must be used.

 

22VAC40-73-580. Food service and nutrition.

 

1. Personnel shall be available to help any resident who may need assistance in reaching the dining room or when eating.

 

1. A minimum of 45 minutes shall be allowed for each resident to complete a meal. If a resident has been assessed on the UAI as dependent in eating/feeding, his individualized service plan shall indicate an approximate amount of time needed for meals to ensure needs are met.

 

1. Facilities shall develop and implement a policy to monitor each resident for:

 

1. Warning signs of changes in physical or mental status related to nutrition; and

 

2. Compliance with any needs determined by the resident’s individualized service plan or prescribed by a physician or other prescriber, nutritionist, or health care professional.

 

1. Facilities shall implement interventions as soon as a nutritional problem is suspected. These interventions shall include the following:

 

1. Weighing residents at least monthly to determine whether the resident has significant weight loss (i.e., 5.0% weight loss in one month, 7.5% in three months, or 10% in six months); and

 

2. Notifying the attending physician if a significant weight loss is identified in any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following the physician’s instructions regarding nutritional care.

 

1. Residents with independent living status who have kitchens equipped with stove, refrigerator, and sink within their individual apartments may have the option of obtaining meals from the facility or from another source. If meals are obtained from another source, the facility must ensure availability of meals when the resident is sick or temporarily unable to prepare meals for himself.

 

22VAC40-73-590. Number of meals and availability of snacks.

 

1. At least three well-balanced meals, served at regular intervals, shall be provided daily to each resident, unless contraindicated as documented by the attending physician in the resident’s record or as provided for in 22VAC40-73-580 G.

 

B. Snacks shall be made available at all times for all residents or in accordance with their physician’s or other prescriber’s orders.

 

22VAC40-73-590. Number of meals and availability of snacks.

 

1. Appropriate adjustments in the provision of snacks to a resident shall be made when orders from the resident’s physician or other prescriber in the resident’s record limits the receipt or type of snacks.

 

2. Vending machines shall not be used as the only source for snacks.

 

22VAC40-73-600. Time interval between meals.

 

1. Time between the scheduled evening meal and scheduled breakfast the following morning shall not exceed 15 hours.

 

1. There shall be at least four hours between scheduled breakfast and lunch and at least four hours between scheduled lunch and supper.

 

1. When multiple seatings are required due to limited dining space, scheduling shall ensure that these time intervals are met for all residents. Schedules shall be made available to residents, legal representatives, staff, volunteers, and any other persons responsible for assisting residents in the dining process.

 

22VAC40-73-610. Menus for meals and snacks.

 

1. Food preferences of residents shall be considered when menus are planned.

 

1. Menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.

 

1. Any menu substitutions or additions shall be recorded on the posted menu.

 

2. A record shall be kept of the menus served for two years. C. Minimum daily menu.

 

1. Unless otherwise ordered in writing by the resident’s physician or other prescriber, the daily menu, including snacks, for each resident shall meet the current guidelines of the U.S. Department of Agriculture’s food guidance system or the dietary allowances of the Food and Nutritional Board of the National Academy of Sciences, taking into consideration the age, sex, and activity of the resident.

 

2. Other foods may be added.

 

3. Second servings and snacks shall be available at no additional charge.

 

At least one meal each day shall include a hot main dish.

 

22VAC40-73-610. Menus for meals and snacks.

 

1. When a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician’s or other prescriber’s orders.

 

1. A copy of a diet manual containing acceptable practices and standards for nutrition shall be kept current and readily available to personnel responsible for food preparation.

 

1. The facility shall make drinking water readily available to all residents. Direct care staff shall know which residents need help getting water or other fluids and drinking from a cup or glass. Direct care staff shall encourage and assist residents who do not have medical conditions with physician or other prescriber ordered fluid restrictions to drink water or other beverages frequently.

 

22VAC40-73-620. Oversight of special diets.

 

54. There shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet. Special diets may also be referred to using terms such as medical nutrition therapy or diet therapy. The dietitian or nutritionist must meet the requirements of § 54.1-2731 of the Code of Virginia.

 

1. The oversight specified in subsection A of this section shall be on site and include the following:

 

1. A review of the physician’s or other prescriber’s order and the preparation and delivery of the special diet.

 

2. An evaluation of the adequacy of the resident’s special diet and the resident’s acceptance of the diet.

 

3. Certification that the requirements of this subsection were met, including the date of the oversight and identification of the residents for whom the oversight was provided. The administrator shall be advised of the findings of the oversight and any recommendations. All of the requirements of this subdivision shall be (i) in writing, (ii) signed and dated by the dietitian or nutritionist, (iii) provided to the administrator within 10 days of the completion of the oversight, and (iv) maintained in the files at the facility for at least two years, with any specific recommendations regarding a particular resident also maintained in the resident’s record.

 

4. Upon receipt of recommendations noted in subdivision 3 of this subsection, the administrator, dietitian, or nutritionist shall report them to the resident’s physician. Documentation of the report shall be maintained in the resident’s record.

 

5. Action taken in response to the recommendations noted in subdivision 3 of this subsection shall be documented in the resident’s record.

22VAC40-73-630. Observance of religious dietary practices.

 

1. The resident’s religious dietary practices shall be respected.

 

1. Religious dietary practices of the administrator or licensee shall not be imposed upon residents unless specifically agreed upon in the admission agreement/acknowledgment between administrator or licensee and resident.

 

22VAC40-73-640. Medication management plan and reference materials.

 

1. The facility shall have, keep current, and implement a written plan for medication management. The facility’s medication plan shall address procedures for administering medication and shall include:

 

1. Methods to ensure an understanding of the responsibilities associated with medication management;

 

2. Standard operating procedures, including the facility’s standard dosing schedule and any general restrictions specific to the facility;

 

3. Methods to prevent the use of outdated, damaged, or contaminated medications;

 

4. Methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages;

 

5. Methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order;

 

6. Methods for monitoring medication administration and the effective use of the MARs for documentation;

 

7. Methods to ensure that MARs are maintained as part of the resident’s record;

 

8. Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes;

 

9. Methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670;

 

10. Methods to ensure that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration;

 

11. A plan for proper disposal of medication;

22VAC40-73-640. Medication management plan and reference materials.

 

12. Methods to ensure that residents do not receive medications or dietary supplements to which they have known allergies;

 

13. Identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber;

 

14. Methods to ensure that staff who are responsible for administering medications are trained on the facility’s medication management plan; and

 

15. Procedures for internal monitoring of the facility’s conformance to the medication management plan.

 

1. The facility’s written medication management plan requires approval by the department.

 

1. Subsequent changes shall be reviewed as part of the department’s regular inspection process.

 

1. In addition to the facility’s written medication management plan, the facility shall have readily accessible at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medications.

 

22VAC40-73-650. Physician’s or other prescriber’s order.

 

1. No medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.

 

1. Physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.

 

1. Physician’s or other prescriber’s oral orders shall:

 

1. Be charted by the individual who takes the order. That individual must be one of the following:

 

1. A licensed health care professional practicing within the scope of his profession; or

 

1. A medication aide.

22VAC40-73-650. Physician’s or other prescriber’s order.

 

2. Be reviewed and signed by a physician or other prescriber within 14 days.

 

1. Medication aides may not transmit an oral order to a pharmacy.

 

1. The resident’s record shall contain the physician’s or other prescriber’s signed written order or a dated notation of the physician’s or other prescriber’s oral order. Orders shall be organized chronologically in the resident’s record.

 

1. Whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident’s return to the facility. The facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders.

 

22VAC40-73-660. Storage of medications.

 

1. A medicine cabinet, container, or compartment shall be used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice.

 

1. The storage area shall be locked.

 

2. Schedule II drugs and any other drugs subject to abuse must be kept in a separate locked storage compartment (e.g., a locked cabinet within a locked storage area or a locked container within a locked cabinet or cart).

 

3. The individual responsible for medication administration shall keep the keys to the storage area on his person.

 

4. When in use, the storage area shall have adequate illumination in order to read container labels.

 

5. The storage area shall not be located in the kitchen or bathroom, but in an area free of dampness or abnormal temperatures unless the medication requires refrigeration.

 

6. When required, medications shall be refrigerated.

 

1. It is permissible to store dietary supplements and foods and liquids used for medication administration in a refrigerator that is dedicated to medication storage if the refrigerator is in a locked storage area.

22VAC40-73-660. Storage of medications.

 

1. When it is necessary to store medications in a refrigerator that is routinely used for food storage, the medications shall be stored together in a locked container in a clearly defined area.

 

7. Single-use and dedicated medical supplies and equipment shall be appropriately labeled and stored. Medical equipment suitable for multi-use shall be stored to prevent cross-contamination.

 

1. A resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents. This does not prohibit the facility from storing or administering all medication and dietary supplements.

 

EXCEPTION: If the facility has no resident with a serious cognitive impairment or substance abuse problem, the facility may determine that the out-of-sight and inaccessibility safeguards specified in this subsection do not apply. If the facility determines that these safeguards do not apply, the facility shall maintain documentation of such, including the date and the names of residents at the time the determination is made. No such determination shall be valid for longer than six months. Such determinations may be renewed under the same conditions and with the same documentation requirements.

 

22VAC40-73-670. Qualifications and supervision of staff administering medications.

 

When staff administers medications to residents, the following standards shall apply:

 

1. Each staff person who administers medication shall be authorized by § 54.1-3408 of the Virginia Drug Control Act. All staff responsible for medication administration shall:

 

1. Be licensed by the Commonwealth of Virginia to administer medications; or

 

1. Be registered with the Virginia Board of Nursing as a medication aide, except as specified in subdivision 2 of this section.

 

2. Any applicant for registration as a medication aide who has provided to the Virginia Board of Nursing evidence of successful completion of the education or training course required for registration may act as a medication aide on a provisional basis for no more than 120 days before successfully completing any required competency evaluation. However, upon notification of failure to successfully complete the written examination after three attempts, an applicant shall immediately cease acting as a medication aide.

22VAC40-73-670. Qualifications and supervision of staff administering medications.

 

3. Medication aides shall be supervised by one of the following:

 

1. An individual employed full time at the facility who is licensed by the Commonwealth of Virginia to administer medications;

 

1. The administrator who is licensed by the Commonwealth of Virginia to administer medications or who has successfully completed a training program approved by the Virginia Board of Nursing for the registration of medication aides. The training program for administrators who supervise medication aides, but are not registered medication aides themselves, must include a minimum of 68 hours of student instruction and training but need not include the prerequisite for the program or the written examination for registration. The administrator must also meet the requirements of 22VAC40-73-160 E; or

 

1. For a facility licensed for residential living care only, the designated assistant administrator, as specified in 22VAC40-73-150 E, who is licensed by the Commonwealth of Virginia to administer medications or who has successfully completed a training program approved by the Virginia Board of Nursing for the registration of medication aides. The training program for designated assistant administrators who supervise medication aides, but are not registered medication aides themselves, must include a minimum of 68 hours of student instruction and training but need not include the prerequisite for the program or the written examination for registration. The designated assistant administrator must also meet the requirements of 22VAC40-73-160 E.

 

22VAC40-73-680. Administration of medications and related provisions.

 

1. Staff who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the UAI.

 

1. Medications shall be removed from the pharmacy container, or the container shall be opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person. Medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.

 

1. Medications shall be administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.

 

D. Medications shall be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.

 

22VAC40-73-680. Administration of medications and related provisions.

 

1. Medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident’s record.

 

1. Sample medications shall remain in the original packaging, labeled by a physician or other prescriber or pharmacist with the resident’s name, the name of the medication, the strength, dosage, and route and frequency of administration, until administered.

 

1. Over-the-counter medication shall remain in the original container, labeled with the resident’s name, or in a pharmacy-issued container, until administered.

 

1. At the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.

 

1. The MAR shall include:

 

1. Name of the resident;

 

2. Date prescribed;

 

3. Drug product name;

 

4. Strength of the drug;

 

5. Dosage;

 

6. Diagnosis, condition, or specific indications for administering the drug or supplement;

 

7. Route (e.g., by mouth);

 

8. How often medication is to be taken;

 

9. Date and time given and initials of direct care staff administering the medication;

 

10. Dates the medication is discontinued or changed;

 

11. Any medication errors or omissions;

 

12. Description of significant adverse effects suffered by the resident;

 

13. For “as needed” (PRN) medications:

 

1. Symptoms for which medication was given;

22VAC40-73-680. Administration of medications and related provisions.

 

1. Exact dosage given; and

 

1. Effectiveness; and

 

14. The name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARs.

 

1. In the event of an adverse drug reaction or a medication error, the following applies:

 

1. Action shall be taken as directed by a physician, pharmacist, or a poison control center;

 

2. The resident’s physician of record and family member or other responsible person shall be notified as soon as possible; and

 

3. Medication administration staff shall document actions taken in the resident’s record.

 

1. The use of PRN medications is prohibited, unless one or more of the following conditions exist:

 

1. The resident is capable of determining when the medication is needed;

 

2. Licensed health care professionals administer the PRN medication; or

 

3. Medication aides administer the PRN medication when the facility has obtained from the resident’s physician or other prescriber a detailed medication order. The order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.

 

1. In order for drugs in a hospice comfort kit to be administered, the requirements specified in subsection K of this section must be met, and each medication in the kit must have a prescription label attached by the pharmacy.

 

1. Medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.

 

1. Stat-drug boxes may only be used when the following conditions are met:

 

1. There is an order from the prescriber for any drug removed from the stat-drug box; and

 

2. The drug is removed from the stat-drug box and administered by a nurse, pharmacist, or prescriber licensed to administer medications. Registered medication

 

22VAC40-73-680. Administration of medications and related provisions.

 

aides are not permitted to either remove or administer medications from the stat-drug box.

 

22VAC40-73-690. Medication review.

 

1. For each resident assessed for residential living care, except for those who self-administer all of their medications, a licensed health care professional, practicing within the scope of his profession, shall perform an annual review of all the medications of the resident.

 

1. For each resident assessed for assisted living care, except for those who self-administer all of their medications, a licensed health care professional, practicing within the scope of his profession, shall perform a review every six months of all the medications of the resident.

 

1. The medication review shall include prescription drugs, over-the-counter medications, and dietary supplements ordered for the resident.

 

1. If deemed appropriate by the licensed health care professional, the review shall include observation of the resident or interview with the resident or staff.

 

1. The review shall include the following:

 

1. All medications that the resident is taking and medications that he could be taking if needed (PRNs).

 

2. An examination of the dosage, strength, route, how often, prescribed duration, and when the medication is taken.

 

3. Documentation of actual and consideration of potential interactions of drugs with one another.

 

4. Documentation of actual and consideration of potential interactions of drugs with foods or drinks.

 

5. Documentation of actual and consideration of potential negative effects of drugs resulting from a resident’s medical condition other than the one the drug is treating.

 

6. Consideration of whether PRNs, if any, are still needed and if clarification regarding use is necessary.

22VAC40-73-690. Medication review.

 

7. Consideration of a gradual dose reduction of antipsychotic medications for those residents with a diagnosis of dementia and no diagnoses of a primary psychiatric disorder.

 

8. Consideration of whether the resident needs additional monitoring or testing.

 

9. Documentation of actual and consideration of potential adverse effects or unwanted side effects of specific medications.

 

10. Identification of that which may be questionable, such as (i) similar medications being taken, (ii) different medications being used to treat the same condition, (iii) what seems an excessive number of medications, and (iv) what seems an exceptionally high drug dosage.

 

11. The health care professional shall notify the resident’s attending physician of any concerns or problems and document the notification.

 

1. The licensed health care professional shall certify that the requirements of subdivisions E 1 through E 11 of this section were met, including the dates of the medication review. The administrator shall be advised of the findings of the medication review and any recommendations. All of the requirements of this subdivision shall be (i) in writing, (ii) signed and dated by the health care professional, (iii) provided to the administrator within 10 days of the completion of the review, and (iv) maintained in the facility files for at least two years, with any specific recommendations regarding a particular resident also maintained in the resident’s record.

 

1. Action taken in response to the recommendations noted in subsection F of this section shall be documented in the resident’s record.

 

22VAC40-73-700. Oxygen therapy.

 

When oxygen therapy is provided, the following safety precautions shall be met and maintained:

 

1. The facility shall have a valid physician’s or other prescriber’s order that includes the following:

 

1. The oxygen source, such as compressed gas or concentrators;

 

1. The delivery device, such as nasal cannula, reservoir nasal cannulas, or masks; and

 

1. The flow rate deemed therapeutic for the resident.

22VAC40-73-700. Oxygen therapy.

 

2. The facility shall post “No Smoking-Oxygen in Use” signs and enforce the smoking prohibition in any room of a building where oxygen is in use.

 

3. The facility shall ensure that only oxygen from a portable source shall be used by residents when they are outside their rooms. The use of long plastic tether lines to the source of oxygen outside their rooms is not permitted.

 

4. The facility shall make available to staff the emergency numbers to contact the resident’s physician or other prescriber and the oxygen vendor for emergency service or replacement.

 

5. The facility shall demonstrate that all direct care staff responsible for assisting residents who use oxygen supplies have had training or instruction in the use and maintenance of resident-specific equipment.

 

6. The facility shall include in its disaster preparedness plan a checklist of information required to meet the identified needs of those residents who require oxygen therapy including the following:

 

1. Whether the facility has on-site, emergency generator capacity sufficient to safely operate oxygen concentrators efficiently.

 

1. Whether in the absence of on-site generators the facility has agreements with vendors to provide emergency generators, including whether those generators will support oxygen concentrators.

 

1. Where the facility maintains chart copies of each resident’s agreement, including emergency preparedness and back-up plans, with his oxygen equipment and supply vendor for ready access in any emergency situation.

 

1. How equipment and supplies will be transported in the event that residents must be evacuated to another location.

 

22VAC40-73-710. Restraints.

 

1. The use of chemical restraints is prohibited. The use of prone or supine restraints is prohibited. The use of any restraint or restraint technique that restricts a resident’s breathing, interferes with a resident’s ability to communicate, or applies pressure on a resident’s torso is prohibited.

 

1. Physical restraints shall not be used for purposes of discipline or convenience. Physical restraints may only be used (i) as a medical/orthopedic restraint for support, according to a physician’s written order and with the written consent of the resident or his legal representative or (ii) in an emergency situation after less intrusive interventions have proven

22VAC40-73-710. Restraints.

 

insufficient to prevent imminent threat of death or serious physical injury to the resident or others.

 

1. If a restraint is used, it must:

 

1. Be imposed in accordance with a physician’s written order that specifies the condition, circumstances, and duration under which the restraint is to be used; and

 

2. Not be ordered on a standing, blanket, or “as needed” (PRN) basis.

 

1. Whenever physical restraints are used, the following conditions shall be met:

 

1. A restraint shall be used only to the minimum extent necessary to protect the resident or others;

 

2. Restraints shall only be applied by direct care staff who have received training in their use as specified by subdivision 2 of 22VAC40-73-270;

 

3. The facility shall closely monitor the condition of a resident with a restraint, which includes checking on the resident at least every 30 minutes;

 

4. The facility shall assist the resident with a restraint as often as necessary, but no less than 10 minutes every hour, for his hydration, safety, comfort, range of motion, exercise, elimination, and other needs;

 

5. The facility shall release the resident from the restraint as quickly as possible; and

 

6. Direct care staff shall keep a record of restraint usage, outcomes, checks, and any assistance required in subdivision 4 of this subsection and shall note any unusual occurrences or problems.

 

1. When restraints are used in nonemergencies, as defined in 22VAC40-73-10, the following conditions shall be met:

 

1. Restraints shall be used as a last resort and only if the facility, after completing,

 

implementing, and evaluating the resident’s comprehensive assessment and service plan, determines and documents that less restrictive means have failed;

 

2. Physician orders for medical/orthopedic restraints must be reviewed by the physician at least every three months and renewed if the circumstances warranting the use of the restraint continue to exist;

 

3. Restraints shall be used in accordance with the resident’s service plan, which documents the need for the restraint and includes a schedule or plan of rehabilitation

22VAC40-73-710. Restraints.

 

training enabling the progressive removal or the progressive use of less restrictive restraints when appropriate;

 

4. Before the initial administration of a restraint, the facility shall explain the use of the restraint and potential negative outcomes to the resident or his legal representative and the resident’s right to refuse the restraint and shall obtain the written consent of the resident or his legal representative;

 

5. Restraints shall be applied so as to cause no physical injury and the least possible discomfort; and

 

6. The facility shall notify the resident’s legal representative or designated contact person as soon as practicable, but no later than 24 hours after the initial administration of a nonemergency restraint. The facility shall keep the resident and his legal representative or designated contact person informed about any changes in restraint usage. A notation shall be made in the resident’s record of such notice, including the date, time, person notified, method of notification, and staff providing notification.

 

1. When restraints are used in emergencies, as defined in 22VAC40-73-10 the following conditions shall be met:

 

1. Restraints may only be used as an emergency intervention of last resort to prevent imminent threat of death or serious physical injury to the resident or others;

 

2. An oral or written order shall be obtained from a physician within one hour of administration of the emergency restraint and the order shall be documented;

 

3. In the case of an oral order, a written order shall be obtained from the physician as soon as possible;

 

4. The resident shall be within sight and sound of direct care staff at all times;

 

5. If the emergency restraint is necessary for longer than two hours, the resident shall be transferred to a medical or psychiatric inpatient facility or monitored in the facility by a mental health crisis team until his condition has stabilized to the point that the attending physician documents that restraints are not necessary;

 

6. The facility shall notify the resident’s legal representative or designated contact person as soon as practicable, but no later than 12 hours after administration of an emergency restraint. A notation shall be made in the resident’s record of such notice, including the date, time, caller and person notified; and

22VAC40-73-710. Restraints.

 

7. The facility shall review the resident’s individualized service plan within one week of the application of an emergency restraint and document additional interventions to prevent the future use of emergency restraints.

 

22VAC40-73-720. Do Not Resuscitate Orders.

 

1. Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest may only be carried out in a licensed assisted living facility when:

 

1. A valid written order has been issued by the resident’s attending physician; and

 

2. The written order is included in the individualized service plan.

 

1. The facility shall have a system to ensure that all staff are aware of residents who have a valid DNR Order.

 

1. The DNR Order shall be readily available to other authorized persons, such as emergency medical technicians (EMTs), when necessary.

 

1. Durable DNR Orders shall not authorize the assisted living facility or its staff to withhold other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or to alleviate pain.

 

63. Section 63.2-1807 of the Code of Virginia states that the owners or operators of any assisted living facility may provide that their staff who are certified in CPR shall not be required to resuscitate any resident for whom a valid written order not to resuscitate in the event of cardiac or respiratory arrest has been issued by the resident’s attending physician and has been included in the resident’s individualized service plan.

 

1. If the owner or operator of a facility has determined that DNR Orders will not be honored, the facility shall have a policy specifying this and, prior to admission, the resident or his legal guardian shall be notified of the policy and sign an acknowledgment of the notification.

 

22VAC40-73-730. Advance directives.

 

1. Upon admission or while residing in the facility, whenever the resident has established advance directives, such as a living will or a durable power of attorney for health care, to the extent available, the facility shall obtain the following:

 

1. The name of and contact information for the individual or individuals who has the document or documents;

 

2. The location of the documents;

22VAC40-73-730. Advance directives.

 

3. Either the advance directives or the content of the advance directives; and

 

4. The name of and contact information for any designated agent, as related to the development and modification of the individualized service plan.

 

1. If the facility is unable to obtain any of the information or documents as noted in subdivisions 1 through 4 of subsection A of this section, the efforts made to do so shall be documented in the resident’s record.

 

1. The information regarding advance directives shall be readily available to other authorized persons, such as emergency medical technicians (EMTs), when necessary.

 

A resident requesting assistance with establishing advance directives shall be referred to his primary health care provider or attorney.