- Following an analysis of the number of residents that the assisted living program intends to serve and the individual needs of each resident, the licensee shall develop a staffing plan that identifies the type and number of staff needed to provide the services required by this chapter.
- The staffing plan shall include on-site staff sufficient in number and qualifications to meet the 24-hour scheduled and unscheduled needs of the residents. When a resident is in the facility, a staff member shall be present.
. Awake Overnight Staff. An assisted living program shall provide awake overnight staff when a resident’s assessment using the Resident Assessment Tool, as provided in Regulation .21A or .26B of this chapter, indicates that awake overnight staff is required according to instructions on that tool. If a physician or assessing nurse, in the physician’s or nurse’s clinical judgment,
does not believe that a resident requires awake overnight staff, the physician or assessing nurse shall document the reasons in the area provided in the Resident Assessment Tool. The licensee shall retain this documentation in the resident’s record.
- A staffing schedule shall be maintained on-site which identifies the date, shift hours, and full name of all staff members scheduled to work.
- The resident’s care needs shall determine:
(1) The services provided to the resident by the program, in accordance with §E of this regulation;
(2) When awake overnight staff is required;
(3) The need for on-site nursing services; and
(4) The need, amount, and frequency of nursing oversight by the registered nurse.
- A program shall have staff with the ability to:
(1) Recognize and accurately describe and define a resident’s health condition and identify likely causes and risks associated with the residents’ condition;
(2) Provide or ensure ongoing access to and coordination of comprehensive health services and interventions including nursing oversight;
(3) Provide or ensure comprehensive support as frequently as needed to compensate for any number of activities of daily living deficits;
(4) Provide or ensure assistance with taking medication;
(5) Administer necessary medication and treatment, including monitoring or arranging for monitoring of the effects of complex medication and treatment regimens;
(6) Monitor and provide or ensure ongoing therapeutic intervention or intensive supervision to manage chronic behaviors which are likely to disrupt or harm the resident or others;
(7) Manage a variety of psychological or psychiatric episodes involving active symptoms, condition changes, or significant risks that may require skilled interpretation or immediate interventions; and
(8) Provide or ensure ongoing access to comprehensive social and recreational services.
F. Awake Overnight Staff.
(1) A licensee shall provide awake overnight staff when a Resident Assessment Tool, as provided in Regulation .18 of this chapter, indicates that a resident requires awake overnight staff.
(2) If the assessing health care practitioner, in their clinical judgment, does not believe that a resident requires awake overnight staff, the health care practitioner shall document the reasons in the area provided in the Resident Assessment Tool.
(3) The licensee shall retain this documentation in the resident’s record.
G. Electronic Monitoring Systems.
(1) Upon the written recommendation of the [resident’s physician or assessing nurse] the health care practiioner, the [assisted living program] may apply to the Department for a waiver in accordance with Regulation [.09] .08 of this chapter to use an electronic monitoring system instead of awake overnight staff.
(2) If an electronic monitoring system is approved by the Department for the assisted living program to use, the licensee shall document the approval of the electronic monitoring system in the area provided on the Resident Assessment Tool.
(3) When a resident is assessed or reassessed using the Resident Assessment Tool, as provided in Regulation [.21A or .26B] .18 of this chapter, the [physician or assessing nurse] health care practitioner shall review and document:
(a) The need for awake overnight staff if the resident’s previous assessment or review of an assessment indicated awake overnight staff was not necessary at the time; and
(b) The continued appropriateness of a waiver to use an approved electronic monitoring system instead of awake overnight staff.
(4) The licensee shall comply with applicable requirements of COMAR 10.27.09.
H. On-Site Nursing Requirements.
(1) [An assisted living] A program shall provide on-site nursing when a delegating nurse or [physician] health care practitioner, based upon the needs of a resident, issues a nursing or clinical order for that service.
(2) If [an assisted living] manager determines that a nursing or clinical order should not or cannot be implemented, the manager, delegating nurse or case manager, and resident’s [physician] health care practioner shall discuss any alternatives that could safely address the resident’s needs. The [assisted living] manager shall document in the resident’s record this discussion and all individuals who participated in the
(3) If there are alternatives that could safely address the resident’s needs, the [assisted living] manager shall notify the resident and, if appropriate, the resident’s legal representative, the delegating nurse or case manager, and resident’s [physician] health care practioner of the change to the order. The assisted living manager shall document in the resident’s record this change and the date of notification.
(4) If a manager fails to implement a nursing or clinical order without identifying and providing alternatives to the care or service order, the delegating nurse or case manager shall notify the resident’s physician, the OHCQ, and the resident or, if appropriate, the legal representative of the resident.
(5) Failure to implement a nursing or clinical order, without demonstrating why the order should not be followed or without identifying alternatives to care, may result in sanctions against [the assisted living program] the licensee.
I. On-site nursing personnel shall work in partnership with the delegating nurse or case manager and [assisted living] program staff to ensure:
(1) Adequate assessment of residents;
(2) Planning of medical services; and
(3) Oversight of nursing activities.