[Federal Register Volume 63, Number 216 (Monday, November 9, 1998)]
[Proposed Rules]
[Pages 60227-60255]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-29597]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Parts 17 and 51
RIN 2900-AE87
Per Diem for Nursing Home Care of Veterans in State Homes
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
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SUMMARY: This document proposes to revise regulations setting forth a
mechanism for paying per diem to State homes providing nursing home
care to eligible veterans. The intended effect of the proposed
regulations is to ensure that veterans receive high quality care in
State homes.
DATES: Comments must be received by VA on or before January 8, 1999.
ADDRESSES: Mail or hand-deliver written comments to: Director, Office
of Regulations Management (02D), Department of Veterans Affairs, 810
Vermont Avenue, NW, Room 1154, Washington, DC 20420. Comments should
indicate that they are submitted in response to ``RIN 2900-AE87.'' All
written comments will be available for public inspection in the Office
of Regulations Management, Room 1158, between the hours of 8 a.m. and
4:30 p.m., Monday through Friday (except holidays).
FOR FURTHER INFORMATION CONTACT: L. Nan Stout, Chief, State Home Per
Diem Program (114), Veterans Health Administration, 202-273-8538.
SUPPLEMENTARY INFORMATION: This document proposes to establish a new
part 51 setting forth a mechanism for paying per diem to State homes
providing nursing home care to eligible veterans. Under the proposal,
VA would pay per diem to a State for providing nursing home care to
eligible veterans in a facility if the Under Secretary for Health
recognizes the facility as a State home based on a current VA
certification that the facility meets the standards set forth in
proposed subpart D.
This new part would cover material currently in manuals. Also, it
would supersede the regulations currently contained in 38 CFR 17.190
through 17.199 that pertain to payment of per diem for nursing home
care in State homes.
The standards in proposed subpart D are patterned after the
standards of the Department of Health and Human Services that nursing
homes must meet to participate in the Medicare and Medicaid programs
(see 42 CFR part 483). The standards are intended to set forth minimum
requirements necessary to ensure that VA pays per diem for eligible
veterans only if the State homes provide high quality care.
The proposed regulations include application and inspection
provisions that are designed to ensure that per diem is paid only to
facilities that have been inspected and found to meet the proposed
standards. Also, in order to ensure continued compliance with the
standards, the proposed regulations include an ongoing review and
certification program. Further, the proposed regulations contain
provisions for withdrawing recognition and stopping payment of per diem
if a facility fails to meet the proposed standards.
The proposed rule sets forth the statutory list of veterans for
whom per diem may be paid. The proposed rule also contains provisions
for determining payment amounts.
The proposed rule would incorporate by reference the 1997 edition
of the National Fire Protection Association Life Safety Code entitled
``NFPA 101, Life Safety Code'' and the 1996 edition of ``NFPA 99,
Standards for Health Care Facilities.'' The regulations are designed to
ensure that State homes meet the fire and safety provisions of the Life
Safety Code.
Regulatory Flexibility Act
The Secretary hereby certifies that the adoption of this proposed
rule would not have a significant economic impact on a substantial
number of small entities as they are defined in the Regulatory
Flexibility Act, 5 U.S.C. 601-612. All of the entities that would be
subject to this proposed rule are State government entities under the
control of State governments. Of the 93 State homes, all are operated
by State governments except for 16 that are operated by entities under
contract with State governments. These contractors are not small
entities. Therefore, pursuant to 5 U.S.C. 605(b), this proposed rule is
exempt from the initial and final regulatory flexibility analysis
requirement of Secs. 603 and 604.
Paperwork Reduction Act of 1995
Under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520),
proposed collections of information are set forth in the provisions of
Secs. 51.20, 51.30, 51.40, 51.70, 51.80, 51.90, 51.100, 51.110, 51.120,
51.150, 51.160, 51.180, 51.190 and 51.210 of this proposed rule.
The information collections in this document concern various
activities related to the operation of a State home providing nursing
home care to eligible veterans. As required under section 3507(d) of
the Act, VA has submitted a copy of this proposed rulemaking action to
the Office of Management and Budget (OMB) for its review of the
collections of information.
OMB assigns control numbers to collections of information it
approves. VA may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a
currently valid OMB control number.
Comments on the collection of information should be submitted to
the Office of Management and Budget, Attention: Desk Officer for the
Department of Veterans Affairs, Office of Information and Regulatory
Affairs, Washington, DC 20503, with copies to the Director, Office of
Regulations Management (02D), Department of Veterans Affairs, 810
Vermont Avenue,
[[Page 60228]]
NW, Washington, DC 20420. Comments should indicate that they are
submitted in response to ``RIN 2900-AE87.''
Title: Aid to States for Care of Veterans in State Homes--Nursing
Home Per Diem.
Summary of collection of information: VA is proposing to establish
the mechanism for paying per diem to State homes providing nursing home
care to eligible veterans. VA proposes to require facilities to supply
various kinds of information regarding facilities providing nursing
home care to ensure that high quality care is furnished to veterans who
are residents in such facilities. The information includes an
application for recognition based on certification; appeal information;
application and justification for payment; records and reports which
facility management must maintain regarding activities of residents; to
include information relating to whether the facility meets standards
concerning residents' rights and responsibilities prior to admission,
during admission, and upon discharge; the records and reports which
facility management and health care professionals must maintain
regarding residents and employees; various types of documentation
pertaining to the management of the facility; food menu planning;
pharmaceutical records; and life safety documentation.
Description of need for information and proposed use of
information: The collections of information contained in the proposed
rule appear to be necessary to ensure that VA per diem payments are
limited to facilities providing high quality care. Without access to
such information VA would not be able to determine whether high quality
care is being provided.
Description of likely respondents: State home officials who receive
per diem for nursing home care for veterans.
Estimated number of respondents: 13,136.
Estimated frequency of responses: 52,872.
Estimated average burden per collection: 14 minutes.
Estimated total annual reporting and record keeping burden: 12,467
hours.
The Department considers comments by the public on proposed
collections of information in--
Evaluating whether the proposed collections of information
are necessary for the proper performance of the functions of the
Department, including whether the information will have practical
utility;
Evaluating the accuracy of the Department's estimate of
the burden of the proposed collections of information, including the
validity of the methodology and assumptions used;
Enhancing the quality, usefulness, and clarity of the
information to be collected; and
Minimizing the burden of the collections of information on
those who are to respond, including through the use of appropriate
automated, electronic, mechanical, or other technological collection
techniques or other forms of information technology, e.g., permitting
electronic submission of responses.
OMB is required to make a decision concerning the proposed
collection of information contained in this proposed rule between 30
and 60 days after publication of this document in the Federal Register.
Therefore, a comment to OMB is best assured of having its full effect
if OMB receives it within 30 days of publication. This does not affect
the deadline for the public to comment on the proposed regulation.
List of Subjects in 38 CFR Parts 17 and 51
Administrative practice and procedure, Alcohol abuse, Alcoholism,
Claims, Day care, Dental health, Drug abuse, Foreign relations,
Government contracts, Grant programs-health, Government programs-
veterans, Health care, Health facilities, Health professions, Health
records, Homeless, Medical and dental schools, Medical devices, Medical
research, Mental health programs, Nursing home care, Philippines,
Reporting and recordkeeping requirements, Scholarships and fellowships,
Travel and transportation expenses, Veterans.
Approved: October 26, 1998.
Togo D. West, Jr.,
Secretary of Veterans Affairs.
For the reason set out in the preamble, 38 CFR Chapter I is
proposed to be amended as follows:
PART 17--MEDICAL
1. The authority citation for part 17 continues to read as follows:
Authority: 38 U.S.C. 501, 1721, unless otherwise noted.
Sec. 17.190 [Amended]
2. In Sec. 17.190, the introductory text is amended by removing
``hospital, domiciliary or nursing home'' and adding, in its place,
``hospital or domiciliary''; paragraph (a) is amended by removing ``or
nursing home care''; paragraph (b) is amended by removing ``nursing
home care patients or''; and paragraph (d) is removed.
Sec. 17.191 [Amended]
3. Section 17.191 is amended by removing ``domiciliary, nursing
home'' and adding, in its place, ``domiciliary''.
Sec. 17.192 [Amended]
4. Section 17.192 is amended by removing ``nursing home or''.
Sec. 17.193 [Amended]
5. Section 17.193 is amended by removing the second sentence
thereof.
Sec. 17.195 [Removed]
6. Section 17.195 is removed.
Sec. 17.197 [Amended]
7. Section 17.197 is amended by removing ``section 1741(a)(2) for
nursing home care''.
Sec. 17.198 [Amended]
8. Section 17.198 is amended by removing ``hospital, domiciliary or
nursing home'' and adding, in its place, ``hospital or domiciliary''.
9. A ``Note'' is added immediately following the authority citation
for Sec. 17.200 to read as follows:
Sec. 17.200 Audit of State homes.
* * * * *
Note: Sections 17.190 through 17.200 do not apply to nursing
home care in State homes. The provisions for nursing home care in
State homes are set forth in 38 CFR part 51.
10. Part 51 is added to read as follows:
PART 51--PER DIEM FOR NURSING HOME CARE OF VETERANS IN STATE HOMES
Subpart A--General
Sec.
51.1 Purpose.
51.2 Definitions.
Subpart B--Obtaining Per Diem for Nursing Home Care in State Homes
51.10 Per diem based on recognition and certification.
51.20 Application for recognition based on certification.
51.30 Recognition and certification.
Subpart C--Per Diem Payments
51.40 Monthly payment.
51.50 Eligible veterans.
Subpart D--Standards
51.60 Standards applicable for payment of per diem.
51.70 Resident rights.
51.80 Admission, transfer and discharge rights.
51.90 Resident behavior and facility practices.
51.100 Quality of life.
51.110 Resident assessment.
51.120 Quality of care.
51.130 Nursing services.
51.140 Dietary services.
[[Page 60229]]
51.150 Physician services.
51.160 Specialized rehabilitative services.
51.170 Dental services.
51.180 Pharmacy services.
51.190 Infection control.
51.200 Physical environment.
51.210 Administration.
51.220 VA Form 10-3567--State Home Inspection: Staffing Profile.
51.221 VA Form 10-5588--State Home Report and Statement of Federal
Aid Claimed.
51.222 VA Form 10-10EZ--Application for Health Benefits.
51.223 VA Form 10-10SH--State Home Program Application for Veteran
Care--Medical Certification.
51.224 VA Form 10-0143A--Statement of Assurance of Compliance with
Section 504 of The Rehabilitation Act of 1973.
51.225 VA Form 10-0143--Department of Veterans Affairs
Certification Regarding Drug-Free Workplace Requirements for
Grantees Other Than Individuals.
51.226 VA Form 10-0144--Certification Regarding Lobbying.
51.227 VA Form 10-0144A--Statement of Assurance of Compliance with
Equal Opportunity Laws.
Authority: 38 U.S.C. 101, 501, 1710, 1741-1743.
Subpart A--General
Sec. 51.1 Purpose.
This part sets forth the mechanism for paying per diem to State
homes providing nursing home care to eligible veterans and is intended
to ensure that veterans receive high quality care in State homes.
Sec. 51.2 Definitions.
For purposes of this part--
Clinical nurse specialist means a licensed professional nurse with
a master's degree in nursing with a major in a clinical nursing
specialty from an academic program accredited by the National League
for Nursing and at least 2 years of successful clinical practice in the
specialized area of nursing practice following this academic
preparation.
Facility means a building or any part of a building for which a
State has submitted an application for recognition as a State home for
the provision of nursing home care or a building or any part of a
building which VA has recognized as a State home for the provision of
nursing home care.
Nurse practitioner means a licensed professional nurse who is
currently licensed to practice in the State; who meets the State's
requirements governing the qualifications of nurse practitioners; and
who is currently certified as an adult, family, or gerontological nurse
practitioner by the American Nurses' Association.
Nursing home care means the accommodation of convalescents or other
persons who are not acutely ill and not in need of hospital care, but
who require skilled nursing care and related medical services.
Physician means a doctor of medicine or osteopathy legally
authorized to practice medicine or surgery in the State.
Physician assistant means a person who meets the applicable State
requirements for physician assistant, is currently certified by the
National Commission on Certification of Physician Assistants (NCCPA) as
a physician assistant, and has an individualized written scope of
practice that determines the authorization to write medical orders,
prescribe medications and other clinical tasks under appropriate
physician supervision which is approved by the primary care physician.
Primary physician or primary care physician means a designated
generalist physician responsible for providing, directing and
coordinating all health care that is indicated for the residents.
State means each of the several States, territories, and
possessions of the United States, the District of Columbia, and the
Commonwealth of Puerto Rico.
State home means a home approved by VA which a State established
primarily for veterans disabled by age, disease, or otherwise, who by
reason of such disability are incapable of earning a living. A State
home may provide domiciliary care, nursing home care, adult day health
care, and hospital care. Hospital care may be provided only when the
State home also provides domiciliary and/or nursing home care.
VA means the U.S. Department of Veterans Affairs.
Subpart B--Obtaining Per Diem for Nursing Home Care in State Homes
Sec. 51.10 Per diem based on recognition and certification.
VA will pay per diem to a State for providing nursing home care to
eligible veterans in a facility if the Under Secretary for Health
recognizes the facility as a State home based on a current
certification that the facility and facility management meet the
standards of subpart D of this part. Also, after recognition has been
granted, VA will continue to pay per diem to a State for providing
nursing home care to eligible veterans in such a facility for a
temporary period based on a certification that the facility and
facility management provisionally meet the standards of subpart D of
this part.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.20 Application for recognition based on certification.
To apply for recognition and certification of a State home for
nursing home care, a State must:
(a) Send a request for recognition and certification to the Under
Secretary for Health(10), VA Headquarters, 810 Vermont Avenue, NW,
Washington, DC 20420. The request must be in the form of a letter and
must be signed by the State official authorized to establish the State
home,
(b) Allow VA to survey the facility as set forth in Sec. 51.30(c),
and
(c) Upon request from the director of the VA medical center of
jurisdiction, submit to the director all documentation required under
subpart D of this part.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.30 Recognition and certification.
(a)(1) The Under Secretary for Health will make the determination
regarding recognition and the initial determination regarding
certification, after receipt of a tentative determination from the
director of the VA medical center of jurisdiction regarding whether,
based on a VA survey, the facility and facility management meet or do
not meet the standards of subpart D of this part. The Under Secretary
for Health will notify the official in charge of the facility, the
State official authorized to oversee operations of the State home, the
VA Network Director (10N 1-22), Chief Network Officer (10N), and the
Chief Consultant, Geriatrics and Extended Care Strategic Healthcare
Group (114) of the action taken.
(2) For each facility recognized as a State home, the director of
the VA medical center of jurisdiction will certify annually whether the
facility and facility management meet, provisionally meet, or do not
meet the standards of subpart D of this part (this certification should
be made every 12 months during the recognition anniversary month or
during a month agreed upon by the VA medical care center director and
officials of the State home facility). A provisional certification will
be issued by the director only upon a determination that the facility
or facility management does not meet one or more of the standards in
subpart D of this part, that the deficiencies do not jeopardize the
health or safety of the residents, and that the facility management and
the director have agreed to a plan of correction to remedy the
deficiencies in a specified amount of time (not more time than the VA
medical center of jurisdiction director determines is reasonable for
correcting the specific deficiencies). The director
[[Page 60230]]
of the VA medical center of jurisdiction will notify the official in
charge of the facility, the State official authorized to oversee the
operations of the State home, the VA Network Director (10N 1-22), Chief
Network Officer (10N) and the Chief Consultant, Geriatrics and Extended
Care Strategic Healthcare Group (114) of the certification, provisional
certification, or noncertification.
(b) Once a facility has achieved recognition, the recognition will
remain in effect unless the State requests that the recognition be
withdrawn or the Under Secretary for Health makes a final decision that
the facility or facility management does not meet the standards of
subpart D of this part. Recognition of a facility will apply only to
the facility as it exists at the time of recognition; any annex,
branch, enlargement, expansion, or relocation must be separately
recognized.
(c) Both during the application process for recognition and after
the Under Secretary for Health has recognized a facility, VA may survey
the facility as necessary to determine if the facility and facility
management comply with the provisions of this part. Generally, VA will
provide advance notice to the State before a survey occurs; however,
surveys may be conducted without notice. A survey, as necessary, will
cover all parts of the facility, and include a review and audit of all
records of the facility that have a bearing on compliance with any of
the requirements of this part (including any reports from State or
local entities). For purposes of a survey, at the request of the
director of the VA medical center of jurisdiction, the State home
facility management must submit to the director a completed VA Form 10-
3567, Staffing Profile, set forth at Sec. 51.220. The director of the
VA medical center of jurisdiction will designate the VA officials to
survey the facility. These officials may include physicians; nurses;
pharmacists; dietitians; rehabilitation therapists; social workers;
representatives from health administration, engineering, environmental
management systems, and fiscal officers.
(d) If the director of the VA medical center of jurisdiction
determines that the State home facility or facility management does not
meet the standards of this part, the director will notify the State
home facility in writing of the standards not meet. The director will
send a copy of this notice to the State official authorized to oversee
operations of the facility, the VA Network Director (10N 1-22), the
Chief Network Officer (10N), and the Chief Consultant, Geriatrics and
Extended Care Strategic Healthcare Group (114). The letter will include
the reasons for the decision and indicate that the State has the right
to appeal the decision.
(e) The State must submit the appeal to the Under Secretary for
Health in writing, within 30 days of receipt of the notice of failure
to meet the standards. In its appeal, the State must explain why the
determination is inaccurate or incomplete and provide any new and
relevant information not previously considered. Any appeal that does
not identify a reason for disagreement will be returned to the sender
without further consideration.
(f) After reviewing the matter, including any relevant supporting
documentation, the Under Secretary for Health will issue a written
determination that affirms or reverses the previous determination. If
the Under Secretary for Health decides that the facility does not meet
the standards of subpart D of this part, the Under Secretary for Health
will withdraw recognition and stop paying per diem for care provided on
and after the date of the decision. The decision of Under Secretary for
Health will constitute a final VA decision. The Under Secretary for
Health will send a copy of this decision to the State home facility and
to the State official authorized to oversee the operations of the State
home.
(g) In the event that a VA survey team or other VA medical center
staff identifies any condition that poses an immediate threat to public
or patient safety or other information indicating the existence of such
a threat, the director of VA medical center of jurisdiction will
immediately report this to the VA Network Director (10N 1-22), Chief
Network Officer (10N), Chief Consultant, Geriatrics and Extended Care
Strategic Healthcare Group (114) and State official authorized to
oversee operations of the State home.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Subpart C--Per Diem Payments
Sec. 51.40 Monthly payment.
(a)(1) During Fiscal Year 1999, VA will pay monthly one-half of the
cost of each eligible veteran's nursing home care for each day the
veteran is in a facility recognized as a State home for nursing home
care, not to exceed $43.92 per diem.
(2) Per diem will be paid only for the days that the veteran is a
resident at the facility. For purposes of paying per diem, VA will
consider a veteran to be a resident at the facility during each full
day that the veteran is receiving care at the facility. VA will not
deem the veteran to be a resident at the facility if the veteran is
receiving care outside the State home facility at VA expense.
Otherwise, VA will deem the veteran to be a resident at the facility
during any absence from the facility that lasts for no more than 96
consecutive hours. This absence will be considered to have ended when
the veteran returns as a resident if the veteran's stay is for at least
a continuous 24-hour period.
(3) As a condition for receiving payment of per diem under this
part, the State must submit a completed VA form 10-5588, State Home
Report and Statement of Federal Aid Claimed. This form is set forth in
full at Sec. 51.221 of this part.
(4) Initial payments will not be made until the Under Secretary for
Health recognizes the State home. However, payments will be made
retroactively for care that was provided on and after the date of the
completion of the VA survey of the facility that provided the basis for
determining that the facility met the standards of this part.
(5) As a condition for receiving payment of per diem under this
part, the State must submit to the VA medical center of jurisdiction
for each veteran the following completed VA forms 10-10EZ, Application
for Medical Benefits, and 10-10SH, State Home Program Application for
Care--Medical Certification, at the time of admission and with any
request for a change in the level of care (domiciliary care or hospital
care). These forms are set forth in full at Sec. 51.222 and
Sec. 51.223, respectively, of this part. If the facility is eligible to
receive per diem payments for a veteran, VA will pay per diem under
this part from the date of receipt of the completed forms required by
this paragraph, except that VA will pay per diem from the day on which
the veteran was admitted to the facility if the completed forms are
received within 10 days after admission.
(b) Total per diem costs for an eligible veteran's nursing home
care consist of those direct and indirect costs attributable to nursing
home care at the facility divided by the total number of patients at
the nursing home. Relevant cost principles are set forth in the Office
of Management and Budget (OMB) Circular number A-87, dated May 4, 1995,
``Cost Principles for State, Local, and Indian Tribal Governments.''
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.50 Eligible veterans.
A veteran is an eligible veteran under this part if VA determines
that the
[[Page 60231]]
veteran needs nursing home care and the veteran is within one of the
following categories:
(a) Veterans with service-connected disabilities;
(b) Veterans who are former prisoners of war;
(c) Veterans who were discharged or released from active military
service for a disability incurred or aggravated in the line of duty;
(d) Veterans who receive disability compensation under 38 U.S.C.
1151;
(e) Veterans whose entitlement to disability compensation is
suspended because of the receipt of retired pay;
(f) Veterans whose entitlement to disability compensation is
suspended pursuant to 38 U.S.C. 1151, but only to the extent that such
veterans' continuing eligibility for nursing home care is provided for
in the judgment or settlement described in 38 U.S.C. 1151;
(g) Veterans who VA determines are unable to defray the expenses of
necessary care as specified under 38 U.S.C. 1722(a);
(h) Veterans of the Mexican border period or of World War I;
(i) Veterans solely seeking care for a disorder associated with
exposure to a toxic substance or radiation or for a disorder associated
with service in the Southwest Asia theater of operations during the
Persian Gulf War, as provided in 38 U.S.C. 1710(e);
(j) Veterans who agree to pay to the United States the applicable
co-payment determined under 38 U.S.C. 1710(f) and 1710(g), if they seek
VA hospital, nursing home, or outpatient care.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Subpart D--Standards
Sec. 51.60 Standards applicable for payment of per diem.
The provisions of this subpart are the standards that a State home
and facility management must meet for the State to receive per diem for
nursing home care.
Sec. 51.70 Resident rights.
The resident has a right to a dignified existence, self-
determination, and communication with and access to persons and
services inside and outside the facility. The facility management must
protect and promote the rights of each resident, including each of the
following rights:
(a) Exercise of rights. (1) The resident has the right to exercise
his or her rights as a resident of the facility and as a citizen or
resident of the United States.
(2) The resident has the right to be free of interference,
coercion, discrimination, and reprisal from the facility management in
exercising his or her rights.
(3) The resident has the right to freedom from chemical or physical
restraint.
(4) In the case of a resident determined incompetent under the laws
of a State by a court of jurisdiction, the rights of the resident are
exercised by the person appointed under State law to act on the
resident's behalf.
(5) In the case of a resident who has not been determined
incompetent by the State court, any legal-surrogate designated in
accordance with State law may exercise the resident's rights to the
extent provided by State law.
(b) Notice of rights and services. (1) The facility management must
inform the resident both orally and in writing in a language that the
resident understands of his or her rights and all rules and regulations
governing resident conduct and responsibilities during the stay in the
facility. Such notification must be made prior to or upon admission and
periodically during the resident's stay.
(2) The resident or his or her legal representative has the right--
(i) Upon an oral or written request, to access all records
pertaining to himself or herself including current clinical records
within 24 hours (excluding weekends and holidays); and
(ii) After receipt of his or her records for review, to purchase at
a cost not to exceed the community standard photocopies of the records
or any portions of them upon request and with 2 working days advance
notice to the facility management.
(3) The resident has the right to be fully informed in language
that he or she can understand of his or her total health status;
(4) The resident has the right to refuse treatment, to refuse to
participate in experimental research, and to formulate an advance
directive as specified in paragraph (b)(7) of this section; and
(5) The facility management must inform each resident before, or at
the time of admission, and periodically during the resident's stay, of
services available in the facility and of charges for those services to
be billed to the resident.
(6) The facility management must furnish a written description of
legal rights which includes--
(i) A description of the manner of protecting personal funds, under
paragraph (c) of this section;
(ii) A statement that the resident may file a complaint with the
State (agency) concerning resident abuse, neglect, misappropriation of
resident property in the facility, and non-compliance with the advance
directives requirements.
(7) The facility management must have written policies and
procedures regarding advance directives (e.g., living wills). These
requirements include provisions to inform and provide written
information to all residents concerning the right to accept or refuse
medical or surgical treatment and, at the individual's option,
formulate an advance directive. This includes a written description of
the facility's policies to implement advance directives and applicable
State law. If an individual is incapacitated at the time of admission
and is unable to receive information (due to the incapacitating
conditions) or articulate whether or not he or she has executed an
advance directive, the facility may give advance directive information
to the individual's family or surrogate in the same manner that it
issues other materials about policies and procedures to the family of
the incapacitated individual or to a surrogate or other concerned
persons in accordance with State law. The facility management is not
relieved of its obligation to provide this information to the
individual once he or she is no longer incapacitated or unable to
receive such information. Follow-up procedures must be in place to
provide the information to the individual directly at the appropriate
time.
(8) The facility management must inform each resident of the name
and way of contacting the primary physician responsible for his or her
care.
(9) Notification of changes. (i) Facility management must
immediately inform the resident; consult with the primary physician;
and if known, notify the resident's legal representative or an
interested family member when there is--
(A) An accident involving the resident which results in injury and
has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or
psychosocial status (i.e., a deterioration in health, mental, or
psychosocial status in either life-threatening conditions or clinical
complications);
(C) A need to alter treatment significantly (i.e., a need to
discontinue an existing form of treatment due to adverse consequences,
or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the
facility as specified in Sec. 51.80(a) of this part.
(ii) The facility management must also promptly notify the resident
and, if known, the resident's legal
[[Page 60232]]
representative or interested family member when there is--
(A) A change in room or roommate assignment as specified in
Sec. 51.100(f)(2); or
(B) A change in resident rights under Federal or State law or
regulations as specified in paragraph (b)(1) of this section.
(iii) The facility management must record and periodically update
the address and phone number of the resident's legal representative or
interested family member.
(c) Protection of resident funds. (1) The resident has the right to
manage his or her financial affairs, and the facility management may
not require residents to deposit their personal funds with the
facility.
(2) Management of personal funds. Upon written authorization of a
resident, the facility management must hold, safeguard, manage, and
account for the personal funds of the resident deposited with the
facility, as specified in paragraphs (c)(3)-(6) of this section.
(3) Deposit of funds. (i) Funds in excess of $50. The facility
management must deposit any residents' personal funds in excess of $50
in an interest bearing account (or accounts) that is separate from any
of the facility's operating accounts, and that credits all interest
earned on resident's funds to that account. (In pooled accounts, there
must be a separate accounting for each resident's share.)
(ii) Funds less than $50. The facility management must maintain a
resident's personal funds that do not exceed $50 in a non-interest
bearing account, interest-bearing account, or petty cash fund.
(4) Accounting and records. The facility management must establish
and maintain a system that assures a full and complete and separate
accounting, according to generally accepted accounting principles, of
each resident's personal funds entrusted to the facility on the
resident's behalf.
(i) The system must preclude any commingling of resident funds with
facility funds or with the funds of any person other than another
resident.
(ii) The individual financial record must be available through
quarterly statements and on request to the resident or his or her legal
representative.
(5) Conveyance upon death. Upon the death of a resident with a
personal fund deposited with the facility, the facility management must
convey within 30 days the resident's funds, and a final accounting of
those funds, to the individual or probate jurisdiction administering
the resident's estate.
(6) Assurance of financial security. The facility management must
purchase a surety bond, or otherwise provide assurance satisfactory to
the Under Secretary for Health, to assure the security of all personal
funds of residents deposited with the facility.
(d) Free choice. The resident has the right to--
(1) Be fully informed in advance about care and treatment and of
any changes in that care or treatment that may affect the resident's
well-being; and
(2) Unless determined incompetent or otherwise determined to be
incapacitated under the laws of the State, participate in planning care
and treatment or changes in care and treatment.
(e) Privacy and confidentiality. The resident has the right to
personal privacy and confidentiality of his or her personal and
clinical records.
(1) Residents have a right to personal privacy in their
accommodations, medical treatment, written and telephone
communications, personal care, visits, and meetings of family and
resident groups. This does not require the facility management to give
a private room to each resident.
(2) Except as provided in paragraph (e)(3) of this section, the
resident may approve or refuse the release of personal and clinical
records to any individual outside the facility;
(3) The resident's right to refuse release of personal and clinical
records does not apply when--
(i) The resident is transferred to another health care institution;
or
(ii) Record release is required by law.
(f) Grievances. A resident has the right to--
(1) Voice grievances without discrimination or reprisal. Residents
may voice grievances with respect to treatment received and not
received; and
(2) Prompt efforts by the facility to resolve grievances the
resident may have, including those with respect to the behavior of
other residents.
(g) Examination of survey results. A resident has the right to--
(1) Examine the results of the most recent VA survey with respect
to the facility. The facility management must make the results
available for examination in a place readily accessible to residents,
and must post a notice of their availability; and
(2) Receive information from agencies acting as client advocates,
and be afforded the opportunity to contact these agencies.
(h) Work. The resident has the right to--
(1) Refuse to perform services for the facility;
(2) Perform services for the facility, if he or she chooses, when--
(i) The facility has documented the need or desire for work in the
plan of care;
(ii) The plan specifies the nature of the services performed and
whether the services are voluntary or paid;
(iii) Compensation for paid services is at or above prevailing
rates; and
(iv) The resident agrees to the work arrangement described in the
plan of care.
(i) Mail. The resident has the right to privacy in written
communications, including the right to--
(1) Send and promptly receive mail that is unopened; and
(2) Have access to stationery, postage, and writing implements at
the resident's own expense.
(j) Access and visitation rights. (1) The resident has the right
and the facility management must provide immediate access to any
resident by the following:
(i) Any representative of the Under Secretary for Health;
(ii) Any representative of the State;
(iii) Physicians of the resident's choice;
(iv) The State long term care ombudsman;
(v) Immediate family or other relatives of the resident subject to
the resident's right to deny or withdraw consent at any time; and
(vi) Others who are visiting subject to reasonable restrictions and
the resident's right to deny or withdraw consent at any time.
(2) The facility management must provide reasonable access to any
resident by any entity or individual that provides health, social,
legal, or other services to the resident, subject to the resident's
right to deny or withdraw consent at any time.
(3) The facility management must allow representatives of the State
Ombudsman Program, described in paragraph (j)(1)(iv) of this section,
to examine a resident's clinical records with the permission of the
resident or the resident's legal representative, subject to State law.
(k) Telephone. The resident has the right to reasonable access to
use a telephone where calls can be made without being overheard.
(l) Personal property. The resident has the right to retain and use
personal possessions, including some furnishings, and appropriate
clothing, as space permits, unless to do so would infringe upon the
rights or health and safety of other residents.
(m) Married couples. The resident has the right to share a room
with his or her
[[Page 60233]]
spouse when married residents live in the same facility and both
spouses consent to the arrangement.
(n) Self-Administration of drugs. An individual resident may self-
administer drugs if the interdisciplinary team, as defined by
Sec. 51.110(d)(2)(ii) of this part, has determined that this practice
is safe.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.80 Admission, transfer and discharge rights.
(a) Transfer and discharge--(1) Definition. Transfer and discharge
includes movement of a resident to a bed outside of the facility
whether that bed is in the same physical plant or not. Transfer and
discharge does not refer to movement of a resident to a bed within the
same facility.
(2) Transfer and discharge requirements. The facility management
must permit each resident to remain in the facility, and not transfer
or discharge the resident from the facility unless--
(i) The transfer or discharge is necessary for the resident's
welfare and the resident's needs cannot be met in the nursing home;
(ii) The transfer or discharge is appropriate because the
resident's health has improved sufficiently so the resident no longer
needs the services provided by the nursing home;
(iii) The safety of individuals in the facility is endangered;
(iv) The health of individuals in the facility would otherwise be
endangered;
(v) The resident has failed, after reasonable and appropriate
notice to pay for a stay at the facility; or
(vi) The nursing home ceases to operate.
(3) Documentation. When the facility transfers or discharges a
resident under any of the circumstances specified in paragraphs
(a)(2)(i) through (a)(2)(vi) of this section, the primary physician
must document in the resident's clinical record.
(4) Notice before transfer. Before a facility transfers or
discharges a resident, the facility must--
(i) Notify the resident and, if known, a family member or legal
representative of the resident of the transfer or discharge and the
reasons for the move in writing and in a language and manner they
understand.
(ii) Record the reasons in the resident's clinical record; and
(iii) Include in the notice the items described in paragraph (a)(6)
of this section.
(5) Timing of the notice. (i) The notice of transfer or discharge
required under paragraph (a)(4) of this section must be made by the
facility at least 30 days before the resident is transferred or
discharged, except when specified in paragraph (a)(5)(ii) of this
section,
(ii) Notice may be made as soon as practicable before transfer or
discharge when--
(A) The safety of individuals in the facility would be endangered;
(B) The health of individuals in the facility would be otherwise
endangered;
(C) The resident's health improves sufficiently so the resident no
longer needs the services provided by the nursing home;
(D) The resident's needs cannot be met in the nursing home;
(6) Contents of the notice. The written notice specified in
paragraph (a)(4) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or
discharged;
(iv) A statement that the resident has the right to appeal the
action to the State official designated by the State; and
(v) The name, address and telephone number of the State long term
care ombudsman.
(7) Orientation for transfer or discharge. A facility management
must provide sufficient preparation and orientation to residents to
ensure safe and orderly transfer or discharge from the facility.
(b) Notice of bed-hold policy and readmission.--(1) Notice before
transfer. Before a facility transfers a resident to a hospital or
allows a resident to go on therapeutic leave, the facility management
must provide written information to the resident and a family member or
legal representative that specifies--
(i) The duration of the facility's bed-hold policy, if any, during
which the resident is permitted to return and resume residence in the
facility; and
(ii) The facility's policies regarding bed-hold periods, which must
be consistent with paragraph (b)(3) of this section, permitting a
resident to return.
(2) Bed-hold notice upon transfer. At the time of transfer of a
resident for hospitalization or therapeutic leave, facility management
must provide to the resident and a family member or legal
representative written notice which specifies the duration of the bed-
hold policy described in paragraph (b)(1) of this section.
(3) Permitting resident to return to facility. A nursing facility
must establish and follow a written policy under which a resident,
whose hospitalization or therapeutic leave exceeds the bed-hold period
is readmitted to the facility immediately upon the first availability
of a bed in a semi-private room, if the resident requires the services
provided by the facility.
(c) Equal access to quality care. The facility management must
establish and maintain identical policies and practices regarding
transfer, discharge, and the provision of services for all individuals
regardless of source of payment.
(d) Admissions policy. The facility management must not require a
third party guarantee of payment to the facility as a condition of
admission or expedited admission, or continued stay in the facility.
However, the facility may require an individual who has legal access to
a resident's income or resources available to pay for facility care to
sign a contract to pay the facility from the resident's income or
resources.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.90 Resident behavior and facility practices.
(a) Restraints. (1) The resident has a right to be free from any
chemical or physical restraints imposed for purposes of discipline or
convenience. When a restraint is applied or used, the purpose of the
restraint is reviewed and is justified as a therapeutic intervention.
(i) Chemical restraint is the inappropriate use of a sedating
psychotropic drug to manage or control behavior.
(ii) Physical restraint is any method of physically restricting a
person's freedom of movement, physical activity or normal access to his
or her body. Bed rails and vest restraints are examples of physical
restraints.
(2) The facility management uses a system to achieve a restraint-
free environment.
(3) The facility management collects data about the use of
restraints.
(4) When alternatives to the use of restraint are ineffective,
restraint is safely and appropriately used.
(b) Abuse. The resident has the right to be free from mental,
physical, sexual, and verbal abuse or neglect, corporal punishment, and
involuntary seclusion.
(1) Mental abuse includes humiliation, harassment, and threats of
punishment or deprivation.
(2) Physical abuse includes hitting, slapping, pinching, or
kicking. Also includes controlling behavior through corporal
punishment.
(3) Sexual abuse includes sexual harassment, sexual coercion, and
sexual assault.
(4) Neglect is any impaired quality of life for an individual
because of the absence of minimal services or
[[Page 60234]]
resources to meet basic needs. Includes withholding or inadequately
providing food and hydration (without physician, resident, or surrogate
approval), clothing, medical care, and good hygiene. May also include
placing the individual in unsafe or unsupervised conditions.
(5) Involuntary seclusion is a resident's separation from other
residents or from the resident's room against his or her will or the
will of his or her legal representative.
(c) Staff treatment of residents. The facility management must
develop and implement written policies and procedures that prohibit
mistreatment, neglect, and abuse of residents and misappropriation of
resident property.
The facility management must:
(i) Not employ individuals who --
(A) Have been found guilty of abusing, neglecting, or mistreating
individuals by a court of law; or
(B) Have had a finding entered into an applicable State registry or
with the applicable licensing authority concerning abuse, neglect,
mistreatment of individuals or misappropriation of their property; and
(ii) Report any knowledge it has of actions by a court of law
against an employee, which would indicate unfitness for service as a
nurse aide or other facility staff to the State nurse aide registry or
licensing authorities.
(2) The facility management must ensure that all alleged violations
involving mistreatment, neglect, or abuse, including injuries of
unknown source, and misappropriation of resident property are reported
immediately to the administrator of the facility and to other officials
in accordance with State law through established procedures.
(3) The facility management must have evidence that all alleged
violations are thoroughly investigated, and must prevent further
potential abuse while the investigation is in progress.
(4) The results of all investigations must be reported to the
administrator or the designated representative and to other officials
in accordance with State law within 5 working days of the incident, and
appropriate corrective action must be taken if the alleged violation is
verified.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.100 Quality of life.
A facility management must care for its residents in a manner and
in an environment that promotes maintenance or enhancement of each
resident's quality of life.
(a) Dignity. The facility management must promote care for
residents in a manner and in an environment that maintains or enhances
each resident's dignity and respect in full recognition of his or her
individuality.
(b) Self-determination and participation. The resident has the
right to--
(1) Choose activities, schedules, and health care consistent with
his or her interests, assessments, and plans of care;
(2) Interact with members of the community both inside and outside
the facility; and
(3) Make choices about aspects of his or her life in the facility
that are significant to the resident.
(c) Resident Council. The facility management must establish a
council of residents that meet at least quarterly. The facility
management must document any concerns submitted to the management of
the facility by the council.
(d) Participation in resident and family groups. (1) A resident has
the right to organize and participate in resident groups in the
facility;
(2) A resident's family has the right to meet in the facility with
the families of other residents in the facility;
(3) The facility management must provide the council and any
resident or family group that exists with private space;
(4) Staff or visitors may attend meetings at the group's
invitation;
(5) The facility management must provide a designated staff person
responsible for providing assistance and responding to written requests
that result from group meetings;
(6) The facility management must listen to the views of any
resident or family group, including the council established under
paragraph (c) of this section, and act upon the concerns of residents,
families, and the council regarding policy and operational decisions
affecting resident care and life in the facility.
(e) Participation in other activities. A resident has the right to
participate in social, religious, and community activities that do not
interfere with the rights of other residents in the facility. The
facility management must arrange for religious counseling by clergy of
various faith groups.
(f) Accommodation of needs. A resident has the right to--
(1) Reside and receive services in the facility with reasonable
accommodation of individual needs and preferences, except when the
health or safety of the individual or other residents would be
endangered; and
(2) Receive notice before the resident's room or roommate in the
facility is changed.
(g) Patient Activities. (1) The facility management must provide
for an ongoing program of activities designed to meet, in accordance
with the comprehensive assessment, the interests and the physical,
mental, and psychosocial well-being of each resident.
(2) The activities program must be directed by a qualified
professional who--
(i) Is a qualified therapeutic recreation specialist or an
activities professional who--
(A) Is licensed or registered, if applicable, by the State in which
practicing; and
(B) Is certified as a therapeutic recreation specialist or as an
activities professional by a recognized accrediting body.
(h) Social Services. (1) The facility management must provide
medically related social services to attain or maintain the highest
practicable mental and psychosocial well being of each resident.
(2) A nursing home with 100 or more beds must employ a qualified
social worker on a full-time basis.
(3) Qualifications of social worker. A qualified social worker is
an individual with--
(i) A bachelor's degree in social work from a school accredited by
the Council of Social Work Education, and
Note: A master's degree social worker with experience in long-
term care is preferred.
(ii) A social work license from the State in which the State home
is located, if offered by the State, and
(iii) A minimum of one year of supervised social work experience,
under the supervision of a social worker with a master's degree, in a
health care setting working directly with individuals.
(4) The facility management must have sufficient support staff to
meet patients' social services needs.
(5) Facilities for social services must ensure privacy for
interviews.
(i) Environment. The facility management must provide--
(1) A safe, clean, comfortable, and homelike environment, allowing
the resident to use his or her personal belongings to the extent
possible;
(2) Housekeeping and maintenance services necessary to maintain a
sanitary, orderly, and comfortable interior;
(3) Clean bed and bath linens that are in good condition;
[[Page 60235]]
(4) Private closet space in each resident room, as specified in
Sec. 51.200(d)(2)(iv) of this part;
(5) Adequate and comfortable lighting levels in all areas;
(6) Comfortable and safe temperature levels. Facilities must
maintain a temperature range of 71-81 degrees F.; and
(7) For the maintenance of comfortable sound levels.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.110 Resident assessment.
The facility management must conduct initially, annually and as
required by a change in the resident's condition a comprehensive,
accurate, standardized, reproducible assessment of each resident's
functional capacity.
(a) Admission orders. At the time each resident is admitted, the
facility management must have physician orders for the resident's
immediate care and a medical assessment, including a medical history
and physical examination, within a time frame appropriate to the
resident's condition, not to exceed 72 hours after admission, except
when an examination was performed within five days before admission and
the findings were recorded in the medical record on admission.
(b) Comprehensive assessments. (1) The facility management must
make a comprehensive assessment of a resident's needs:
(i) Using the Health Care Financing Administration Long Term Care
Resident Assessment Instrument Version 2.0; and
(ii) Describing the resident's capability to perform daily life
functions, strengths, performances, needs as well as significant
impairments in functional capacity.
(iii) All nursing homes must be in compliance with this standard by
no later than January 1, 2000.
(2) Frequency. Assessments must be conducted--
(i) No later than 14 days after the date of admission;
(ii) Promptly after a significant change in the resident's
physical, mental, or social condition; and
(iii) In no case less often than once every 12 months.
(3) Review of assessments. The nursing facility management must
examine each resident no less than once every 3 months, and as
appropriate, revise the resident's assessment to assure the continued
accuracy of the assessment.
(4) Use. The results of the assessment are used to develop, review,
and revise the resident's individualized comprehensive plan of care,
under paragraph (d) of this section.
(c) Accuracy of assessments. (1) Coordination--
(i) Each assessment must be conducted or coordinated with the
appropriate participation of health professionals.
(ii) Each assessment must be conducted or coordinated by a
registered nurse that signs and certifies the completion of the
assessment.
(2) Certification. Each person who completes a portion of the
assessment must sign and certify the accuracy of that portion of the
assessment.
(d) Comprehensive care plans. (1) The facility management must
develop an individualized comprehensive care plan for each resident
that includes measurable objectives and timetables to meet a resident's
physical, mental, and psychosocial needs that are identified in the
comprehensive assessment. The care plan must describe the following--
(i) The services that are to be furnished to attain or maintain the
resident's highest practicable physical, mental, and psychosocial well-
being as required under Sec. 51.120; and
(ii) Any services that would otherwise be required under
Sec. 51.120 of this part but are not provided due to the resident's
exercise of rights under Sec. 51.70, including the right to refuse
treatment under Sec. 51.70(b)(4) of this part.
(2) A comprehensive care plan must be--
(i) Developed within 7 calendar days after completion of the
comprehensive assessment;
(ii) Prepared by an interdisciplinary team, that includes the
primary physician, a registered nurse with responsibility for the
resident, and other appropriate staff in disciplines as determined by
the resident's needs, and, to the extent practicable, the participation
of the resident, the resident's family or the resident's legal
representative; and
(iii) Periodically reviewed and revised by a team of qualified
persons after each assessment.
(3) The services provided or arranged by the facility must--
(i) Meet professional standards of quality; and
(ii) Be provided by qualified persons in accordance with each
resident's written plan of care.
(e) Discharge summary. Prior to discharging a resident, the
facility management must prepare a discharge summary that includes--
(1) A recapitulation of the resident's stay;
(2) A summary of the resident's status at the time of the discharge
to include items in paragraph (b)(2) of this section; and
(3) A post-discharge plan of care that is developed with the
participation of the resident and his or her family, which will assist
the resident to adjust to his or her new living environment.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.120 Quality of care.
Each resident must receive and the facility management must provide
the necessary care and services to attain or maintain the highest
practicable physical, mental, and psychosocial well-being, in
accordance with the comprehensive assessment and plan of care.
(a) Reporting of Sentinel Events. (1) Definition. A sentinel event
is an adverse event that results in the loss of life or limb or
permanent loss of function.
(2) Examples of sentinel events are as follows:
(i) Any resident death, paralysis, coma or other major permanent
loss of function associated with a medication error; or
(ii) Any suicide of a resident, including suicides following
elopement (unauthorized departure) from the facility; or
(iii) Any elopement of a resident from the facility resulting in a
death or a major permanent loss of function; or
(iv) Any procedure or clinical intervention, including restraints,
that result in death or a major permanent loss of function; or
(v) Assault, homicide or other crime resulting in patient death or
major permanent loss of function; or
(vi) A patient fall that results in death or major permanent loss
of function as a direct result of the injuries sustained in the fall.
(3) The facility management must report sentinel events to the
director of VA medical center of jurisdiction, VA Network Director (10N
1-22), Chief Network Officer (10N), and Chief Consultant, Geriatrics
and Extended Care Strategic Healthcare Group (114) within 24 hours of
identification.
(4) The facility management must establish a mechanism to review
and analyze a sentinel event resulting in a written report no later
than 10 working days following the event.
(i) Goal. The purpose of the review and analysis of a sentinel
event is to prevent injuries to residents, visitors, and personnel, and
to manage those injuries that do occur and to minimize
[[Page 60236]]
the negative consequences to the injured individuals and facility.
(b) Activities of daily living. Based on the comprehensive
assessment of a resident, the facility management must ensure that--
(1) A resident's abilities in activities of daily living do not
diminish unless circumstances of the individual's clinical condition
demonstrate that diminution was unavoidable. This includes the
resident's ability to--
(i) Bathe, dress, and groom;
(ii) Transfer and ambulate;
(iii) Toilet;
(iv) Eat; and
(v) Talk or otherwise communicate.
(2) A resident is given the appropriate treatment and services to
maintain or improve his or her abilities specified in paragraph (b)(1)
of this section; and
(3) A resident who is unable to carry out activities of daily
living receives the necessary services to maintain good nutrition,
hydration, grooming, personal and oral hygiene, mobility, and bladder
and bowel elimination.
(c) Vision and hearing. To ensure that residents receive proper
treatment and assistive devices to maintain vision and hearing
abilities, the facility must, if necessary, assist the resident--
(1) In making appointments, and
(2) By arranging for transportation to and from the office of a
practitioner specializing in the treatment of vision or hearing
impairment or the office of a professional specializing in the
provision of vision or hearing assistive devices.
(d) Pressure sores. Based on the comprehensive assessment of a
resident, the facility management must ensure that--
(1) A resident who enters the facility without pressure sores does
not develop pressure sores unless the individual's clinical condition
demonstrates that they were unavoidable; and
(2) A resident having pressure sores receives necessary treatment
and services to promote healing, prevent infection and prevent new
sores from developing.
(e) Urinary and Fecal Incontinence. Based on the resident's
comprehensive assessment, the facility management must ensure that--
(1) A resident who enters the facility without an indwelling
catheter is not catheterized unless the resident's clinical condition
demonstrates that catheterization was necessary; and
(2) A resident who is incontinent of urine receives appropriate
treatment and services to prevent urinary tract infections and to
restore as much normal bladder function as possible.
(3) A resident who has persistent fecal incontinence receives
appropriate treatment and services to treat reversible causes and to
restore as much normal bowel function as possible.
(f) Range of motion. Based on the comprehensive assessment of a
resident, the facility management must ensure that--
(1) A resident who enters the facility without a limited range of
motion does not experience reduction in range of motion unless the
resident's clinical condition demonstrates that a reduction in range of
motion is unavoidable; and
(2) A resident with a limited range of motion receives appropriate
treatment and services to increase range of motion and/or to prevent
further decrease in range of motion.
(g) Mental and Psychosocial functioning. Based on the comprehensive
assessment of a resident, the facility management must ensure that a
resident who displays mental or psychosocial adjustment difficulty,
receives appropriate treatment and services to correct the assessed
problem.
(h) Enteral Feedings. Based on the comprehensive assessment of a
resident, the facility management must ensure that--
(1) A resident who has been able to adequately eat or take fluids
alone or with assistance is not fed by enteral feedings unless the
resident's clinical condition demonstrates that use of enteral feedings
was unavoidable; and
(2) A resident who is fed by enteral feedings receives the
appropriate treatment and services to prevent aspiration pneumonia,
diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-
pharyngeal ulcers and other skin breakdowns, and to restore, if
possible, normal eating skills.
(i) Accidents. The facility management must ensure that--
(1) The resident environment remains as free of accident hazards as
is possible; and
(2) Each resident receives adequate supervision and assistance
devices to prevent accidents.
(j) Nutrition. Based on a resident's comprehensive assessment, the
facility management must ensure that a resident--
(1) Maintains acceptable parameters of nutritional status, such as
body weight and protein levels, unless the resident's clinical
condition demonstrates that this is not possible; and
(2) Receives a therapeutic diet when a nutritional deficiency is
identified.
(k) Hydration. The facility management must provide each resident
with sufficient fluid intake to maintain proper hydration and health.
(l) Special needs. The facility management must ensure that
residents receive proper treatment and care for the following special
services:
(1) Injections;
(2) Parenteral and enteral fluids;
(3) Colostomy, ureterostomy, or ileostomy care;
(4) Tracheostomy care;
(5) Tracheal suctioning;
(6) Respiratory care;
(7) Foot care; and
(8) Prostheses.
(m) Unnecessary drugs--(1) General. Each resident's drug regimen
must be free from unnecessary drugs. An unnecessary drug is any drug
when used:
(i) In excessive dose (including duplicate drug therapy); or
(ii) For excessive duration; or
(iii) Without adequate monitoring; or
(iv) Without adequate indications for its use; or
(v) In the presence of adverse consequences which indicate the dose
should be reduced or discontinued; or
(vi) Any combinations of the reasons above.
(2) Antipsychotic Drugs. Based on a comprehensive assessment of a
resident, the facility management must ensure that--
(i) Residents who have not used antipsychotic drugs are not given
these drugs unless antipsychotic drug therapy is necessary to treat a
specific condition as diagnosed and documented in the clinical record;
and
(ii) Residents who use antipsychotic drugs receive gradual dose
reductions, and behavioral interventions, unless clinically
contraindicated, in an effort to discontinue these drugs.
(n) Medication Errors. The facility management must ensure that--
(1) Medication errors are identified and reviewed on a timely
basis; and
(2) strategies for preventing medication errors and adverse
reactions are implemented.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.130 Nursing services.
The facility management must provide an organized nursing service
with a sufficient number of qualified nursing personnel to meet the
total nursing care needs, as determined by resident assessment and
individualized comprehensive plans of care, of all patients within the
facility 24 hours a day, 7 days a week.
(a) The nursing service must be under the direction of a full-time
registered nurse who is currently licensed by the State and has, in
writing, administrative authority, responsibility, and
[[Page 60237]]
accountability for the functions, activities, and training of the
nursing services staff.
(b) The facility management must provide registered nurses 24 hours
per day, 7 days per week.
(c) The director of nursing service must designate a registered
nurse as a supervising nurse for each tour of duty.
(1) Based on the application and results of the case mix and
staffing methodology, the director of nursing may serve in a dual role
as director and as an onsite-supervising nurse only when the facility
has an average daily occupancy of 60 or fewer residents in nursing
home.
(2) Based on the application and results of the case mix and
staffing methodology, the evening or night supervising nurse may serve
in a dual role as supervising nurse as well as provides direct patient
care only when the facility has an average daily occupancy of 60 or
fewer residents in nursing home.
(d) The facility management must provide nursing services to ensure
that there is a minimum direct care nurse staffing per patient per 24
hours, 7 days per week of no less than 2.5 hours.
(e) Nurse staffing must be based on a staffing methodology that
applies case mix and is adequate for meeting the standards of this
part.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.140 Dietary services.
The facility management must provide each resident with a
nourishing, palatable, well-balanced diet that meets the daily
nutritional and special dietary needs of each resident.
(a) Staffing. The facility management must employ a qualified
dietitian either full-time, part-time, or on a consultant basis.
(1) If a qualified dietitian is not employed full-time, the
facility management must designate a person to serve as the director of
food service who receives at least a monthly scheduled consultation
from a qualified dietitian.
(2) A qualified dietitian is one who is qualified based upon
registration by the Commission on Dietetic Registration of the American
Dietetic Association.
(b) Sufficient staff. The facility management must employ
sufficient support personnel competent to carry out the functions of
the dietary service.
(c) Menus and nutritional adequacy. Menus must--
(1) Meet the nutritional needs of residents in accordance with the
recommended dietary allowances of the Food and Nutrition Board of the
National Research Council, National Academy of Sciences;
(2) Be prepared in advance; and
(3) Be followed.
(d) Food. Each resident receives and the facility provides--
(1) Food prepared by methods that conserve nutritive value, flavor,
and appearance;
(2) Food that is palatable, attractive, and at the proper
temperature;
(3) Food prepared in a form designed to meet individual needs; and
(4) Substitutes offered of similar nutritive value to residents who
refuse food served.
(e) Therapeutic diets. Therapeutic diets must be prescribed by the
primary care physician.
(f) Frequency of meals. (1) Each resident receives and the facility
provides at least three meals daily, at regular times comparable to
normal mealtimes in the community.
(2) There must be no more than 14 hours between a substantial
evening meal and breakfast the following day, except as provided in
paragraph (f)(4) of this section.
(3) The facility staff must offer snacks at bedtime daily.
(4) When a nourishing snack is provided at bedtime, up to 16 hours
may elapse between a substantial evening meal and breakfast the
following day if a resident group agrees to this meal span, and a
nourishing snack is served.
(g) Assistive devices. The facility management must provide special
eating equipment and utensils for residents who need them.
(h) Sanitary conditions. The facility must--
(1) Procure food from sources approved or considered satisfactory
by Federal, State, or local authorities;
(2) Store, prepare, distribute, and serve food under sanitary
conditions; and
(3) Dispose of garbage and refuse properly.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.150 Physician services.
A physician must personally approve in writing a recommendation
that an individual be admitted to a facility. Each resident must remain
under the care of a physician.
(a) Physician supervision. The facility management must ensure
that--
(1) The medical care of each resident is supervised by a primary
care physician;
(2) Each resident's medical record must list the name of the
resident's primary physician, and
(3) Another physician supervises the medical care of residents when
their primary physician is unavailable.
(b) Physician visits. The physician must--
(1) Review the resident's total program of care, including
medications and treatments, at each visit required by paragraph (c) of
this section;
(2) Write, sign, and date progress notes at each visit; and
(3) Sign and date all orders.
(c) Frequency of physician visits.
(1) The resident must be seen by the primary physician at least
once every 30 days for the first 90 days after admission, and at least
once every 60 days thereafter, or more frequently based on the
condition of the resident.
(2) A physician visit is considered timely if it occurs not later
than 10 days after the date the visit was required.
(3) Except as provided in paragraphs (c)(4) of this section, all
required physician visits must be made by the physician personally.
(4) At the option of the physician, required visits in the facility
after the initial visit may alternate between personal visits by the
physician and visits by a physician assistant, nurse practitioner, or
clinical nurse specialist in accordance with paragraph (e) of this
section.
(d) Availability of physicians for emergency care. The facility
management must provide or arrange for the provision of physician
services 24 hours a day 7 days per week, in case of an emergency.
(e) Physician delegation of tasks. (1) Except as specified in
paragraph (e)(2) of this section, a primary physician may delegate
tasks to:
(i) a certified physician assistant or a certified nurse
practitioner, or
(ii) a clinical nurse specialist who--
(A) Is acting within the scope of practice as defined by State law;
and
(B) Is under the supervision of the physician.
Note: A certified clinical nurse specialist with experience in
long term care is preferred.
(2) The primary physician may not delegate a task when the
regulations specify that the primary physician must perform it
personally, or when the delegation is prohibited under State law or by
the facility's own policies.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.160 Specialized rehabilitative services.
(a) Provision of services: If specialized rehabilitative services
such as but not limited to physical therapy, speech
[[Page 60238]]
therapy, occupational therapy, and mental health services for mental
illness are required in the resident's comprehensive plan of care,
facility management must--
(1) Provide the required services; or
(2) Obtain the required services from an outside resource, in
accordance with Sec. 51.210(h) of this part, from a provider of
specialized rehabilitative services.
(b) Specialized rehabilitative services must be provided under the
written order of a physician by qualified personnel.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.170 Dental services.
A facility--
(a) Must provide or obtain from an outside resource, in accordance
with Sec. 51.210(h) of this part, routine and emergency dental services
to meet the needs of each resident;
(b) May charge a resident an additional amount for routine and
emergency dental services;
(c) Must, if necessary, assist the resident--
(1) In making appointments; and
(2) By arranging for transportation to and from the dental
services; and
(3) Promptly refer residents with lost or damaged dentures to a
dentist.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.180 Pharmacy services.
The facility management must provide routine and emergency drugs
and biologicals to its residents, or obtain them under an agreement
described in Sec. 51.210(h) of this part. The facility management must
have a system for disseminating drug information to medical and nursing
staff.
(a) Procedures. The facility management must provide pharmaceutical
services (including procedures that assure the accurate acquiring,
receiving, dispensing, and administering of all drugs and biologicals)
to meet the needs of each resident.
(b) Service consultation. The facility management must employ or
obtain the services of a pharmacist licensed in a State in which the
facility is located who--
(1) Provides consultation on all aspects of the provision of
pharmacy services in the facility;
(2) Establishes a system of records of receipt and disposition of
all controlled drugs in sufficient detail to enable an accurate
reconciliation; and
(3) Determines that drug records are in order and that an account
of all controlled drugs is maintained and periodically reconciled.
(c) Drug regimen review. (1) The drug regimen of each resident must
be reviewed at least once a month by a licensed pharmacist.
(2) The pharmacist must report any irregularities to the primary
physician and the director of nursing, and these reports must be acted
upon.
(d) Labeling of drugs and biologicals. Drugs and biologicals used
in the facility management must be labeled in accordance with currently
accepted professional principles, and include the appropriate accessory
and cautionary instructions, and the expiration date when applicable.
(e) Storage of drugs and biologicals. (1) In accordance with State
and Federal laws, the facility management must store all drugs and
biologicals in locked compartments under proper temperature controls,
and permit only authorized personnel to have access to the keys.
(2) The facility management must provide separately locked,
permanently affixed compartments for storage of controlled drugs listed
in Schedule II of the Comprehensive Drug Abuse Prevention and Control
Act of 1976 and other drugs subject to abuse.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.190 Infection control.
The facility management must establish and maintain an infection
control program designed to provide a safe, sanitary, and comfortable
environment and to help prevent the development and transmission of
disease and infection.
(a) Infection control program. The facility management must
establish an infection control program under which it--
(1) Investigates, controls, and prevents infections in the
facility;
(2) Decides what procedures, such as isolation, should be applied
to an individual resident; and
(3) Maintains a record of incidents and corrective actions related
to infections.
(b) Preventing spread of infection. (1) When the infection control
program determines that a resident needs isolation to prevent the
spread of infection, the facility management must isolate the resident.
(2) The facility management must prohibit employees with a
communicable disease or infected skin lesions from direct contact with
residents or their food, if direct contact will transmit the disease.
(3) The facility management must require staff to wash their hands
after each direct resident contact for which hand washing is indicated
by accepted professional practice.
(c) Linens. Personnel must handle, store, process, and transport
linens so as to prevent the spread of infection.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.200 Physical environment.
The facility management must be designed, constructed, equipped,
and maintained to protect the health and safety of residents, personnel
and the public.
(a) Life safety from fire. The facility must meet the applicable
provisions of the 1997 edition of the Life Safety Code of the National
Fire Protection Association (which is incorporated by reference).
Incorporation of the 1997 edition of the National Fire Protection
Association's Life Safety Code (published February 7, 1997; ANSI/NFPA)
was approved by the Director of the Federal Register in accordance with
5 U.S.C. 552(a) and 1 CFR part 51 that govern the use of incorporations
by reference.1
---------------------------------------------------------------------------
\1\ The Code is available for inspection at the Office of the
Federal Register Information Center, room 8301, 1110 L Street NW.,
Washington, DC. Copies may be obtained from the National Fire
Protection Association, Batterymarch Park, Quincy, MA 02200. If any
changes in this code are also to be incorporated by reference, a
notice to that effect will be published in the Federal Register.
---------------------------------------------------------------------------
(b) Emergency power. (1) An emergency electrical power system must
be provided to supply power adequate for illumination of all exit signs
and lighting for the means of egress, fire alarm and medical gas
alarms, emergency communication systems, and generator task
illumination.
(2) The system must be the appropriate type essential electrical
system in accordance with the requirements of NFPA 99, Health Care
Facilities.
(3) When electrical life support devices are used, an emergency
electrical power system must also be provided for devices in accordance
with NFPA 99, Health Care Facilities.
(4) The source of power must be an on-site emergency standby
generator of sufficient size to serve the connected load or other
approved sources per NFPA 99, Health Care Facilities.
(c) Space and equipment. Facility management must--
(1) Provide sufficient space and equipment in dining, health
services, recreation, and program areas to enable staff to provide
residents with needed services as required by these standards and as
identified in each resident's plan of care; and
[[Page 60239]]
(2) Maintain all essential mechanical, electrical, and patient care
equipment in safe operating condition.
(d) Resident rooms. Resident rooms must be designed and equipped
for adequate nursing care, comfort, and privacy of residents (1)
Bedrooms must--
(i) Accommodate no more than four residents;
(ii) Measure at least 115 net square feet per resident in multiple
resident bedrooms;
(iii) Measure at least 150 net square feet in single resident
bedrooms;
(iv) Measure at least 245 net square feet in small double resident
bedrooms; and
(v) Measure at least 305 net square feet in large double resident
bedrooms used for spinal cord injury residents. It is recommended that
the facility have one large double resident bedroom for every 30
resident bedrooms.
(vi) Have direct access to an exit corridor;
(vii) Be designed or equipped to assure full visual privacy for
each resident;
(viii) Except in private rooms, each bed must have ceiling
suspended curtains, which extend around the bed to provide total visual
privacy in combination with adjacent walls and curtains;
(ix) Have at least one window to the outside; and
(x) Have a floor at or above grade level.
(2) The facility management must provide each resident with--
(i) A separate bed of proper size and height for the safety of the
resident;
(ii) A clean, comfortable mattress;
(iii) Bedding appropriate to the weather and climate; and
(iv) Functional furniture appropriate to the resident's needs, and
individual closet space in the resident's bedroom with clothes racks
and shelves accessible to the resident.
(e) Toilet facilities. Each resident room must be equipped with or
located near toilet and bathing facilities. It is recommended that
public toilet facilities be also located near the resident's dining and
recreational areas.
(f) Resident call system. The nurse's station must be equipped to
receive resident calls through a communication system from--
(1) Resident rooms; and
(2) Toilet and bathing facilities.
(g) Dining and resident activities. The facility management must
provide one or more rooms designated for resident dining and
activities. These rooms must--
(1) Be well lighted;
(2) Be well ventilated;
(3) Be adequately furnished; and
(4) Have sufficient space to accommodate all activities.
(h) Other environmental conditions. The facility management must
provide a safe, functional, sanitary, and comfortable environment for
the residents, staff and the public. The facility must--
(1) Establish procedures to ensure that water is available to
essential areas when there is a loss of normal water supply;
(2) Have adequate outside ventilation by means of windows, or
mechanical ventilation, or a combination of the two;
(3) Equip corridors with firmly secured handrails on each side; and
(4) Maintain an effective pest control program so that the facility
is free of pests and rodents.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
Sec. 51.210 Administration.
A facility must be administered in a manner that enables it to use
its resources effectively and efficiently to attain or maintain the
highest practicable physical, mental, and psychosocial well being of
each resident.
(a) Governing body. (1) The State must have a governing body, or
designated person functioning as a governing body, that is legally
responsible for establishing and implementing policies regarding the
management and operation of the facility; and
(2) The governing body or State official with oversight for the
facility appoints the administrator who is--
(i) Licensed by the State where licensing is required; and
(ii) Responsible for operation and management of the facility.
(b) Disclosure of State agency and individual responsible for
oversight of facility. The State must give written notice to the Chief
Consultant, Geriatrics and Extended Care Strategic Healthcare Group
(114), VA Headquarters, 810 Vermont Avenue, NW, Washington, DC 20420,
at the time of the change, if any of the following change:
(1) The State agency and individual responsible for oversight of a
State home facility;
(2) The State home administrator;
(3) The State home director of nursing; or
(4) The State employee responsible for oversight of the State home
facility if a contractor operates the State home.
(c) Required Information. The facility management must submit the
following to the director of the VA medical center of jurisdiction as
part of the application for recognition and thereafter as often as
necessary to be current:
(1) The copy of legal and administrative action establishing the
State-operated facility (e.g., State laws);
(2) Site plan of facility and surroundings.
(3) Legal title, lease, or other document establishing right to
occupy facility;
(4) Organizational charts and the operational plan of the facility;
(5) The number of the staff by category indicating full-time, part-
time and minority designation;
(6) The number of nursing home patients who are veterans and non-
veterans, the number of veterans who are minorities and the number of
non-veterans who are minorities;
(7) Annual State Fire Marshall's report;
(8) Annual certification from the responsible State Agency showing
compliance with Section 504 of the Rehabilitation Act of 1973 (Public
Law 93-112) (VA Form 10-0143A set forth at Sec. 51.224);
(9) Annual certification for Drug-Free Workplace Act of 1988 (VA
Form 10-0143 set forth at Sec. 51.225);
(10) Annual certification regarding lobbying in compliance with
Public Law 101-121 (VA Form 10-0144 set forth at Sec. 51.226);
(11) Annual certification of compliance with Title VI of the Civil
Rights Act of 1964 as incorporated in Title 38 CFR 18.1-18.3 (VA Form
27-10-0144A located at Sec. 51.227);
(d) Percentage of Veterans. The percent of the facility residents
eligible for VA nursing home care must be at least 75 percent veterans
except that the veteran percentage need only be more than 50 percent if
the facility was constructed or renovated solely with State funds. All
non-veteran residents must be spouses of veterans or parents all of
whose children died while serving in the armed forces of the United
States.
(e) Management Contract Facility. If a facility is operated by an
entity contracting with the State, the State must assign a State
employee to monitor the operations of the facility on a full-time
onsite basis.
(f) Licensure. The facility and facility management must comply
with applicable State and local licensure laws.
(g) Staff qualifications. (1) The facility management must employ
on a full-time, part-time or consultant basis those professionals
necessary to carry out the provisions of these requirements.
(2) Professional staff must be licensed, certified, or registered
in accordance with applicable State laws.
[[Page 60240]]
(h) Use of outside resources. (1) If the facility does not employ a
qualified professional person to furnish a specific service to be
provided by the facility, the facility management must have that
service furnished to residents by a person or agency outside the
facility under a written agreement described in paragraph (h)(2) of
this section.
(2) Agreements pertaining to services furnished by outside
resources must specify in writing that the facility management assumes
responsibility for--
(i) Obtaining services that meet professional standards and
principles that apply to professionals providing services in such a
facility; and
(ii) The timeliness of the services.
(i) Medical director. (1) The facility management must designate a
primary care physician to serve as medical director.
(2) The medical director is responsible for--
(i) Participating in establishing policies, procedures, and
guidelines to ensure adequate, comprehensive services;
(ii) Directing and coordinating medical care in the facility;
(iii) Helping to arrange for continuous physician coverage to
handle medical emergencies;
(iv) Reviewing the credentialing and privileging process;
(v) Participating in managing the environment by reviewing and
evaluating incident reports or summaries of incident reports,
identifying hazards to health and safety, and making recommendations to
the administrator; and
(vi) Monitoring employees' health status and advising the
administrator on employee-health policies.
(j) Credentialing and privileging. Credentialing is the process of
obtaining, verifying, and assessing the qualifications of a health care
practitioner, which may include physicians, podiatrists, dentists,
psychologists, physician assistants, nurse practitioners, licensed
nurses to provide patient care services in or for a health care
organization. Privileging is the process whereby a specific scope and
content of patient care services are authorized for a health care
practitioner by the facility management, based on evaluation of the
individual's credentials and performance.
(1) The facility management must uniformly apply credentialing
criteria to licensed independent practitioners applying to provide
resident care or treatment under the facility's care.
(2) The facility management must verify and uniformly apply the
following core criteria: Current licensure; current certification, if
applicable, relevant education, training, and experience; current
competence; and a statement that the individual is able to perform the
services he or she is applying to provide.
(3) The facility management must decide whether to authorize the
independent practitioner to provide resident care or treatment, and
each credentials file must indicate that these criteria are uniformly
and individually applied.
(4) The facility management must maintain documentation of current
credentials for each licensed independent practitioner practicing
within the facility.
(5) When reappointing a licensed independent practitioner, the
facility management must review the individual's track record.
(6) The facility management systematically must assess whether
individuals with clinical privileges act within the scope of privileges
granted.
(k) Required training of nursing aides. (1) Nurse aide means any
individual providing nursing or nursing-related services to residents
in a facility who is not a licensed health professional, a registered
dietitian, or a volunteer who provide such services without pay.
(2) The facility management must not use any individual working in
the facility as a nurse aide whether permanent or not unless:
(i) That individual is competent to provide nursing and nursing
related services; and
(ii) That individual has completed a training and competency
evaluation program, or a competency evaluation program approved by the
State.
(3) Registry verification. Before allowing an individual to serve
as a nurse aide, facility management must receive registry verification
that the individual has met competency evaluation requirements unless
the individual can prove that he or she has recently successfully
completed a training and competency evaluation program or competency
evaluation program approved by the State and has not yet been included
in the registry. Facilities must follow up to ensure that such an
individual actually becomes registered.
(4) Multi-State registry verification. Before allowing an
individual to serve as a nurse aide, facility management must seek
information from every State registry established under HHS regulations
at 42 CFR 483.156 which the facility believes will include information
on the individual.
(5) Required retraining. If, since an individual's most recent
completion of a training and competency evaluation program, there has
been a continuous period of 24 consecutive months during none of which
the individual provided nursing or nursing-related services for
monetary compensation, the individual must complete a new training and
competency evaluation program or a new competency evaluation program.
(6) Regular in-service education. The facility management must
complete a performance review of every nurse aide at least once every
12 months, and must provide regular in-service education based on the
outcome of these reviews. The in-service training must--
(i) Be sufficient to ensure the continuing competence of nurse
aides, but must be no less than 12 hours per year;
(ii) Address areas of weakness as determined in nurse aides'
performance reviews and may address the special needs of residents as
determined by the facility staff; and
(iii) For nurse aides providing services to individuals with
cognitive impairments, also address the care of the cognitively
impaired.
(l) Proficiency of nurse aides. The facility management must ensure
that nurse aides are able to demonstrate competency in skills and
techniques necessary to care for residents' needs, as identified
through resident assessments, and described in the plan of care.
(m) Level B Requirement Laboratory services. (1) The facility
management must provide or obtain laboratory services to meet the needs
of its residents. The facility is responsible for the quality and
timeliness of the services.
(i) If the facility provides its own laboratory services, the
services must meet all applicable certification standards, statutes,
and regulations for laboratory services.
(ii) If the facility provides blood bank and transfusion services,
it must meet all applicable certification standards, statutes, and
regulations.
(iii) If the laboratory chooses to refer specimens for testing to
another laboratory, the referral laboratory must be certified in the
appropriate specialties and subspecialties of services and meet
certification standards, statutes, and regulations.
(iv) The laboratory performing the testing must have a current,
valid CLIA number (Clinical Laboratory Improvement Amendments of 1988).
The facility management must provide VA surveyors with the CLIA number
and a copy of the results of the last CLIA inspection.
[[Page 60241]]
(v) Such services must be available to the resident seven days a
week, 24 hours a day.
(2) The facility management must--
(i) Provide or obtain laboratory services only when ordered by the
primary physician;
(ii) Promptly notify the primary physician of the findings;
(iii) Assist the resident in making transportation arrangements to
and from the source of service, if the resident needs assistance; and
(iv) File in the resident's clinical record laboratory reports that
are dated and contain the name and address of the testing laboratory.
(n) Radiology and other diagnostic services. (1) The facility
management must provide or obtain radiology and other diagnostic
services to meet the needs of its residents. The facility is
responsible for the quality and timeliness of the services.
(i) If the facility provides its own diagnostic services, the
services must meet all applicable certification standards, statutes,
and regulations.
(ii) If the facility does not provide its own diagnostic services,
it must have an agreement to obtain these services. The services must
meet all applicable certification standards, statutes, and regulations.
(iii) Radiologic and other diagnostic services must be available 24
hours a day, seven days a week.
(2) The facility must--
(i) Provide or obtain radiology and other diagnostic services only
when ordered by the primary physician;
(ii) Promptly notify the primary physician of the findings;
(iii) Assist the resident in making transportation arrangements to
and from the source of service, if the resident needs assistance; and
(iv) File in the resident's clinical record signed and dated
reports of x-ray and other diagnostic services.
(o) Clinical records. (1) The facility management must maintain
clinical records on each resident in accordance with accepted
professional standards and practices that are--
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized.
(2) Clinical records must be retained for--
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no
requirement in State law.
(3) The facility management must safeguard clinical record
information against loss, destruction, or unauthorized use;
(4) The facility management must keep confidential all information
contained in the resident's records, regardless of the form or storage
method of the records, except when release is required by--
(i) Transfer to another health care institution;
(ii) Law;
(iii) Third party payment contract; or
(iv) The resident.
(5) The clinical record must contain--
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The plan of care and services provided;
(iv) The results of any pre-admission screening conducted by the
State; and
(v) Progress notes.
(p) Quality assessment and assurance. (1) Facility management must
maintain a quality assessment and assurance committee consisting of--
(i) The director of nursing services;
(ii) A primary physician designated by the facility; and
(iii) At least 3 other members of the facility's staff.
(2) The quality assessment and assurance committee--
(i) Meets at least quarterly to identify issues with respect to
which quality assessment and assurance activities are necessary; and
(ii) Develops and implements appropriate plans of action to correct
identified quality deficiencies; and
(3) Identified quality deficiencies are corrected within an
established time period.
(4) The VA Under Secretary for Health may not require disclosure of
the records of such committee unless such disclosure is related to the
compliance with requirements of this section.
(q) Disaster and emergency preparedness. (1) The facility
management must have detailed written plans and procedures to meet all
potential emergencies and disasters, such as fire, severe weather, and
missing residents.
(2) The facility management must train all employees in emergency
procedures when they begin to work in the facility, periodically review
the procedures with existing staff, and carry out unannounced staff
drills using those procedures.
(r) Transfer agreement. (1) The facility management must have in
effect a written transfer agreement with one or more hospitals that
reasonably assures that--
(i) Residents will be transferred from the nursing home to the
hospital, and ensured of timely admission to the hospital when transfer
is medically appropriate as determined by the primary physician; and
(ii) Medical and other information needed for care and treatment of
residents, and, when the transferring facility deems it appropriate,
for determining whether such residents can be adequately cared for in a
less expensive setting than either the nursing home or the hospital,
will be exchanged between the institutions.
(2) The facility is considered to have a transfer agreement in
effect if the facility has an agreement with a hospital sufficiently
close to the facility to make transfer feasible.
(s) Compliance with Federal, State, and local laws and professional
standards. The facility management must operate and provide services in
compliance with all applicable Federal, State, and local laws,
regulations, and codes, and with accepted professional standards and
principles that apply to professionals providing services in such a
facility. This includes the Single Audit Act of 1984 (Title 31, Section
7501 et. seq.) and the Cash Management Improvement Acts of 1990 and
1992 (Pub. L. 101-453 and 102-589, see 31 U.S.C. 3335, 3718, 3720A,
6501, 6503)
(t) Relationship to other Federal regulations. In addition to
compliance with the regulations set forth in this subpart, facilities
are obliged to meet the applicable provisions of other Federal laws and
regulations, including but not limited to those pertaining to
nondiscrimination on the basis of race, color, national origin,
handicap, or age (38 CFR part 18); protection of human subjects of
research (45 CFR part 46), section 504 of the Rehabilitation Act of
1993, Pub. L. 93-112; Drug-Free Workplace Act of 1988, 38 CFR part 44,
Secs. 44.100 through 44.420; section 319 of Pub. L. 101-121; Title VI
of the Civil Rights Act of 1964, 38 CFR 18.1-18.3. Although these
regulations are not in themselves considered requirements under this
part, their violation may result in the termination or suspension of,
or the refusal to grant or continue payment with Federal funds.
[[Page 60242]]
(u) Intermingling. A building housing a facility recognized as a
State home for providing nursing home care may only provide nursing
home care in the areas of the building recognized as a State home for
providing nursing home care.
(v) VA Management of State Veterans Homes. Except as specifically
provided by statute or regulations, VA employees have no authority
regarding the management or control of State homes providing nursing
home care.
(Authority: 38 U.S.C. 101, 501, 1710, 1741-1743)
BILLING CODE 8320-01-P
[[Page 60243]]
Sec. 51.220 VA Form 10-3567--State Home Inspection Staffing
Profile
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[[Page 60244]]
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[[Page 60245]]
[GRAPHIC] [TIFF OMITTED] TP09NO98.002
[[Page 60246]]
Sec. 51.221 VA Form 10-5588-State Home Report and Statement of
Federal Aid Claimed
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[[Page 60247]]
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[[Page 60248]]
Sec. 51.222 VA Form 10-10EZ-Application for Health Benefits
[GRAPHIC] [TIFF OMITTED] TP09NO98.005
[[Page 60249]]
[GRAPHIC] [TIFF OMITTED] TP09NO98.006
[[Page 60250]]
Sec. 51.223 VA Form 10-10SH-State Home Program Application for
Veteran Care Medical Certification
[GRAPHIC] [TIFF OMITTED] TP09NO98.007
[[Page 60251]]
[GRAPHIC] [TIFF OMITTED] TP09NO98.008
[[Page 60252]]
Sec. 51.224 VA Form 10-0143A--Statement of Assurance of Compliance
with Section 504 of The Rehabilitation Act of 1973
[GRAPHIC] [TIFF OMITTED] TP09NO98.009
[[Page 60253]]
Sec. 51.225 VA Form 10-0143--Department of Veterans Affairs
Certification Regarding Drug-Free Workplace Requirements for
Grantees Other Than Individuals
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[[Page 60254]]
Sec. 51.226 VA Form 10-0144--Certification Regarding Lobbying
[GRAPHIC] [TIFF OMITTED] TP09NO98.011
[[Page 60255]]
Sec. 51.227 VA Form 10-0144A--Statement of Assurance of Compliance
with Equal Opportunity Laws
[GRAPHIC] [TIFF OMITTED] TP09NO98.012
[FR Doc. 98-29597 Filed 11-6-98; 8:45 am]
BILLING CODE 8320-01-C
