3000 Division of Long Term Care Residents Protection
3205 Nursing Home Regulations for Intermediate Care (Formerly Regulation No. 58)
1.0 Definition
“Nursing Home” is an institution that provides permanent facilities that include in-patient beds and medical services, including continuous nursing services, to provide treatment for patients who do not currently require continuous hospital services. Nursing homes may have various levels of care; however, in no case will a patient be cared for in an area designated at a lower level of care than his needs, as determined by a physician. Nursing homes shall be subject all applicable code requirements of the State Fire Prevention Commission.
“Intermediate Care” - Nursing Home provides care which is less than skilled care but more than Rest (Residential) or Rest (Family Care). The services are given in accordance with physician's orders, updated at least every sixty (60) days, and require the competence nursing aides under the supervision of a registered professional nurse or licensed practical nurse. A registered professional nurse or licensed practical nurse shall be employed full-time and on duty during the day shift, seven (7) days a week.
“Intermediate Care” - Nursing Home provides care to residents who may need a minimum of medical care but require a great deal of physical and emotional support to return them to a previous level of, or a new stage of, independence or to prevent regression. It can involve direct aide given in getting out of bed, walking, bathing, dressing, feeding and administration of medications, and similar forms of assistance on a regular basis.
2.0 Glossary of Terms
“Activities of Daily Living” - Getting out of bed, bathing, dressing, eating and ambulation.
“Continuous” - Available at all times without cessation, break or interruption.
“Direction” - Authoritative policy or procedural guidance for the accomplishment of a function or activity.
“Facilities” - The site, physical structure and equipment necessary to provide the required service.
“In-Patient Beds” - Accommodations with supportive services (such as; food, laundry, housekeeping) for patients who generally stay in excess of twenty-four (24) hours.
“Institution” - The term "institution" as it appears in these regulations is used to refer to all facilities covered by 16 Del.C. §1101.
“Licensed Health Practitioner”- Dentist, Podiatrist, Occupational or Physical Therapist or any health practitioner licensed to practice in the State of Delaware.
“Licensed Practical Nurse” - A nurse who is licensed to practice as a practical nurse in the State of Delaware.
“Medical Services” - The services pertaining to medical care and performed at the direction of a physician on behalf of patients; by physicians, dentists, nurses or any other professional or technical personnel.
“Nursing Service Personnel” - Those licensed or unlicensed persons giving direct services to the patients, pertaining to the curative, restorative or preventive aspects of nursing care, supervised by a registered professional nurse or a licensed practical nurse.
“Nursing Services” - Those medical services pertaining to the curative, restorative or preventive aspects of nursing care that are performed or supervised by a registered professional nurse or a licensed practical nurse, at the direction of a physician.
“Patient” - A person admitted to the nursing home because of illness and for whom there is planned continuing medical care, including nursing care, directed toward improvement in health, or for whom palliative medical measures are required though improvement in health or recovery cannot be expected.
“Personal Care Services” - Those health related services that include general supervision of, and direct assistance to, individuals in their activities of daily living.
“Physician“- A physician licensed to practice in the State of Delaware.
“Registered Professional Nurse” - A nurse who is a graduate of an approved school of professional nursing and who is licensed to practice in the State of Delaware.
“Rehabilitation” - The restoration of an ill or injured person to self-sufficiency at his highest attainable level.
“Resident Beds” - Accommodations with supportive services (such as: food, laundry, housekeeping) for persons who generally stay in excess of twenty-four (24) hours.
“Restraint” - Insofar as these regulations are concerned, restraint shall mean providing comfortable support and protection by limiting activity hazardous to the patient or others.
“Supervision” - Direct overseeing and inspection of the act of accomplishing a function or activity.
3.0 Licensing Requirements and Procedures
3.1 When an institution is classified under this Law or Regulations and plans to construct, extensively remodel or convert any buildings, two (2) copies of properly prepared plans and specifications for the entire institution shall be submitted to the Division of Public Health. An approval. in writing, is to be obtained before such work is begun. After the work is completed, in accordance with the plans and specifications, a new license to operate will be issued.
3.2 Separate licenses are required for institutions maintained in separate locations, even though operated under the same management. A separate license is not required for separate buildings maintained by the same management on the same grounds. A license is not transferable from person to person nor from one location to another.
In the event of the sale of a nursing home, the prospective buyer shall be informed of the waivers which were officially granted the previous owner. The Division of Public Health may grant the new owner of the nursing home the same waivers which had been granted to the former owner. Such a waiver may be granted with the condition that a plan for correcting all deficiencies within a reasonable time may be required to be submitted to and accepted by the Division of Long Term Care prior to the issuance of a license.
3.3 The license shall be conspicuously posted.
3.4 All applications for renewal of licenses shall be filed with the Division of Public Health at least thirty (30) days prior to expiration. Licenses will be issued for a period of not to exceed one (1) year, twelve (12) months.
3.5 Licenses are issued with reference to levels of care. The number of patients and the type of patients shall be in accordance with the license.
4.0 General Requirements
4.1 All required records maintained by the institution shall be open to inspection by the authorized representatives of the Division of Public Health.
4.2 The term 'nursing home" shall not be used as a part of the name of any institution in this State, unless it has been so classified by the Division of Public Health.
4.3 Reserved.
4.4 Reserved.
4.5 No rules shall be adopted by the licensee or administrator of any institution which are in conflict with these regulations.
4.6 The Division of Public Health shall be notified, in writing, of any changes in the administrator, assistant administrator or director of nurses.
4.7 The nursing home must establish written policies regarding the rights and responsibilities of patients, and these policies and procedures are to be made available to patients, guardians, next of kin, or sponsoring agency(ies).
4.8 Each facility shall exhibit with the admission agreement, to all patients or their sponsors, a complete statement enumerating all charges for services, materials and equipment which shall or may be furnished to the patient during the period of residency.
4.9 Each facility shall make known, in writing, the refund and prepayment policy at the time of admission, and in the case of third party payment, an exact statement of responsibility in the event of retroactive denial.
5.0 Plant, Equipment and Physical Environment
5.1 Site Provisions:
Each institution shall be located on a site which is considered suitable by the Division of Public Health. The site must be easily drained and must be suitable for disposal of sewage and furnishing a potable water supply.
5.2 Water Supply and Sewage Disposal:
5.2.1 The water supply and the sewage disposal system shall be approved by the Division of Public Health and the Department of Natural Resources and Environmental Control respectively.
5.2.2 The water system shall be designed to supply adequate hot and cold water, under pressure, at all times.
5.2.3 Hot water at shower, bathing and hand washing facilities shall not exceed 110 F. (43 C).
5.3 Building:
5.3.1 All new construction, extensive remodeling or conversions shall comply with the applicable parts of the standards as set forth under Long Term Care of the General Standards of Construction for Hospital and Medical Facilities, a publication of the Department of Health and Human Services, and its amendment.
5.3.2 Window space shall not be less than one tenth (1/10) of the floor space. Up to 25% reduction may be allowed when approved mechanical ventilation is utilized in multi-bed rooms.
5.3.3 All windows in rooms to be used by patients are to be constructed to eliminate drafts and to provide adequate light and ventilation and shall be easy to open and close.
5.3.4 The building shall be so constructed and maintained to prevent the entrance or existence of rodents and insects at all times. All exterior openings shall be effectively screened during the fly season. Screen doors shall open outward. All screening shall have at least sixteen (16) mesh per inch.
5.3.5 Patient’s rooms shall open directly into a corridor.
5.4 Plumbing:
The plumbing shall meet the requirements of all municipal or county codes. Where there is no local law, the provisions of the Division of Public Health Sanitary Plumbing Code shall prevail.
5.5 Heating:
The heating equipment for all living and sleeping quarters shall be adequate, safe, protected and easily controlled. It shall be capable of maintaining the temperature in each room used by patients at a minimum of 72 F (21 C).
5.6 Lighting:
Each room must be suitably lighted at all times for maximum safety, comfort, sanitation, and efficiency of operation. A minimum of 30 foot candles of light shall be provided for all working and reading surfaces, and a minimum of 10 foot candles of light in all other areas including hallways.
5.7 Safety Equipment:
5.7.1 To prevent slipping, staircases shall have stair treads and sturdy handrails.
5.7.2 Stairways shall be well lighted with electric switches at the top and bottom, and shall have a night light.
5.7.3 Hallways shall have night lights.
5.7.4 Low windows, open porches, changes in floor level and danger areas on the grounds shall be protected.
5.7.5 Floor surfaces shall not be slippery and shall be kept in good repair. If rugs are used, they shall be large enough so that they will not slip nor curl up at the edges.
5.7.6 Bedrails shall be available as deemed necessary by nursing or physician staff.
5.7.7 All doors for areas used by patients shall be capable of being opened from both sides.
5.8 Bedrooms:
5.8.1 Each room shall be well lighted and well ventilated. Each room shall be an outside room with at least one (1) window opening directly to the outside. The window sill shall be at least three (3) feet above the floor and above grade. Windows shall be so constructed as to allow a maximum of sunlight and air and to eliminate drafts. Windows shall also be easy to easy to open and close.
5.8.2 Bedrooms for the mentally retarded shall have at least 80 square feet per person in a single resident room and 60 square feet per person in multi-resident rooms. (Minimum room areas are exclusive of toilet rooms, closets, lockers, wardrobes, alcoves and vestibules.) The ceiling shall not be less than seven (7) feet from the floor.
5.8.3 Each bedroom shall have walls that go to the ceiling and also have a door that can be closed.
5.8.4 Cubicle screens or bed screens shall be available in multi-bed rooms to ensure privacy for patient where it is deemed advisable by medical or nursing staff.
5.8.5 Adequate electrical outlets shall be conveniently located in each room and each room shall have general lighting and night lighting. A reading light shall be provided for each patient. At least one light fixture shall be switched at the entrance to each bedroom.
5.8.6 Walls shall be finished in colors which are light and cheerful.
5.8.7 Bedrooms shall not be arranged in such a way that the only means of communication to the outside is through another room.
5.8.8 One (1) or more rooms; vented to the outside, shall be provided with private toilet and hand washing facilities to be used for patients who are critically ill or who require isolation.
5.8.9 Facilities shall ensure adequate privacy and separation of sexes in sleeping arrangements, except in cases of husband and wife and children from birth to age 9 years inclusive.
5.8.10 If bedroom doors of patients are locked, all persons on duty must carry a master key for those locks.
5.8.11 The maximum capacity per room shall be four (4) patients. However, where a physician or psychologist has justified in writing in the patient’s medical record that the patient’s programmatic needs can be better met by assignment to a room with more than four residents, a capacity in excess of four patients per room may be permitted.
5.9 Bathrooms:
5.9.1 Bathrooms shall be constructed so that the walls and floors are impervious to water. At least one (1) window or mechanical ventilation to the outside shall be provided. Floors shall not be slippery.
5.9.2 Bathtubs or showers shall be provided at the rate of one (1) for each twelve (12) beds which are not otherwise served by bathing facilities within patient’s rooms. At least one (1) bathtub with shower shall be provided on each nursing unit. Each tub or shower shall be in an individual room or enclosure which provides space for the private use of the bathing fixture, for drying and dressing, and for a wheelchair and attendant. Showers in central bathing facilities shall be at least four (4) feet square, without curbs, and designed to permit use by a wheelchair patient.
5.9.3 When toilets, washbasins and showers are in the same room, provisions shall be made for privacy. At least one (1) toilet for every four (4) patients and one (1) washbasin, with hot and cold water, for every four (4) patients shall be located on the floor occupied by the patients.
5.9.4 Each toilet, bathtub or shower used by the patients shall be provided with a substantial hand-grip.
5.9.5 Reserved.
5.9.6 Separate bathroom facilities shall be provided for the staff in facilities with more than four (4) patients, and shall include hand washing facilities, soap and individual towels.
5.9.7 Adequate facilities shall be provided for the orderly storage of employee’s clothing and personal belongings.
5.9.8 Doors are to be wide enough for wheelchairs.
5.10 Dayroom and Dining Area:
5.10.1 Allow at least 30 square feet per bed for the first 100 beds and 27 square feet per bed for all beds in excess of 100; in areas furnished for patient dining, recreational and social activities.
5.10.2 The dining area shall be large enough to accommodate all patients that are not confined to their rooms. Patients are to be encouraged to eat in the dining room if their condition permits, even if a wheelchair is needed.
5.10.3 When a multi-purpose room is used, it shall have sufficient space to accommodate all activities to prevent interference one of with the other.
5.11 Kitchen and Food Storage Areas:
The Division of Public Health's Regulations Governing the Sanitation of Public Eating Places shall apply to institutions and are appended hereto.
5.12 Sanitation and Housekeeping:
5.12.1 A ventilated janitor's closet shall be provided for each nursing unit or floor. This closet shall contain a service, floor-level, sink; hot and cold water; and a mixing faucet.
5.12.2 All areas used for soiled linen are to be vented directly outside and have a higher air removal rate than the surrounding area.
5.12.3 If linen chutes are used, they shall be provided with adequate means of cleaning.
5.12.4 Linen Services:
5.12.4.1 On Site Processing Requirements:
The laundry shall include: One room with separate areas for receiving, sorting and washing of soiled linen, one room for drying, mending and storing clean linen; and hand washing facilities immediately accessible to both the preceding areas.
5.12.4.2 Off Site Processing Requirements:
A soiled linen holding room and a dean linen receiving and storage room.
5.12.4.3 There shall be a reasonable amount of dean linen available at all times.
5.12.5 Suitable bedpan cleaning unit shall be available unless disposable bedpans are used throughout the facility.
5.12.6 All rooms and every part of the building shall be kept clean, orderly and free of offensive odors.
5.13 Nursing Equipment and Supplies:
5.13.1 There shall be sufficient equipment and supplies for nursing care to meet the needs of each patient. It shall be the responsibility of the administrator to obtain specific items required for individual cases, when so requested by the attending physician or supervisor of nursing services.
5.13.2 Each patient shall be provided with:
5.13.2.1 A bed in good repair with a comfortable well-constructed mattress. The mattress shall be covered or protected with nonporous material.
5.13.2.2 A satisfactory bed-side stand with a drawer and provisions for a towel rack, bedpan, urinal, emesis basin and washbasin.
5.13.2.3 A minimum of at feast two (2) drawers in a dresser or chest of drawers.
5.13.2.4 A private enclosed space for hanging clothing.
5.13.2.5 A comfortable chair.
Furniture shall be so arranged and located as to provide convenient access to patients.
5.13.3 Each bedroom shall be provided with a wall, door or dresser mirror.
5.13.4 Over-bed tables or lap tables shall be provided for patients who are unable to take meals in the dining room.
5.13.5 See section 5.8.4.
5.13.6 Reserved.
5.13.7 There shall be sufficient space and facilities available for the proper cleansing, disinfection, sterilization and storage of nursing supplies and equipment.
5.13.8 The nursing home shall provide safe storage for patient’s valuables.
6.0 Fire Safety
6.1 Fire safety in nursing homes shall comply with the adopted rules and regulations of the State Fire Prevention Commission. Enforcement of the fire regulations is the responsibility of the State Fire Prevention Commission. All applications for license or renewal of license must include, with the application, a letter certifying compliance by the Fire Marshal having jurisdiction. Notification of non-compliance with the Rules and Regulations of the State Fire Prevention Commission shall be grounds for revocation of license.
6.2 The staff shall be made familiar, by regular fire drills, at least quarterly, with emergency and evacuation plans. Written records shall be kept of attendance and content of such drills. Emergency plans shall be posted in a conspicuous place at each nursing station. Staff on all shifts shall be instructed on the emergency plans. All staff members shall participate.
7.0 Intermediate Nursing Care
7.1 Mentally Retarded Facilities of 25 beds or less shall have a registered professional nurse or a licensed practical nurse employed and on duty a minimum or twenty (20) hours per week.
7.2 There shall be a sufficient number of appropriately qualified and trained personnel who are responsible for the residents as follows:
7.2.1 For units serving residents who are severely/profoundly retarded, severely handicapped, are aggressive, assaultive or pose a security risk or for units serving residents who manifest severely hyperactive or psychotic-like behavior, the overall ratio of staff members to residents shall be 1 to 2.
7.2.2 For units serving moderately retarded residents requiring habit training, the overall ratio of staff members to residents shall be 1 to 2.5.
7.2.3 For units serving residents in vocational training programs and adults who work in sheltered employment situations, the overall ratio of staff members to residents shall be 1 to 5.
7.3 Under supervision of a physician who sees patients and renews orders as needed.
7.4 Provision for a restorative and functional maintenance health program with nursing care.
7.5 In facilities where a licensed practical nurse serves as the charge nurse, consultation is provided by a registered professional nurse through a formal written contract, at regular intervals, but not less than four (4) hours weekly.
7.6 Only registered professional nurses or licensed practical nurses shall be permitted to administer medication.
7.7 Definition of Nurse Aide/Nurse Assistant:
An individual under the supervision of a licensed nurse, who provides care that does not require the judgment and skills of a licensed nurse.
The care may include but is not limited to the following: bathing, dressing, grooming, toileting, ambulating, transferring and feeding, observing and reporting the general well being for the person(s) to whom they are providing care.
Nurse Aide/Nurse Assistant Requirements:
Each nurse aide/nurse assistant employed by any nursing home either as contract/agency or facility staff as of October 1, 1990, shall be required to meet the following:
7.7.1 Training/Testing
7.7.1.1 Nurse aide/nurse assistant shall complete a nurse aide training course approved by Delaware State Board of Nursing and by the State Board of Health.
7.7.1.2 Nurse aide/nurse assistant is required to pass competency evaluation test approved by State of Delaware.
7.7.1.3 Employees of Delaware nursing homes shall by duly certified within 4 months of employment.
7.7.1.4 Contract aides must be certified prior to placement in any nursing home.
7.7.2 A nurse aide/nurse assistant who has not performed nursing related services for pay for a continuous 24 month period after completion of a training and testing program, must complete and pass a new training and competency evaluation (testing) program.
7.7.3 A nurse aide/nurse assistant who has not been employed in health care setting for three years will be required to meet the requirements in section 7.7.1 above.
7.7.4 A nurse aide/nurse assistant trained and certified outside the State of Delaware may be deemed qualified to meet the Division of Public Health requirements based on a case by case review and approval.
7.7.5 Employees hired as nurse aide/nurse assistant who are currently enrolled in a nursing program and have satisfactorily completed the fundamentals of nursing course with a clinical component will be deemed to meet the training and testing requirements. These individuals will be approved with submittal of a letter from their school of nursing attesting to current enrollment status and satisfactory course completion as described.
7.8 Nursing Aide Training Program Curriculum
The following material identifies the minimum curriculum content for nurse aides/nursing assistants being prepared to work in nursing home facilities either as direct on contract staff.
The curriculum content for the nurse aide training program must include material which will provide a basic level of both knowledge and demonstrable skills for each individual completing the program. The program must be a minimum of 75 hours in length, divided equally between skills training and classroom instruction. Additional hours may be in either of these areas or both.
Programs may expand the curriculum content to provide opportunities for nurse aides to be placed in settings where nurse aides/nurse assistants are employed to perform basic skills as delegated by a licensed nurse in support of a professional plan of care.
7.8.1 The Nurse Aide Role and Function
7.8.1.1 Key Concepts:
Introduces the characteristics of an effective nurse aide: personal attributes, on-the-job-conduct, appearance, grooming, health and ethical behavior. Also presented are the responsibilities of the nurse aide as a member of the patient care team. Legal aspects of patient care and patient rights are presented. Relevant Federal and State statutes are referenced.
7.8.1.2 Competencies:
Function as a nurse aide within the legal and ethical standard set forth by the profession of nursing.
7.8.1.2.1 Define the role and functions of the nurse aide and provide awareness of the legal limitations of being a nurse aide.
7.8.1.2.2 Recognize the responsibilities of the nurse aide as a member of the health care team.
7.8.1.2.3 Identify the “chain of command” in the organizational structure of the health care agency.
7.8.1.2.4 Maintain acceptable personal hygiene and exhibit appropriate dress practices.
7.8.1.2.5 Recognize the importance of punctuality and commitment on the job.
7.8.1.2.6 Differentiate between ethical and unethical behavior on the job.
7.8.1.3 Demonstrate behavior which maintains resident's and/or client's rights.
7.8.1.3.1 Provide privacy and maintenance of confidentiality.
7.8.1.3.2 Promote the resident's right to make personal choices to accommodate individual needs.
7.8.1.3.3 Give assistance in resolving grievances.
7.8.1.3.4 Provide needed assistance in giving to and participating in resident and family groups and other activities.
7.8.1.3.5 Maintain care and security of resident's personal possessions.
7.8.1.3.6 Provide care which maintains the residents free from abuse, mistreatment or neglect and report any instances of such poor care to appropriate facility staff.
7.8.1.3.7 Maintain the resident's environment and care through appropriate nurse aide behavior so as to minimize the need for physical and chemical restraints.
7.8.2 Environmental Needs of the Patient
7.8.2.1 Key Concerts:
Introduces the nurse aide to the need to keep patients safe from injury and infection in the long-term care setting. The nurse aide is taught why and how to use infection control and isolation techniques. Safety through. prevention of fires and accidents, and emergency procedures for fire and other disasters are presented.
7.8.2.2 Competencies:
7.8.2.2.1 Apply the basic principles of infection control.
7.8.2.2.1.1 Identify how diseases are transmitted.
7.8.2.2.1.2 Demonstrate handwashing technique.
7.8.2.2.1.3 Perform basic cleaning, disinfecting, and sterilizing tasks.
7.8.2.2.1.4 Demonstrate proper isolation and safety techniques in care of infectious resident.
7.8.2.3 Assist with basic emergency procedures.
7.8.2.3.1 Follow safety and emergency procedures.
7.8.2.3.2 Identify safety measures that prevent accidents to residents.
7.8.2.3.3 Recognize signs when a resident is choking or may have an obstructed airway.
7.8.2.3.4 Assist with clearing obstructed airway.
7.8.2.3.5 Call for help when encountering convulsive disorders, loss of consciousness, shock, hemorrhage, and assist the resident until professional help arrives.
7.8.2.3.6 Follow disaster procedures.
7.8.2.3.7 Report emergencies accurately and immediately.
7.8.2.3.8 Identify potential fire hazards.
7.8.3 Provide a safe, clean environment.
7.8.3.1 Identify the resident's need for a clean and comfortable environment.
7.8.3.2 Report unsafe conditions.
7.8.3.3 Report pests.
7.8.3.4 Report non-functioning equipment.
7.8.3.5 Prepare soiled linen for laundry.
7.8.3.6 Clean and disinfect unit for admission or following discharge.
7.8.3.7 Arrange furniture and equipment for the resident’s convenience.
7.8.4 Psycho-Social Needs of the Patient
7.8.4.1 Key Concepts:
Focus is placed on the social, emotional, recreational and religious needs of patients in a long term care setting. It describes some of the physical, mental, and emotional changes associated with aging and institutionalization, and presents ways in which the nurse aide may effectively communicate with patients an their families.
7.8.4.2 Competencies:
7.8.4.2.1 Demonstrates appropriate and effective communication skills.
7.8.4.2.1.1 Demonstrate effective verbal and non-verbal communications in keeping with the nurse aide’s role with residents and their families.
7.8.4.2.1.2 Observe by using the senses of sight, hearing, touch and smell to report resident behavior to the licensed nurse.
7.8.4.2.1.3 Document observations using appropriate terms.
7.8.4.2.1.4 Recognize the importance of maintaining the patient’s record.
7.8.4.2.1.5 Communicate with residents according to their state of development.
7.8.4.2.2 Demonstrate basic skills by identifying the psycho-social characteristics of the populations being served in the nursing facility including persons with mental retardation, mental illness and persons with dementia, Alzheimer’s disease and related disorders.
7.8.4.2.2.1 Indicate the ways to meet the resident’s basic human needs for life and mental well-being.
7.8.4.2.2.2 Modify his/her own behavior in response to resident’s behavior.
7.8.4.2.2.3 Identify developmental tasks associated with the aging process.
7.8.4.2.2.4 Provide training in, and the opportunity for, self care according to resident’s capabilities.
7.8.4.2.2.5 Demonstrate principles of behavior management by reinforcing appropriate behavior and reducing or eliminating inappropriate behavior.
7.8.4.2.2.6 Demonstrate skills supporting age-appropriate behavior by allowing the resident to make personal choice, providing and reinforcing other behavior consistent with resident’s dignity.
7.8.4.2.2.7 Utilize resident’s family as a source of emotional support.
7.8.4.2.2.8 Recognize how age, illness and disability affect sexuality.
7.8.5 Physical Needs of the Patient
7.8.5.1 Key Concepts:
Presents the basic skills which nurse aides use in the physical care of patients. The nurse aide will learn basic facts about body systems and what is needed to promote good functioning. The nurse aide will learn to provide physical care to patients safely and to keep the patient clean, dry and comfortable. The nurse aide will also learn to make observations regarding patients and to record and/or report observations. The nurse aide will learn to maintain range of motion while providing physical care to patient. Introduction of the basics of range of motion and its integration into routine personal care activities.
7.8.5.2 Competencies:
7.8.5.2.1 Apply the principles of basic nutrition in the preparation and serving of meals.
7.8.5.2.1.1 List general principles of basic nutrition.
7.8.5.2.1.2 Read the instructions for special diets.
7.8.5.2.1.3 Serve prepared foods as instructed.
7.8.5.2.1.4 Identify cultural variations in diet.
7.8.5.2.2 Recognize abnormal signs and symptoms of common diseases and conditions. Examples are:
7.8.5.2.2.1 Upper respiratory infection - Report coughing, sneezing, elevated temperatures, etc.
7.8.5.2.2.2 Diabetes Report excessive thirst, frequent urination, change in urine output and drowsiness, excessive perspiration and headache.
7.8.5.2.2.3 Urinary tract infection - Report frequent urination, burning or pain on urination, change in color of urine. blood or sediment in urine and strong odors.
7.8.5.2.2.4 Cardiovascular conditions - Report shortness of breath, chest pain, blue color to lips, indigestion, sweating, change in pulse, etc.
7.8.5.2.2.5 Cerebral vascular conditions - Report dizziness, changes in vision such as seeing double, etc., change in blood pressure, numbness in any part of the body, or inability to move arm or leg, etc.
7.8.5.2.2.6 Skin conditions - Report break in skin, discoloration such as redness, black and blue areas, rash, itching, etc.
7.8.5.2.2.7 Gastrointestinal conditions - Report nausea, vomiting, pain, inability to swallow, bowel movement changes such as color. diarrhea, constipation. (Continue to list common diseases and conditions based on the population being served.)
7.8.5.2.3 Provide personal care and basic nursing skills as directed by the Licensed nurse.
7.8.5.2.3.1 Provide for resident’s privacy when providing personal care.
7.8.5.2.3.2 Assist the resident to dress and undress.
7.8.5.2.3.3 Assist the resident with bathing and personal grooming.
7.8.5.2.3.4 Observe and report condition of the skin.
7.8.5.2.3.5 Assist the resident with oral hygiene.
7.8.5.2.3.6 Administer oral hygiene for the unconscious resident.
7.8.5.2.3.7 Demonstrate measures to prevent decubitus ulcer, i.e., positioning turning, and applying heel and elbow protectors.
7.8.5.2.3.8 Assist the resident in using the bathroom.
7.8.5.2.3.9 Assist the resident in using a bedside commode, urinal and bedpan.
7.8.5.2.3.10 Demonstrate proper bedmaking procedures.
7.8.5.2.3.11 Feed residents oral table foods in an appropriate manner.
7.8.5.2.3.12 Distribute nourishment and water.
7.8.5.2.3.13 Accurately measure and record:
7.8.5.2.3.13.1 intake out output
7.8.5.2.3.13.2 height and weight
7.8.5.2.3.13.3 T.P.R
7.8.5.2.3.14 Assist the resident with shaving.
7.8.5.2.3.15 Shampoo and groom hair.
7.8.5.2.3.16 Provide basic care of toenails and fingernails if appropriate.
7.8.5.2.3.17 Assist with catheter care.
7.8.5.2.3.18 Assist the professional nurse with a physical examination.
7.8.5.2.3.19 Apply a non-sterile dressing.
7.8.5.2.3.20 Apply non-sterile compresses and soaks.
7.8.5.2.3.21 Apply cold and/or heat applications.
7.8.5.2.4 Demonstrate skills which incorporate principles of restorative care under the direction of a licensed nurse.
7.8.5.2.4.1 Assist the resident in bowel and bladder training.
7.8.5.2.4.2 Assist the resident in activities of daily living and encourage self help activities.
7.8.5.2.4.3 Assist the resident with ambulation aids, i.e., care, quadcane, walker, crutches, wheelchair and transfer aids, i.e., hydraulic lifts.
7.8.5.2.4.4 Perform range of motion exercise as instructed by the physical therapist or the professional nurse.
7.8.5.2.4.5 Assist in care and use of prosthetic devices.
7.8.5.2.4.6 Assist the resident in proper use of body mechanics.
7.8.5.2.4.7 Assist the resident with dangling, standing and walking.
7.8.5.2.4.8 Demonstrate proper turning and/or positioning both in bed and in a chair.
7.8.5.2.4.9 Demonstrate proper technique of transferring resident from bed to chair.
7.8.5.2.5 One man cardiopulmonary resuscitation (CPR) skills in checking of conscious and unconscious victims.
7.8.5.2.6 Provide care to resident when death is imminent.
7.8.5.2.6.1 Discuss own feelings and attitude about death.
7.8.5.2.6.2 Explain how culture and religion influence a person’s attitude toward death.
7.8.5.2.6.3 Discuss the stages of dying.
7.8.5.2.6.4 Recognize and report the common signs of approaching death.
7.8.5.2.6.5 Provide care (if appropriate) to the resident’s body after death.
7.9 Instructors
7.9.1 Primary instructor is an individual responsible for overall coordination and implementation of nurse aide training program.
7.9.2 Qualifications:
7.9.2.1 RN licensure in the State of Delaware.
7.9.2.2 Two (2) years nursing experience in caring for the elderly and/or chronically ill of any age.
7.9.2.3 For instructors without prior teaching experience:
7.9.2.3.1 Successful completion of a "Train the Trainer" program which provides preparation in teaching adult learners principles of effective teaching and teaching methodologies.
7.9.2.4 Waiver of the Train the Trainer requirement is made for those nurses who demonstrate at least one (1) year of continuous teaching experience at the nursing assistant or LPN or RN program level.
7.9.3 Program Trainer(s) is the individual(s) who provide assistance to primary instructors as resource personnel from the health field.
7.9.3.1 Qualifications:
7.9.3.1.1 Trainers may include: registered nurses, licensed practical nurses, pharmacists, dietitians, social workers, physical or occupational therapists, environmental health specialists, etc.
7.9.3.1.2 One (1) year of current experience in caring for the elderly and/or chronically ill of any age or have equivalent experience.
7.9.3.1.3 Trainers are to be licensed, registered and/or certified in their field, where applicable.
7.10 Training for Primary Instructors
7.10.1 The approved instructors will develop into competent trainers, possessing the necessary skills to train nursing assistants to meet the established certification criteria. The trainers will understand the roles and responsibilities associated with training. They will be able to design and implement a training program, assess its value, and modify it as needed. They will recognize the characteristics of adult learners and create a training environment conducive to effective learning.
7.10.1.1 Training course outline shall include:
7.10.1.1.1 Role of trainer.
7.10.1.1.2 Communication techniques.
7.10.1.1.3 Demonstration skills.
7.10.1.1.4 Teaching a process.
7.10.1.1.5 Teaching techniques.
7.10.1.1.6 Training techniques.
7.10.1.1.7 Developing a formal training plan.
7.10.1.2 Course Management Information
7.10.1.2.1 Training time will consist of sixteen minimum hours.
7.10.1.2.2 The instructor must have formal educational preparation or experience with skills of adult learning.
8.0 Personnel/Administrative
8.1 The administrator(s) shall be responsible for complying with the regulations herein contained. In the absence of the administrator, an employee shall be authorized, in writing, to be in charge.
8.2 The chief administrative officer shall be a full-time and qualified as a licensed nursing home administrator or qualified mental retardation professional or, in the case of hospital, as a hospital administrator. Facilities of 25 beds or less shall have the services of a part-time Chief Administrative Officer for a minimum of twenty (20) hours per week. If the chief administrative officer is a qualified mental retardation professional, it shall be a person who has specialized training or one year of experience in treating or working with the mentally retarded; and in addition, is one of the following:
8.2.1 A psychologist with a master’s degree from an accredited program.
8.2.2 A physician licensed by the State of Delaware.
8.2.3 An educator with a degree in education from an accredited program.
8.2.4 A social worker with a bachelor’s degree in
8.2.4.1 Social work from an accredited program; or
8.2.4.2 A field other than social work and at least three (3) years of social work experience under the supervision of a qualified social worker.
8.2.5 A physical or occupational therapist who is a graduate of an accredited program and has a State of Delaware license or registration.
8.2.6 A speech pathologist or audiologist who is a graduate of an accredited program and licensed by the State of Delaware.
8.2.7 A registered professional nurse who is licensed by the State of Delaware.
8.2.8 A therapeutic recreation specialist who is a graduate of an accredited program and is registered with the National Therapeutic Recreation Society.
8.2.9 A rehabilitation counselor who is certified by the Committee on Rehabilitation Counselor Certification.
8.3 A staff of persons sufficient in number and adequately trained to meet requirements for care shall be employed. In addition to the staff engaged in the direct care and treatment of patients, there must be sufficient personnel to provide basic services; such as: food service, laundry, housekeeping and plant maintenance.
8.4 No employee shall be less than sixteen (16) years of age, unless they have been issued proper working papers.
8.5 The institution shall have written personnel policies and procedures that adequately support sound patient care. Personnel records are to be kept current and available for each employee, and contain sufficient information to support placement in the positions to which assigned.
8.6 Minimum requirements for employee physical examination:
8.6.1 Each person. including volunteers, who is involved in the care of patients shall have a screening test for tuberculosis as a prerequisite to employment. Either a negative intra-dermal skin test or a chest x-ray showing no evidence of active tuberculosis shall satisfy this requirement.
8.6.2 A report of this test shall be on file at the facility of employment.
8.7 No person having a communicable disease shall be permitted to give care or service. All reportable communicable diseases shall be reported to the County Health Officer.
9.0 Services to Patients
9.1 General Services:
9.1.1 The intermediate care nursing facility shall provide to all patients the care deemed necessary for their comfort, safety, nutritional requirements and general well-being. There shall be specific evaluation and program plans for each resident that are:
9.1.1.1 Available to direct care staff in each living unit
9.1.1.2 Reviewed by a member or members of an interdisciplinary program team at least monthly, with documentation of such review entered in the resident’s record.
9.1.2 The intermediate care nursing facility shall have in effect a written transfer agreement with one (1) or more hospitals which provides the basis for effective working arrangements under which in-patient hospital care, or other hospital services, are available promptly to the facility’s patient’s, when needed.
9.1.3 The intermediate care nursing facility shall have a written provision for promptly obtaining required laboratory, x-ray and other diagnostic services. These services may be obtained from other facilities that are approved by the Division of Public Health.
9.2 Medical Services:
9.2.1 All persons admitted to an institution (intermediate care nursing home) shall be under the care of a licensed physician.
9.2.2 All nursing homes shall arrange for one (1) or more licensed physicians to be called in an emergency. Names and phone numbers of these physicians shall be posted at all nurse’s stations.
9.2.3 All order for medications, treatments, diets, diagnostic services, etc., shall be in writing and signed by the attending physician.
9.2.4 All statements of medical treatment goals and management plans shall be reviewed and updated as needed, but, at least annually, to ensure continuing appropriateness of the goals, consistency of management methods with the goals and the achievement of progress towards the goals.
9.2.5 A progress note shall be written and signed by the physician on each visit.
9.2.6 All telephone orders shall be countersigned by the physician within forty-eight (48) hours.
9.3 Specialized Services:
9.3.1 All specialized services shall be ordered, in writing, by the attending physician; such as: physical therapy, occupational therapy, speech therapy, etc.
9.3.2 The nursing home shall notify the family or guardian, as soon as feasible, when a special service has been ordered by the physician.
9.4 Nursing Services:
9.4.1 Individual nursing care plans shall be developed by nursing services as part of the total rehabilitation program with modification of the nursing as needed to meet the resident’s daily needs. Nursing care plans are to be reviewed at least annually for adults and more frequently for children, in accordance with developmental changes.
9.4.2 There shall be a registered professional nurse or a licensed practical nurse designated as the supervisory nurse, who shall:
9.4.2.1 For facilities of twenty-five (25) beds or less, a registered professional nurse or licensed practical nurse must be on duty at least twenty (20) hours weekly.
9.4.2.2 Designate adequate relief personnel, including a registered professional or licensed practical nurse, so that a responsible person is available at all times in the event of an emergency.
9.4.2.3 Develop and maintain nursing service objectives, standards of nursing practice and nursing procedure manuals.
9.4.2.4 Assign and supervise all levels of nursing service personnel.
9.4.2.5 Coordinate nursing services with physicians, physical therapy, dietary, pharmaceutical, recreational activities and other specialized services.
9.4.2.6 Provide orientation programs for the new nursing service personnel and in-service education for all nursing personnel. Written records of the content of each program must be kept on file for one (1) year.
9.4.2.7 Participate in the selection of prospective patients, in terms of nursing services that they need, and nursing competencies available.
9.4.3 Should the Supervising Nurse (Director of Nurses) terminate her employment, the Division of Public Health shall be immediately notified in writing of this termination along with the name of her replacement, registration and current license number.
9.4.4 Each institution shall have at least two (2) or more nursing service personnel monitoring the patients twenty-four (24) hours a day.
9.4.5 Treatments and the administration of medications ordered by a physician shall be carried out according to his order, using acceptable techniques.
9.4.6 Orders for restraints shall be in writing and signed by the physician and shall contain:
9.4.6.1 Resident’s name.
9.4.6.2 Reason for type of restraints prescribed.
9.4.6.3 The time it is to be administered and removed.
9.4.7 In applying restraints, careful consideration shall be given to the methods by which they can speedily be removed in case of fire, or other emergency. Restraints shall be applied by a nurse or aide who has received proper training in this procedure.
9.5 Medications:
9.5.1 All medications administered to patients shall be ordered in writing, and signed by the attending physician.
9.5.2 All medications shall be stored in a locked cabinet located in, or convenient to, the nurse’s station. The key to this cabinet shall be kept in the possession of, or accessible to, only the licensed nursing personnel responsible for administering medications.
9.5.3 Internal medications shall be stored separately from external medications.
9.5.4 Schedule II substances shall be kept in separately locked, securely fixed boxes or drawers in the locked medication cabinet; hence, under two (2) locks.
9.5.5 Medications requiring refrigeration shall be kept in a refrigerator within the drug room or in a separate locked box within a refrigerator near the nursing station and separate from the foods.
9.5.6 All medications shall be accurately and plainly labeled, with a label affixed to the outside of the container. The label shall have he patient’s name, name of the drug, potency, and the name of the prescribing physician. If the medication is for in-patient use, it may be labeled, to be administered according to current physician’s orders provided that (1) the MAR accurately reflects the prescriber’s current orders; and (2) the pharmacy is informed of any changes in directions within 24 hours and promptly records the change on the patient profile. Prescriptions for outpatient use must be labeled in compliance with 24 Del.C. 2563.
9.5.7 Medication containers having soiled, damaged, incomplete, illegible or makeshift labels must be returned to the pharmacist for relabeling or disposal. Containers not having any label shall be returned to the pharmacist for disposal.
9.5.8 Medications shall be given only to the individual patient for whom the prescription was issued, and shall be given in accordance with the directions, as prescribed.
9.5.9 Only licensed nurses may prepare and administer medications. The same licensed nurse who prepares the medications, shall given them and then record them on the patient’s chart.
9.5.10 Medications shall not be returned to the container and in circumstances such as refusal of drugs by the patient, the drug shall be discarded and so indicated on the patient’s chart.
9.5.11 Discontinued prescription (legend) pharmaceuticals shall not be retained, but shall be disposed of in one of two ways: (1) Flushed into the sewage system in the presence of a witness, or (2) Returned to the pharmacist for proper disposition; and the method so noted on the patient’s chart.
9.5.12 No stock supplies of drugs except those commonly available without prescription (non-legend drugs, e.g., antacids, aspirins, laxatives) shall be kept in the facility. Exception to this shall be allowed in a facility where a licensed pharmacy is maintained.
9.5.13 All disinfectants, cleaning materials and poisons shall be kept in a safe place, separate and apart from medications and food, and accessible only to the operator and designated employees.
9.5.14 Schedule II substances shall be handled in the manner outlined by the State and Federal Laws and Regulations. All unused Schedule II substances shall be returned to the pharmacist for disposition.
9.5.15 Upon approval by the Board of Pharmacy, emergency kits containing controlled substances or emergency supplies of such substances may be maintained provided that:
9.5.15.1 Approved Schedule 11 substances are secured in a double-locked cabinet in compliance with "D" of this Section.
9.5.15.2 Schedule III through V substances are secured in a single-lock cabinet or case.
9.5.15.3 The controlled substances are accessible to only licensed personnel responsible for administering medications.
9.5.15.4 Readily retrievable records are maintained showing the receipt and disposition of the controlled substance.
9.5.15.5 A written policy is adopted which outlines the emergency conditions under which the use of the substance is authorized. The policy must be approved by the Pharmaceutical Control Officer. The Division of Public Health may revoke the right of institutions to maintain emergency kits containing controlled substances or emergency supplies of such substances if it receives evidence of noncompliance.
9.5.16 Medications shall be released to patients on discharge or transfer only on the written authorization of the patient's physician. Patients who may leave the nursing home on a short leave may be issued a quantity of medication to meet their needs, with the approval of the patient's physician. These doses must be packaged and labeled by the pharmacist, unless the home administers medication fro an individually packaged unit dose system.
9.5.17 Hypodermic syringes and needles supplied by the resident or his representative must carry a prescription label affixed to the outside of the container indicating that the syringes or needles were obtained with a physician's prescription. Facilities do not need a prescription to purchase hypodermic syringes and needles. (See Section 4757 of the Delaware Uniform Controlled Substance Act.)
9.5.18 The barrel, plunger and needle of disposable hypodermic syringes must be rendered useless, immediately after use and then properly discarded.
9.5.19 Each nursing home shall have an advisory pharmacist to advise the administrator on pharmaceutical services, drugs and policies. A policy and procedure manual shall be set up and shall include policies pertaining to automatic stop orders.
9.5.20 A current drug reference text shall be available in each nursing home.
9.5.21 The administrator shall notify the Office of Narcotics and Dangerous Drugs, Division of Public Health, of any theft or unexplained loss of any controlled substances, syringes, or needles, or prescription pads within 48 hours of the discovery of such loss or theft.
9.6 Food Service
9.6.1 A minimum of three (3) meals shall be served in each twenty-four (24) hour period. There shall not be more than a fourteen (14) hour span between the evening meal and breakfast
9.6.2 he food served shall be suitably prepared and of sufficient quantity and quality to meet the nutritional needs of the patients.
9.6.3 Special diets served shall be on the written prescription of the physician.
9.6.4 A copy of the current week’s menus - regular and therapeutic - shall be posted in the kitchen and in a public area.
9.6.5 A copy of a recent diet manual shall be available for planning therapeutic menus and as a resource reference for physicians.
9.6.6 Menus showing food actually served each day shall be kept on file for at least one (1) month.
9.6.7 A two (2) day supply of food for emergency feeding shall be kept on the premises. (Items that need little or no water and heat to be served are recommended.)
9.6.8 A suspected occurrence of food poisoning shall be reported immediately, by telephone, to the County Health Officer.
9.7 Housekeeping Services:
9.7.1 Routine housekeeping duties shall not be assigned to nursing service personnel.
9.7.2 Housekeeping personnel shall be sufficient to maintain all rooms and every part of the building clean and orderly.
9.7.3 Waste material, obsolete and unnecessary articles, cans, rubbish and other litter shall not be permitted to accumulate on the premises of the institution.
9.7.4 Infectious waste shall be stored in sanitary containers and disposed of in a sanitary manner.
9.7.5 No laundry operations may be carried out where food is prepared, served or stored.
9.8 Communicable Diseases:
9.8.1 Persons suffering from a communicable disease may, at the discretion of the Director of the Division of Public Health, be admitted to and reside in a nursing home except for strict isolation and respiratory care as recommended by the Centers for Disease Control. Such facility must be properly equipped and have adequate and trained staff to treat the communicable disease.
9.8.2 The nursing home shall establish a written procedure to be followed in the event that a patient with a communicable disease is admitted or an episode of communicable disease occurs. It is the responsibility of the nursing home to see that:
9.8.2.1 The necessary precautions stated in the written procedures are followed.
9.8.2.2 All rules of the Delaware Division of Public Health are followed so there is a minimum danger of transmission to staff and residents.
9.8.3 Any patient found to have active tuberculosis in an infectious stage may not continue to reside in a nursing home that does not have approved facilities for respiratory isolation.
9.8.4 An individual, when suspected or diagnosed as having a communicable disease, shall be placed on the appropriate isolation or precaution as recommended for that disease by the Center for Disease Control. Those with a communicable disease which has been determined by the Director of the Division of Public Health, or his designee, to be a health hazard to visitors, staff, and other residents shall be placed on isolation care until they can be moved to an appropriate room or transferred to another facility.
9.8.5 The admission or occurrence of a patient with a communicable disease within a nursing home shall be reported to the Director of the Division of Public Health so as to determine the potential health hazard involved as currently required by the Division of Public Health. (See Appendix A Notifiable Diseases)
9.8.6 All facilities shall have on file results of tuberculin tests (1) performed annually for all employees and (2) performed on all newly admitted patients. The tuberculin test to be used is the Mantoux test containing 5 TU-PPD stabilized with Tween, injected intradermally, using a needle and syringe, usually on the volar surface of the forearm. Persons found to have a significant reaction (defined as 10 mm of induration or greater) to tests shall be reported to the Division of Public Health and managed according to recommended medical practice. A tuberculin test as specified, done within the twelve months prior to admission or employment, satisfies this requirement for asymptomatic individuals. A report of this skin test shall be kept on file.
9.8.61 Employees and patients who do not have a significant reaction to the initial tuberculin test (those individuals who have less than 10 mm induration) should be retested within 7 - 21 days to identify those who demonstrate delayed reactions. Tests done within one year of a previous test need not be repeated in 7 - 21 days.
9.8.7 All facilities shall have on file evidence of annual vaccination against influenza for all residents, as recommended by the Immunization Practice Advisory Committee of the Center for Disease Control, unless medically contraindicated.
9.8.8 All facilities shall have on file evidence of vaccination against pneumococcal pneumonia for all residents after the age of 65 years and as recommended by the Immunization Practice Advisory Committee of the Centers for Disease Control unless medically contraindicated.
9.9 Mental Illness:
9.9.1 Patients who are, or become, mentally ill and who may be harmful to themselves or others, shall not be admitted or retained in an intermediate care nursing home.
9.9.2 If a patient becomes disturbed or unmanageable, he/she shall be evaluated by a physician or psychiatrist. If the patient's condition does not respond to treatment and improve, the patient shall be removed to a more suitable facility.
9.10 Records and Reports:
9.10.1 There shall be a separate clinical record maintained on each patient, which wi l be a chronological history of the patient's stay in the nursing home. Every patient's record shall contain:
9.10.1.1 Admission record: Including patients name; birth date; home address prior to entering the facility; identification numbers, such as social security, medicaid, medicare, etc.; date of admission; physician’s name, address and phone number; admitting diagnosis; next of kin (relationship, name, address, and phone number); and the facility’s medical record number.
9.10.1.2 History and physical examination: Prepared by a physician within seven (7) days of the patient’s admission to the home. If the patient has been admitted to the home immediately after discharge from a hospital, the patient’s summary and history which was prepared at the hospital and the patient’s physical examination which was performed at the hospital, if performed within seven (7) days prior to admission to the home, may be substituted in lieu of the above records. Additionally, a record of an annual medical evaluation performed by a physician must be contained in each patient’s file.
9.10.1.3 Statement of complete diagnosis and prognosis.
9.10.1.4 Physician’s orders: Including complete list of medications, medication name, dosage, frequency and route of administration, treatments, diets level of permitted activity, and use of restraints (if the patient’s condition requires them).
9.10.1.5 Physician’s progress notes.
9.10.1.6 Nursing notes.
9.10.1.7 Medication sheets: Including medication, name, dosage, frequency and route of administration, space for recording initials of the nurse for each dose administered, signature identifying administering nurses’ initials, including professional status.
9.10.1.8 Inventory of personal effects.
9.10.1.9 Accident reports.
9.10.1.10 Results of laboratory and special tests and x-rays ordered by the physician.
9.10.1.11 Discharge record or notes: Including condition on discharge, place to which discharged, and prognosis, if appropriate.
9.10.1.12 Special service notes: e.g., social services and activities, results of specialty consultations requested by the physician, physical therapy, dental and podiatry.
9.10.1.13 Inter-agency transfer forms, if the patient was admitted from an acute care facility or any other long-term facility.
9.10.2 Records shall be available at all times to legally authorized persons; otherwise, such records shall be held confidential.
9.10.3 For the legal protection of the institution, records shall be retained for five (5) years before being destroyed.
9.10.4 An accident report, with adequate documentation, shall be completed for each incident. Adequate documentation shall consist of patient involved, time of injury, disposition of patient, and documentation that physician and family have been contacted. Accident reports are to be kept on file in the facility.
9.11 Patient Care Policies:
9.11.1 Every nursing home shall develop written policies pertaining to the services they provide. Such policies shall include:
9.11.1.1 Admission, transfer and discharge policies.
9.11.1.2 The categories of patients accepted or not accepted.
9.11.1.3 Physician's services.
9.11.1.4 Nursing services.
9.11.1.5 Dietary services.
9.11.1.6 Rehabilitative services.
9.11.1.7 Pharmaceutical services,
9.11.1.8 Diagnostic services.
9.11.1.9 A written policy denoting care of patients:
9.11.1.9.1 In an emergency.
9.11.1.9.2 During a communicable disease episode.
9.11.1.9.3 In case of critical illness or mental disturbance.
9.11.1.10 Dental services.
9.11.1.11 Social services.
9.11.1.12 Patient activities: recreational, social, religious.
9.11.1.13 Clinical records.
9.11.1.14 Fire and safety policies.
9.11.2 The policies should reflect the philosophy and objectives of the individual home, i.e.:
9.11.2.1 To provide on a continuing basis good medical and nursing care for all persons admitted to the home who require such care.
9.11.2.2 To stimulate as much as possible the rehabilitation of each patient to his/her maximum level.
9.11.2.3 To preserve the dignity and individuality of all patients.
9.11.2.4 Through recreational activities, create a feeling of usefulness and security.
10.0 Severability
10.1 Should any section, sentence, clause or phrase of these regulations be legally declared unconstitutional or invalid for any reason, the remainder of said regulations shall not be effected thereby.
11.0 Waiver of Standards
11.1 Specific standards may be waived by the State Board of Health provided that each of the following conditions are met:
11.1.1 Strict enforcement of the standard would result in unreasonable hardship on the license.
11.1.2 The Waiver is in accordance with the particular needs of any client of the licensee.
11.1.3 A Waiver must not adversely affect the health, safety, welfare, or rights of any client of the licensee.
11.1.4 The request for a Waiver must be made to the State Board of Health in writing by the licensee with substantial detail justifying the request.
11.1.5 Prior to filing a request for a waiver, the facility shall provide written notice of the request to each resident, each court-appointed guardian of any resident, each person appointed in the durable power of attorney of any resident, each person appointed to be a resident’s health care agent under the Death with Dignity Act and each spouse and adult child of any resident. Prior to filing a request for a waiver, the facility shall also provided written notice of the request to the Office of Long Term Care Ombudsman. The notice shall state that the recipient has the right to object to the waiver request orally at the State Board of Health meeting when the request is being considered or in writing to the Board of Health in advance of such meeting.
11.1.6 A Waiver granted by the State Board of Health is not transferable to another licensee in the event of a change of ownership.
11.1.7 A Waiver shall be granted for the term of the license.
APPENDIX A
These Regulations are adopted by the Director, Division of Public Health pursuant to 16 Del.C. 1124.
PATIENT' S BILL OF RIGHTS
RESPECT
1. Every patient and resident shall be treated with consideration, respect and full recognition of their dignity and individuality.
2. Every patient and resident shall receive care, treatment and services which are adequate and appropriate.
SERVICES AND PAYMENT
3. Each patient and resident and their families shall, prior to or upon admission, and during their stay, receive a written statement of the services provided by the facility including those required to be offered on an "as needed" basis.
A. They shall also receive a statement of related charges, including any charges for services not covered under Medicare, Medicaid or the facility's basic per diem rate.
B. Upon receiving such statement, the patient and his representative shall sign a written receipt which shall be retained by the facility.
TREATMENT
4. Each patient shall receive from the attending physician or resident physician of the facility, in lay terns, complete and current information regarding his diagnosis, treatment and prognosis, unless medically inadvisable.
5. Each patient and resident:
A. Shall participate in the planning of their medical treatment;
B. May refuse medication or treatment;
C. Shall be informed of the medical consequences of all medication and treatment alternatives; and
D. Shall give prior informed consent to participation in any experimental research, which shall be verified by his signature and the signature of a family member or representative.
6. The facility shall see to it that the name, address and telephone number of the patient or resident's physician is readily accessible to them at their bedside.
7. Each patient and resident's medical care program shall be conducted discreetly and in accordance with the patient's need for privacy.
A. Persons not directly involved in patient care shall not be present during medical examinations, treatment and case discussion.
B. Personal and medical records shall be treated confidentially; shall not be made public without the consent of the patient or resident; shall not be released to any person inside or outside the facility who has no demonstrable need for such records.
8. Every patient and resident shall be free from mental and physical abuse and also from chemical and physical restraints, unless authorized by a physician according to clear and indicated medical requirement.
COMMUNICATIONS
9. Every patient and resident shall receive from the Administrator or staff of the facility a courteous and reasonable response to his requests.
10. Every patient and resident shall be provided with information as to any relationships of the facility to other health care facilities as far as the patient's care is concerned.
11. To maintain reasonable continuity of care, every patient and resident at the least shall be informed of the availability of physicians and appointment times.
12. Every patient and resident may associate privately with people and groups of his own choice at any reasonable hour.
A. May send and receive mail promptly and unopened.
B. Shall have access to any reasonable hour to a telephone where he may speak privately.
C. Shall have access to writing instruments, stationery and postage.
CONTROL OF FINANCIAL AFFAIRS
13. Each patient and resident has the right to manage his own financial affairs.
A. If, by written request, the facility manages the patient's financial affairs, it shall have available for inspection a monthly accounting and shall furnish.a quarterly statement upon request to the patient or a designated representative.
B. The patient and resident shall have unrestricted access to such accounts at reasonable hours.
PRIVACY
14. If married, every patient and resident shall enjoy privacy in visits by his spouse and, if both reside in the facility, they shall be allowed to share a room, unless medically contraindicated.
15. Every patient and resident has the right of privacy in their room and the facility’s staff shall respect this right by knocking on the door before entering the room.
GRIEVANCES
16. Every patient and resident has the right, personally, or through others, to present grievances to the Division of Aging, the Ombudsman or to others.
A. There shall be no reprisal, restraint, interference, coercion or discrimination of the patient as a result of such grievance or suggestion.
B. Any alleged violation of any of the provisions of these Rules and Regulations should be presented orally or in writing and forwarded to the attention of the Ombudsman.
C. The Ombudsman shall consult with the complainant to determine if he/she wishes to pursue an investigation. If the complainant wishes to pursue the matter, the Ombudsman shall work closely with the complainant and the institution to resolve the matter. In any case, the confidentiality of the complainant shall not be revealed without his/her consent.
D. On completion of the investigation, the Ombudsman shall report the findings to the complainant and with the complainant's consent to the facility wherein the complaint originated.
E. If the grievance is not resolved at the end of the investigation by the Ombudsman, the grievance findings shall be forwarded to the State `Board of Health for appropriate action after obtaining the consent of the complainant.
PERSONAL CHOICE/PERSONAL PROPERTY
17. A patient or resident shall not be required to perform services for the facility.
18. Every patient and resident shall have the right to retain and use their personal clothing and possessions where reasonable and shall be entitled to have security in their storage and use.
TRANSFERS/ DISCHARGES
19. No patient or resident shall be transferred or discharged from a facility except for the following:
A. For medical reasons;
B. For the patient's own welfare or the welfare of the other patients; and
C. For non-payment of justified charges.
20. If good cause exists, the patient or resident shall be given 30 days advance notice of the proposed action and the reasons for the action and may request an impartial hearing. In emergency situations, such notice need not be given.
21. If a hearing is requested, it shall be held within ten (10) working days of the request. The hearing shall be conducted by the Division of Public Health. Hearing officers could include:
A. Nursing Home Ombudsman;
B. A staff member of the advocacy section, Division of Aging;
C. A physician from the Division of Public Health, not employed by a hospital operated by the Division;
D. The licensure program director for the type of home involved.
The Deputy Attorney General for the Division of Public Health may attend as legal officer in these hearings.
22. If the hearing determines in favor of the patient, the home shall be instructed to comply. If the home refuses to comply, the matter will be referred to the Attorney General's office to see if further action is called for or permissible under the law.
DEVOLUTION OF RIGHTS
Where consistent with the above rights, all rights, particularly as they pertain to a patient adjudicated incompetent, a patient determined to be medically incompetent by his attending physician or a patient unable to communicate, shall devolve to that patient's next of kin, guardian, representative, sponsoring agency or representative payee (except where the facility is the representative payee).
NOTICE-AWARENESS OF RIGHTS
1. These provisions shall be posted conspicuously in a public place in each facility.
2. Copies are to be furnished to the patient or. resident upon admission. and to all current patients and residents and next of kin, guardian, representative, sponsoring agency or representative payee.
3. Receipts for the statement signed by the above parties shall be retained in the facility's files.
APPENDIX B
Notifiable Diseases
1. Acquired Immune Deficiency Syndrome
2. Amebiasis
3. Anthrax
4. Botulism
5. Brucellosis
6. Campylobacteriosis
7. Chancroid
8. Chlamydia trachomatous infections
9. Cholera
10. Condylomata acuminate (venereal warts)
11. Diphtheria
12. Encephalitis
13. Foodborne Disease outbreaks
14. Giardiasis
15. Gonococcal Infections
16. Granuloma Inguinale
17. Hansen's Disease (Leprosy)
18. Hepatitis (viral-all types)
19. Herpes
20. Histoplasmosis
21. Human Immunodeficiency Virus (HIV)
22. Influenza
23. Lead Poisoning
24. Legionnaires Disease
25. Leptospirosis
26. Lyme Disease
27. Lymphogranuloma Venereum
28. Malaria
29. Measles
30. Meningitis (bacterial)
31. Meningitis (aseptic)
32. Meningococcal Disease (other)
33. Mumps
34. Pertussis
35. Plague
36. Poliomyelitis
37. Psittacosis
38. Rabies (man, animal)
39. Reye's Syndrome
40. Rocky Mountain Spotted Fever
41. Rubella
42. Rubella, Congenital Syndrome
43. Salmoneliosis
44. Shigellosis
45. Smallpox
46. Syphilis
47. Tetanus
48. Toxic Shock Syndrome
49. Trichinosis
50. Tuberculosis
51. Tularemia
52. Typhoid Fever
53. Typhus Fever
54. Vaccine Adverse Reactions
55. Waterborne Disease Outbreaks
56. Yellow Fever
Please note: The DHSS regulations on this website are not as yet complete. In conjunction with the Delaware Registrar of Regulations, DHSS is in process of compiling regulations relating to Title 16, as part of the continuing project to develop the Delaware Administrative Code.
