R432.  Health, Family Health and Preparedness, Licensing.
R432-200.  Small Health Care Facility (Four to Sixteen Beds).
R432-200-1.  Legal Authority.
	This rule is adopted pursuant to Title 26, Chapter 21.

R432-200-2.  Purpose.
	This rule allows services at varying levels of health care intensity to be provided in structures that depart from the traditional institutional setting.  Health care may be delivered in a less restrictive, residential, or home-like setting.  Small health care facilities are categorized as Level I, Level II, Level III, or Level IV according to the resident's ability or capability for self-preservation: to exit a building unassisted in an emergency.

R432-200-3.  Compliance.
	All small health care facilities shall be in full compliance at the time of licensure.  All Medicare and Medicaid certified facilities must comply with Title XVIII and Title XIX regulations.

R432-200-4.  Definitions.
	(1)  See common definitions in R432-1-3.
	(2)  Special Definitions:
	(a)  "Levels of Care" mean the range of programs and the physical facilities in which they may be offered according to these rules.
	(b)  "Level I" refers to a skilled nursing care facility that provides at least 24-hour care and licensed nursing services to persons who are non-mobile and non-ambulatory.  All Level I facilities shall conform to the requirements in the Utah Department of Health, Nursing Care Facility rules R432-150.  A Level I facility with a bed capacity of 16 beds or less, may request a variance from some construction standards for nursing care facilities, if the health, safety, and welfare of residents can be preserved.
	(i)  Skilled Nursing Facility shall maintain and operate 24-hour skilled nursing services for the care and treatment of chronically ill or convalescent residents whose primary need is the availability of skilled nursing care or related service on an extended basis.
	(ii)  Intermediate Care Facility shall provide 24-hour in resident care to residents who need licensed nursing supervision and supportive care, but who do not require continuous nursing care.
	(c)  "Level II" refers to a facility that provides at least 24-hour care, 24-hour staff coverage, and licensed therapy or nursing care (based on program requirements) to 4-16 persons who are non-mobile and non-ambulatory.  Level II facilities may include:
	(i)  Health Care Nursery shall provide full-time supervision and care to children under six years of age who do not require continuous nursing care.  The facility shall provide at least the following:
	(A)  Twenty-four hour care and/or staff availability;
	(B)  Provision for medical coverage;
	(C)  Provision for dietary services;
	(D)  Provision for licensed therapies, as required.
	(ii)  Intermediate Care Facility for the Mentally Retarded shall provide 24-hour supervisory care to developmentally disabled and mentally retarded individuals, (note: An ICF/MR facility may be categorized as a Level IV facility if no resident is under therapy that utilizes chemical or physical restraints which may render the resident incapable of self-preservation in an emergency), who need supervision in a coordinated and integrated program of health, habilitative and supportive services, but who do not require continuous nursing care. The facility shall, except as indicated in the supplement, provide the following:
	(A)  Twenty-four hour care and staff availability;
	(B)  Provision for medical coverage;
	(C)  Provision for dietary services;
	(D)  Provision for licensed therapies, as required.
	(iii)  Home for the Aging shall provide group housing, supervision, social support, personal care, therapy, and some nursing care to elderly persons who do not need intermediate or skilled nursing care.  The facility shall provide at least the following:
	(A)  Twenty-four hour staff availability;
	(B)  Provision for medical coverage;
	(C)  Provision for dietary services for at least three meals;
	(D)  Provision for licensed therapies, as necessary.
	(iv)  Social Rehabilitation Facility shall provide group housing, personal care, social rehabilitation, and treatment for alcoholism, drug abuse, or mental problems to persons who do not require intermediate or skilled nursing care. (Note: if each resident in the program is certified by a physician or QMRP as ambulatory and in an alcohol or drug abuse rehabilitation program designed to lead to independent living, then the facility may be categorized as a Level IV facility.)  The facility shall provide the following:
	(A)  Twenty-four hour staff availability or program care;
	(B)  Provision for medical coverage;
	(C)  Provision for dietary services for at least three meals;
	(D)  Provision for licensed therapies, as necessary.
	(d)  "Level III" refers to a facility that provides at least 24-hour staff coverage and licensed therapy (based on program requirements) to 4-16 persons who are ambulatory and mobile but who are under chemical or physical restraints. Level III facilities may include:
	(i)  Mental Health Facility shall provide 24 hour care to persons with mental illness who require medical and psychiatric supervision including diagnosis and treatment.  The facility shall provide at least the following:
	(A)  Twenty-four hour staff coverage;
	(B)  Provision for medical and psychiatric supervision;
	(C)  Provision for dietary services;
	(D)  Provision for licensed therapies, as necessary.
	(ii)  Youth Correction Center shall provide 24-hour supervision, care, training, treatment, and therapy to persons who by court order may be restricted in their daily activities, and under security control that includes lock-up.  The facility shall provide at least the following:
	(A)  Twenty-four hour staff coverage;
	(B)  Provision for medical and psychiatric supervision;
	(C)  Provision for dietary services;
	(D)  Provision for licensed therapies, as necessary.
	(e)  "Level IV" refers to a facility that provides specialized program and support care to 4-16 persons who are ambulatory and mobile, who require programs of care and more supervision than provided in a residential care facility.  Level IV facilities may include:
	(i)  Intermediate Care Facility for the Mentally Retarded. All mentally retarded residents in a Level IV facility must be ambulatory to qualify for Medicaid/Medicare reimbursement.
	(ii)  Mental Health Facility. (See R432-200-4(2)(d)(i), Level III)
	(iii)  Home for the Aging. (See R432-200-4(2)(c)(iii), Level II)
	(iv)  Social Rehabilitation Facility. (See R432-200-4(2)(c)(iv), Level II)

R432-200-5.  License Required.
	See R432-2.

R432-200-6.  Construction and Physical Environment.
	(1)  See R432-12, Small Health Care Facility Construction rules.

R432-200-7.  Administration and Organization.
	(1)  Organization.
	Each facility shall be operated by a licensee.
	(2)  Duties and Responsibilities.
	The licensee shall be responsible for compliance with Utah law and licensure requirements and for the organization, management, operation, and control of the facility.  Responsibilities shall include at least the following:
	(a)  Comply with all federal, state and local laws, rules, and regulations;
	(b)  Adopt and institute by-laws, policies and procedures relative to the general operation of the facility including the health care of the residents and the protection of their rights;
	(c)  Adopt a policy that states the facility will not discriminate on the basis of race, color, sex, religion, ancestry or national origin in accordance with Section 13-7-1;
	(d)  Appoint, in writing, a qualified administrator to be responsible for the implementation of facility by-laws and policies and procedures, and for the overall management of the facility;
	(e)  Secure and update contracts for professional and other services;
	(f)  Receive and respond, as appropriate, to the inspection report by the Department;
	(g)  Notify the Department, in writing, at least 30 days prior to, but not later than five days after, a change of administrator. The notice shall include the name of the new administrator and the effective date of the change.
	(3)  Administrator.
	(a)  Administrator's Appointment.
	Each facility shall appoint, in writing, an administrator professionally licensed by the Utah Department of Commerce in a health care field.
	(b)  A copy of the administrator's license or credentials shall be posted alongside the facility's license in a place readily visible to the public.
	(c)  The administrator shall act as the administrator of no more than four small health care facilities (or a maximum of 60 beds)  at any one time.
	(d)  The administrator shall have sufficient freedom from other responsibilities and shall be on the premises of the facility a sufficient number of hours in the business day (at least four hours per week for each six residents)  and as necessary to properly manage the facility and respond to appropriate requests by the Department.
	(e)  The administrator shall designate, in writing, the name and title of the person who shall act as administrator in his absence. This person shall have sufficient power, authority, and freedom to act in the best interests of resident safety and well-being. It is not the intent of this paragraph to permit an unlicensed de facto administrator to supplant or replace the designated, licensed administrator.
	(4)  Administrator Responsibilities.
	The administrator shall have the following responsibilities:
	(a)  Complete, submit and file all records and reports required by the Department;
	(b)  Act as a liaison among the licensee, medical and nursing staff, and other supervisory staff of the facility, as appropriate, and respond to recommendations of the quality assurance committee;
	(c)  Assure that employees are oriented to their job functions and receive appropriate in-service training;
	(d)  Implement policies and procedures for the operation of the facility;
	(e)  Hire and maintain the required number of licensed and non-licensed staff as specified in these rules to meet the needs of residents;
	(f)  Maintain facility staffing records for 12 months;
	(g)  Secure and update contracts required for professional and other services not provided directly by the facility;
	(h)  Verify all required licenses and permits of staff and consultants at the time of hire and effective date of contract;
	(i)  Review all incident and accident reports and take appropriate action.
	(5)  Medical Director.
	The administrator of each facility shall retain, by formal agreement, a licensed physician to serve as medical director or advisory physician on a consulting basis according to the residents' and facility's needs.
	(6)  Medical Director Responsibilities.
	The medical director or advisory physician shall have responsibility for at least the following:
	(a)  Review or develop written resident-care policies and procedures including the delineation of responsibilities of attending physicians;
	(b)  Review resident-care policies and procedures annually with the administrator;
	(c)  Serve as liaison between the resident's physician and the administrator;
	(d)  Serve as a member of the quality assurance committee (see R432-200-10);
	(e)  Review incident and accident reports at the request of the administrator to identify health hazards to residents and employees;
	(f)  Act as consultant to the health services supervisor in matters relating to resident-care policies.
	(7)  Staff and Personnel.
	(a)  Organization.
	The administrator shall employ qualified personnel who are able and competent to perform their respective duties, services, and functions.
	(b)  Qualifications and Orientation.
	(i)  The administrator shall develop job descriptions including job title, job summary, responsibilities, qualifications, required skills and licenses, and physical requirements for each position or employee.
	(ii)  Periodic employee performance evaluations shall be documented.
	(iii)  All personnel shall have access to the facility's policies and procedures manuals, resident- care policies, therapeutic manuals, and other information necessary to effectively perform their duties and carry out their responsibilities.
	(8)  Health Surveillance.
	(a)  The facility shall establish a policy and procedure for the health screening of all facility personnel which conforms with the provisions of R432-150-10(4).
	(b)  All dietary and other staff who handle food shall obtain a Food Handler's Permit from the local health department.
	(9)  In-service Training.
	There shall be planned and documented in-service training for all facility personnel. The following topics shall be addressed annually:
	(a)  Fire prevention (see R432-200-11);
	(b)  Accident prevention and safety procedures including instruction in the following:
	(i)  Body mechanics for all employees required to lift, turn, position, or ambulate residents;
	(ii)  Proper safety precautions when floors are wet or waxed;
	(iii)  Safety precautions and procedures for heat lamps, hot water bottles, bathing and showering temperatures;
	(c)  Review and drill of emergency procedures and evacuation plan (See R432-200-11);
	(d)  Prevention and control of infections (see R432-150-25);
	(e)  Confidentiality of resident information;
	(f)  Residents' rights;
	(g)  Behavior Management and proper use and documentation of restraints;
	(h)  Oral hygiene and first aid; and
	(i)  Training in the principles of Cardiopulmonary Resuscitation (CPR)  for licensed nursing personnel and others as appropriate;
	(j)  Training in habilitative care;
	(k)  Reporting abuse, neglect and exploitation.

R432-200-8.  Smoking Policies.
	Smoking policies shall comply with Title 26, Chapter 38 the, "Utah Indoor Clean Air Act", and Section 31-4.4 of the 1991 Life Safety Code.

R432-200-9.  Contracts and Agreements.
	(1)  Contracts.
	(a)  The licensee shall secure and update contracts for required professional and other services not provided directly by the facility.
	(b)  Contracts shall include:
	(i)  The effective and expiration dates of the contract;
	(ii)  A description of goods or services provided by the contractor to the facility;
	(iii)  A statement that the contractor will conform to the standards required by Utah law or rules.
	(c)  The contract shall be available for review by the Department.
	(2)  Transfer Agreements.
	(a)  The licensee shall maintain, a written transfer agreement with one or more hospitals (or nearby health facilities) to facilitate the transfer of residents and essential resident information.
	(b)  The transfer agreement shall include provisions for:
	(i)  Criteria for transfer;
	(ii)  Appropriate methods of transfer;
	(iii)  Transfer of information needed for proper care and treatment of the individual being transferred;
	(iv)  Security and accountability of the personal property of the individual being transferred;
	(v)  Proper notification of the hospital and next of kin or responsible person before transfer.

R432-200-10.  Quality Assurance.
	(1)  The administrator shall monitor the quality of services offered by the facility through the formation of a committee that addresses infection control, pharmacy, therapy, resident care, and safety, as applicable.
	(2)  The committee shall include the administrator, consulting physician or medical director, health services supervisor, and consulting pharmacist.  Special program directors and maintenance and housekeeping personnel shall serve as necessary.
	(3)  The committee shall meet quarterly and keep minutes of the proceedings.
	(4)  Infection Control Requirements.
	See R432-150-11.
	(5)  Pharmacy Requirements.
	Based on the services offered, the committee shall:
	(a)  Monitor the pharmaceutical services in the facility;
	(b)  Recommend changes to improve pharmaceutical services;
	(c)  Evaluate medication usage; and
	(d)  Develop and review pharmacy policies and procedures annually, and recommend changes to the administrator and licensee.
	(6)  Resident Care Requirements.
	Based on the services offered, the committee shall address the following:
	(a)  Review, at least annually, the facility's resident care policies including rehabilitative and habilitative programs, as appropriate.
	(b)  Make recommendations to the medical director and advisory physician as appropriate;
	(c)  Review recommendations from other facility committees to improve resident care.
	(7)  Safety Requirements.
	Based on the services offered, the committee shall address the following:
	(a)  Review all incident and accident reports and recommend changes to the administrator to prevent or reduce their reoccurrence;
	(b)  Review facility safety policies and procedures, at least annually, and make recommendations;
	(c)  Establish a procedure to inspect the facility periodically for hazards.  An inspection report shall be filed with the Committee.

R432-200-11.  Emergency and Disaster.
	(1)  Facilities have the responsibility to assure the safety and well-being of their residents in the event of an emergency or disaster.  An emergency or disaster may include utility interruption, explosion, fire, earthquake, bomb threat, flood, windstorm, or epidemic.
	(2)  Policies and Procedures.
	(a)  The licensee and the administrator shall be responsible for the development of a plan, coordinated with state and local emergency or disaster authorities, to respond to emergencies and disasters.
	(b)  The written plan shall be distributed to all facility staff to assure prompt and efficient implementation.
	(c)  The plan shall be reviewed and updated to conform with local emergency plans, at least annually, by the administrator and the licensee.
	(d)  The plan shall be available for review by the Department.
	(3)  Staff and residents shall receive education, training, and drills to respond in an emergency.
	(a)  Drills and training shall be documented and comply with applicable laws and regulations.
	(b)  The name of the person in charge and names and telephone numbers of emergency medical personnel, agencies, and emergency transport systems shall be posted.
	(4)  Emergency Procedures.
	The facility's response procedures shall address the following:
	(a)  Evacuation of occupants to a safe place within the facility or to another location;
	(b)  Delivery of essential care and services to facility occupants by alternate means;
	(c)  Delivery of essential care and services when additional persons are housed in the facility during an emergency;
	(d)  Delivery of essential care and services to facility occupants when staff is reduced by an emergency;
	(e)  Maintenance of safe ambient air temperatures within the facility;
	(i)  Emergency heating plans must have the approval of the local fire department.
	(ii)  An ambient air temperature of 58 degrees F (14 degrees C) or less constitutes an imminent danger to the health and safety of the residents in the facility.  The person in charge shall take immediate and appropriate action in the best interests of the resident.
	(5)  Emergency Plan.
	(a)  The facility's emergency plan shall delineate:
	(i)  The person or persons with decision-making authority for fiscal, medical, and personnel management;
	(ii)  On-hand personnel, equipment, and supplies and how to acquire additional help, supplies, and equipment after an emergency or disaster;
	(iii)  Assignment of personnel to specific tasks during an emergency;
	(iv)  Methods of communicating with local emergency agencies, authorities, and other appropriate individuals;
	(v)  The individuals who shall be notified in an emergency in the order of priority.  Telephone numbers shall be accessible to staff at each nurse's station;
	(vi)  Methods of transporting and evacuating residents and staff to other locations;
	(vii)  Conversion of facility for emergency use.
	(b)  Documentation of emergency events and responses and a record of residents and staff evacuated from the facility to another location shall be kept.  Any resident emergency shall be documented in the resident's record.
	(c)  Drills shall be held semi-annually for all residents and staff.
	(d)  There shall be regular in-service training on disaster prepare
	(6)  Fire Emergencies.
	(a)  The licensee and administrator shall develop a written fire-emergency and evacuation plan in consultation with qualified fire safety personnel.
	(b)  An evacuation plan delineating evacuation routes, location of fire alarm boxes, fire extinguishers, and emergency telephone numbers of the local fire department shall be posted throughout the facility.
	(c)  The written fire-emergency plan shall include fire-containment procedures and how to use alarm systems and signals.
	(d)  Fire and internal disaster drills shall be held, at least quarterly, under varied conditions for each shift.
	(i)  The actual evacuation of residents during a drill is optional except in a facility caring for residents who are capable of self-preservation.
	(ii)  The actual evacuation of residents during a drill on the night shift is optional.

R432-200-12.  Residents' Rights.
	(1)  Residents' Rights Policies and Procedures.
	(a)  A committee shall be appointed to update policy, evaluate, and act on residents' rights complaints.
	(b)  Written residents' rights shall be established, posted in areas accessible to residents, and made available to the resident, or guardian, or next of kin.
	(c)  These shall be available to the public and the Department upon request.
	(2)  Each resident admitted to the facility shall have the following rights:
	(a)  To be fully informed, as evidenced by the resident's written acknowledgement prior to or at the time of admission and during stay, of residents' rights and of all rules governing resident conduct;
	(b)  To be fully informed, prior to or at the time of admission and during stay, of services available in the facility and of related charges, including any charges for services not covered by the facility's basic per diem rate or not covered under Titles XVIII or XIX of the Social Security Act;
	(c)  To be fully informed of his medical condition, by a physician, unless medically contraindicated and documented in the resident's health record by the attending physician;
	(d)  To be afforded the opportunity to participate in the planning of his medical treatment and to refuse to participate in experimental research;
	(e)  To refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal;
	(f)  To be transferred or discharged only for medical reasons, or his welfare or that of other residents, or for nonpayment for his stay, and to be given reasonable advance notice to ensure orderly transfer or discharge; such actions shall be documented in his health record;
	(g)  To be encouraged and assisted throughout the period of stay to exercise rights as a resident and as a citizen, and to this end to voice grievances and recommend changes in policies and services to facility staff or outside representatives of his choice, free from restraint, interference, coercion, discrimination, or reprisal;
	(h)  To manage his personal financial affairs, or to be given at least quarterly or upon request an accounting of financial transactions made on his behalf should the facility accept his written delegation of this responsibility;
	(i)  To be free from mental and physical abuse and to be free from chemical and (except in emergencies)  physical restraints except as authorized in writing by a physician for a specified and limited period of time, or when necessary to protect the resident from injury to himself or to others (see R432-150-12);
	(j)  To be assured confidential treatment of his personal and medical records and to approve or refuse their release to any individual outside the facility, except in the case of his transfer to another health facility, or as required by law or third party payment contract;
	(k)  To be treated with consideration, respect and full recognition of his dignity and individuality, including privacy in treatment and in care for personal needs;
	(l)  Not to be required to perform services for the facility that are not included for therapeutic purposes in his plan of care;
	(m)  To associate and communicate privately with persons of his choice, and to send and receive personal mail unopened;
	(n)  To meet with and participate in activities of social, religious, and community groups at his discretion;
	(o)  To retain and use personal clothing and possessions as space permits, unless to do so would infringe upon rights of other residents;
	(p)  If married, to be assured privacy for visits by his spouse and if both are residents in the facility, to be permitted to share a room;
	(q)  To have daily visiting hours established;
	(r)  To have members of the clergy admitted at the request of the resident or person responsible at any time;
	(s)  To allow relatives or persons responsible to visit residents at any time;
	(t)  To be allowed privacy for visits with family, friends, clergy, social workers or for professional or business purposes;
	(u)  To have reasonable access to telephones both to make and receive confidential calls.
	(v)  To wear appropriate personal clothing and religious or other symbolic items as long as they do not interfere with diagnostic procedures or treatment.
	(3)  Safeguards for Residents' Monies and Valuables
	Each facility to whom a resident's money or valuables have been entrusted according to R432-200- 12(2)(h), above shall comply with the following:
	(a)  No licensee shall use residents' monies or valuables as his own or mingle them with his own.
	(i)  Residents' monies and valuables shall be separated and intact and free from any liability that the licensee incurs in the use of his own or the institution's funds and valuables.
	(ii)  Each licensee shall maintain adequate safeguards and accurate records of residents' monies and valuables entrusted to the licensee's care.
	(b)  Records of residents' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, an account for each resident and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits, and balance.
	(c)  Records of residents' monies and other valuables entrusted to the licensee for safekeeping shall include a copy of the receipt furnished to the resident or to the person responsible for the resident.
	(d)  Residents' monies not kept in the facility shall be deposited within five days of receipt of such funds in an interest-bearing account in a local bank authorized to do business in Utah, the deposits of which must be insured.
	(e)  A person, firm, partnership, association or corporation which is licensed to operate more than one health facility shall maintain a separate account for each such facility and shall not commingle resident funds from one facility with another.
	(f)  When the amount of residents' money entrusted to a licensee exceeds $150, all money in excess of $150 shall be deposited in an interest-bearing account as specified in R432-200-12(3)(c) and (d)  above.
	(g)  Upon discharge of a resident, all money and valuables of that resident which have been entrusted to the licensee shall be surrendered to the resident in exchange for a signed receipt.  Money and valuables kept within the facility shall be surrendered upon demand and those kept in an interest-bearing account shall be made available within three normal banking days.
	(h)  Within 30 days following the death of a resident, except in a coroner or medical examiner case, all money and valuables of that resident which have been entrusted to the licensee shall be surrendered to the person responsible for the resident or to the executor or the administrator of the estate in exchange for a signed receipt. When a resident dies without a representative or known heirs, immediate written notice thereof shall be given by the facility to the State Medical Examiner and the registrar of the local probate court, and a copy of said notice shall be filed with the Department.

R432-200-13.  Admission and Discharge.
	Each facility shall develop admission and discharge policies that shall be available to the public upon request.
	(1)  Admission Policies.
	(a)  Residents shall be accepted for treatment and care only if the facility is properly licensed for the treatment required and has the staff and resources to meet the medical, physical, and emotional needs of the resident.
	(b)  Residents shall be admitted by, and remain under the care of, a physician or individual licensed to prescribe care for the resident.
	(c)  There shall be a written order (a documented telephone order is acceptable) for admission and care at the time of admission.
	(d)  A resident shall be assessed within seven days of admission unless otherwise indicated by a program requirement.  Admission policies shall define the assessment process including an identification of the resident's medical, nursing, social, physical, and emotional needs.
	(e)  A physical examination shall be performed, in accordance with R432-200-14(2), by the attending physician or by an individual licensed and so authorized.
	(f)  Upon admission, a brief narrative of the resident's condition including his temperature, pulse, respiration, blood pressure, and weight shall be documented.
	(g)  The resident shall be informed of his rights as a resident.
	(i)  A written copy of the facility's residents' rights shall be explained and given to the resident.
	(ii)  If the resident is unable to comprehend his rights, a written copy shall be given to the next of kin or other responsible party.
	(iii)  The inability of the resident to provide consent shall be documented in the resident's record.
	(2)  Discharge Policies.
	(a)  The resident shall be discharged when the facility is no longer able to meet the resident's identified needs.
	(b)  There shall be an order for the resident's discharge by the physician or person in charge of the resident's care.
	(c)  A discharge summary containing a brief narrative of the resident's diagnoses, course of treatment, conditions, and final disposition shall be documented in the medical record.
	(d)  Upon discharge of a resident, all money and valuables of that resident which have been entrusted to the licensee shall be surrendered to the resident in exchange for a signed receipt (see R432-200-12(3)).

R432-200-14.  Physician Services.
	(1)  General Requirements.
	(a)  Each resident in need of nursing services, habilitative, or rehabilitative care shall be under the care of a licensed physician.
	(b)  Each resident shall be permitted to choose his physician.
	(c)  Upon admission, each resident shall have orders for treatment and care.
	(2)  Physician Responsibilities.
	(a)  Each resident shall have a medical history and pertinent physical examination at least annually.
	(b)  Each intermediate care resident shall be seen at least once during the first 60 days of residency.
	(c)  The attending physician or medical practitioner shall see the resident whenever necessary but at least every 60 days, unless the attending physician or practitioner documents in the resident's record why the resident does not need to be seen this frequently.
	(d)  The physician or practitioner shall establish and follow a schedule alternating visits.
	(e)  Each visit and evaluation shall be documented in the resident's record.
	(3)  Policies and Procedures.
	There shall be policies and procedures that provide for:
	(a)  Access to physician services in case of medical emergency or when the attending physician is not available;
	(b)  Names and telephone numbers of on-call physicians in the health services supervisor's office;
	(c)  Reevaluation of the resident and review of care and treatment orders when there is a change of attending physician which shall be completed within 15 days of such change.
	(4)  Non-Physician Practitioners.
	The following practitioners may render medical services according to state law:
	(a)  Nurse practitioners licensed to practice in the state of Utah;
	(b)  Physicians' assistants working under the supervision of a licensed physician and performing only those selected diagnostic and therapeutic tasks identified in Rules and Regulations and Standards for Utilization of Physician Assistants.
	(5)  Physician Orders and Notes.
	(a)  The following items shall be part of the treatment record and shall be signed and dated by a physician:
	(i)  Admission orders;
	(ii)  Medication, treatment, therapy, laboratory, and diet orders;
	(iii)  History and physical examinations;
	(iv)  Physician's progress notes;
	(v)  The discharge summary;
	(vi)  All discharge orders;
	(b)  All telephone orders shall be recorded immediately and include:
	(i)  date and time of order;
	(ii)  the receiver's signature and title; and
	(iii)  the order shall be countersigned and dated within 15 days by the physician who prescribed the order.
	(c)  The attending physician shall complete the resident's medical record within 60 days of the resident's discharge, transfer, or death.
	(6)  Notification of Physician.
	(a)  The attending physician shall be notified promptly upon:
	(i)  Admission of the resident;
	(ii)  A sudden and/or marked adverse change in the resident's signs, symptoms, or behavior;
	(iii)  Any significant weight change in a 30-day period unless the resident's physician stipulates another parameter in writing;
	(iv)  Any adverse response or reaction by a resident to a medication or treatment;
	(v)  Any error in medication administration or treatment;
	(vi)  The discovery of a decubitus ulcer, the beginning of treatment, and if treatment is not effective.  Notification shall be documented.
	(b)  The physician shall be notified if the facility is unable to obtain or administer drugs, equipment, supplies, or services promptly as prescribed.  If the attending physician or his designee is not readily available, emergency medical care shall be provided.  The telephone numbers of the emergency care physician shall be posted at the control station.
	(c)  All attempts to notify physicians shall be noted in the resident's record including the time and method of communication and the name of the person acknowledging contact, if any.

R432-200-15.  Nursing Care.
	(1)  Organization.
	(a)  Each facility shall provide nursing care services commensurate with the needs of the residents served.
	(b)  All licensed nursing personnel shall maintain current Utah licenses to practice nursing.
	(2)  Responsibilities of the Health Services Supervisor.
	The health services supervisor shall have the following responsibilities and comply with R432-1-3(55):
	(a)  Direct the implementation of physician's orders;
	(b)  Plan and direct the delivery of nursing care, treatments, procedures, and other services to assure that each resident's needs are met;
	(c)  Review the health care needs of each resident admitted to the facility and formulate with other professional staff a resident care plan according to the attending physician's orders;
	(d)  Review the medication system for completeness of information, accuracy in the transcription of physician's orders, and adherence to stop-order policies;
	(e)  Ensure that nursing notes describe the care rendered including the resident's response.  Instruct staff on the legal requirements of charting;
	(f)  Supervise clinical staff to assure they perform restorative measures in their daily care of residents;
	(g)  Teach and coordinate habilitative and rehabilitative care to promote and maintain optimal physical and mental functioning of the resident;
	(h)  Keep the administrator and attending physician informed of significant changes in the resident's health status;
	(i)  Plan with the physician, family, and health-related agencies the care of the resident upon discharge;
	(j)  Coordinate resident services through the quality assurance committees (see R432-200-10);
	(k)  Assign qualified supervisory and supportive staff throughout the day and night to assure that the health needs of residents are met;
	(l)  Develop written job descriptions for all health service personnel and orient all new personnel to the facility and their duties and responsibilities;
	(m)  Evaluate and document the performance of each member of the staff at least annually.  This evaluation shall be available for Departmental review;
	(n)  Plan and conduct documented orientation and in-service programs for staff.
	(3)  Required Staffing Hours.
	(a)  Any facility that provides nursing care shall provide at least two hours (120 minutes) of nursing-staff coverage (RN + LPN + Aides) per resident per 24 hours of which 20 percent or 24 minutes per resident shall be provided by licensed staff (RN + LPN).
	(b)  Facilities providing rehabilitative or habilitative care shall:
	(i)  Provide adequate staff care and supervision to meet the resident's needs based on the resident-care plan, or;
	(ii)  Conform to the specific program requirements in the appropriate supplement.
	(c)  The above requirements are minimum only.  Additional staff may be necessary to ensure adequate coverage in the event of staff illness, turnover, sudden increase in resident population, or similar event.
	(d)  Facilities that participate in the Medicare/Medicaid programs shall, as a condition of such participation, meet the staffing standards approved through administrative rule.
	(4)  Nursing or Health Care Services.
	(a)  The health services procedure manual shall be reviewed and updated annually by the health services supervisor.
	(b)  The manual shall be accessible to all clinical staff and available for review by the Department.
	(c)  The procedures shall address the following:
	(i)  Bathing;
	(ii)  Positioning;
	(iii)  Enema administration;
	(iv)  Decubitus prevention and care;
	(v)  Bed making;
	(vi)  Isolation procedures;
	(vii)  Clinitest procedures;
	(viii)  Laboratory requisitions;
	(ix)  Telephone orders;
	(x)  Charting;
	(xi)  Rehabilitative nursing;
	(xii)  Diets and feeding residents;
	(xiii)  Oral hygiene and denture care;
	(xiv)  Naso-gastric tube insertion and care (by registered nurses, LPNs, with appropriate training, or physicians only).
	(5)  Measures to Reduce Incontinence.
	Measures shall be implemented to prevent and reduce incontinence for each resident.
	(a)  There shall be a written assessment by a licensed nurse to determine the resident's ability to participate in a bowel and bladder management program.
	(b)  An individualized plan for each incontinent resident shall begin within two weeks of the initial assessment.
	(c)  A weekly evaluation of the resident's performance in the bowel/bladder management program shall be recorded in the resident's record by a licensed nurse.
	(d)  Fluid intake and output shall be recorded for each resident as ordered by the physician or charge nurse.
	(i)  Intake and output records shall be evaluated at least weekly and each evaluation shall be included in the resident's record;
	(ii)  Physician's or nurse's orders shall be reevaluated periodically.
	(6)  Rehabilitative Nursing.
	Nursing personnel shall be trained in rehabilitative nursing.
	(a)  Rehabilitative nursing services shall be performed daily for residents who require such services and shall be documented in the resident's record when provided.
	(b)  Rehabilitative services shall be provided to maintain function or to improve the resident's ability to carry out the activities of daily living.
	(c)  Rehabilitative nursing services shall include the following:
	(i)  Turning and positioning of residents;
	(ii)  Assisting residents to ambulate;
	(iii)  Improving resident's range of motion;
	(iv)  Restorative feeding;
	(v)  Bowel and bladder retraining;
	(vi)  Teaching residents self-care skills;
	(vii)  Teaching residents transferring skills;
	(viii)  Teaching residents self-administration of medications, as appropriate;
	(ix)  Taking measures to prevent secondary disabilities such as contractions and decubitus ulcers.

R432-200-16.  General Resident Care Policies.
	(1)  Each resident shall be treated as an individual with dignity and respect in accordance with Residents' Rights (R432-200-12).
	(2)  Each facility shall develop and implement resident care policies to be reviewed annually by the health services supervisor.
	(3)  These policies shall address the following:
	(a)  Each resident upon admission shall be oriented to the facility, services, and staff.
	(b)  Each admission shall comply with R432-200-13(1).
	(c)  Each resident shall receive care to ensure good personal hygiene.  This care shall include bathing, oral hygiene, shampoo and hair care, shaving or beard trimming, fingernail and toenail care.
	(d)  Linens and other items in contact with the resident shall be changed weekly or as the item is soiled.
	(e)  Each resident shall be encouraged and assisted to achieve and maintain the highest level of functioning and independence including:
	(i)  teaching the resident self-care,
	(ii)  assisting residents to adjust to their disabilities and prosthetic devices,
	(iii)  directing residents in prescribed therapy exercises, and
	(iv)  redirecting residents interests as necessary.
	(f)  Residents must be reevaluated annually to determine if a less restrictive setting might be more appropriate to help them achieve independence.
	(g)  Each resident shall receive care and treatment to ensure the prevention of decubiti, contractions, and deformities.
	(h)  Each resident shall be provided with good nutrition and adequate fluids for hydration.
	(i)  All residents shall have ready access to water and drinking glasses;
	(ii)  Residents unable to feed themselves shall be assisted to eat in a prompt, orderly manner;
	(iii)  Residents shall be provided with adapted equipment to assist in eating and drinking.
	(i)  Visual privacy shall be provided for each resident during treatments and personal care.
	(j)  Call lights or signals (where required) shall be answered promptly.
	(k)  Humidifier bottles on oxygen equipment shall be sterile and changed every 24 hours or at the manufacturers direction.
	(4)  Notification of Family.
	The person in charge shall immediately notify the resident's family or guardian of any accident, injury, or adverse change in the resident's condition after the first attempt to notify the physician.  This notification shall be documented in the resident's record.

R432-200-17.  Resident-Care Plans.
	(1)  General Provisions.
	(a)  A written resident-care plan, coordinated with nursing and other services, shall be initiated for each resident upon admission.
	(b)  The resident-care plan shall be personalized and indicate measurable and time-limited objectives, the actual plan of care, and the professional discipline responsible for each element of care.
	(c)  The resident care plan shall be developed, reviewed, revised, and updated at least annually through conferences with all professionals involved in the resident's care.  Such conferences shall be documented.
	(d)  Each resident's care shall be based on this plan.
	(e)  The resident-care plan shall be available to all personnel who care for the resident.
	(f)  The resident and family shall participate in the development and review of the resident's plan.
	(g)  Upon transfer or discharge of the resident, relevant information from the resident-care plan shall be available to the responsible institution or agency.
	(h)  A licensed nurse or other clinical specialist, where appropriate, shall summarize, each month, the resident's status and problems identified in the resident-care plan.
	(2)  Resident-Care Plans Contents.
	The resident-care plan shall include at least the following:
	(a)  Name, age, and sex of resident;
	(b)  Diagnosis, symptoms, complaints;
	(c)  A description of the functional level of the individual;
	(d)  Care objectives and time frames for accomplishment, reevaluation, and completion;
	(e)  Discipline or person responsible for each objective;
	(f)  Discharge plan;
	(g)  Date of admission;
	(h)  Name of attending physician or medical practitioner.

R432-200-18.  Medication Administration.
	(1)  Standing Orders.
	Standing orders for medications, treatments, and laboratory procedures shall not be used.  All orders shall be written for the individual resident.
	(2)  Administration of Medication and Treatments.
	Medication and treatment shall be administered as follows:
	(a)  No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order.
	(b)  Medications and treatments shall be administered as prescribed and according to facility policy.
	(c)  All medications and treatments shall be administered by licensed medical or licensed nursing personnel.  Student doctors and nurses may administer medication and treatment only in the course of study and when supervised by a licensed instructor or designated staff.
	(d)  Monitoring of vital signs and other observations done in conjunction with the administration of medication shall be carried out as ordered by the physician or practitioner and as indicated by accepted professional practice.
	(e)  Preparation of doses for more than one scheduled time of administration shall not be permitted.
	(f)  Medication shall be administered when ordered or as soon thereafter as possible but no more than two hours after the dose has been prepared.
	(g)  Medication shall be administered by the same person who prepared the dose for administration.
	(h)  Residents shall be identified prior to the administration of any drug or treatment.
	(i)  No medication shall be used for any resident other than the resident for whom it was prescribed.
	(j)  If the person who prescribed a medication does not limit the duration of the drug order or the number of doses, the facility's automatic stop-order policy shall indicate how long a drug may be administered.  The prescriber shall be notified before the medication is discontinued.
	(k)  All orders for treatment or therapy shall contain:
	(i)  the name of the treatment or therapy,
	(ii)  the frequency and time to be administered,
	(iii)  the length of time the treatment or therapy is to continue,
	(iv)  the name and professional title of the practitioner who gave the order,
	(v)  the date of order, and
	(vi)  signature of the person prescribing the treatment or therapy.
	(l)  All nursing personnel shall comply with the provisions for administration of medication according to standards and ethics of the profession.
	(m)  Injectable medications shall be administered only by authorized persons.
	(i)  If a physician certifies that a resident is capable of administering his own insulin or oral medications, the resident may self-inject the prescribed insulin or self-administer the prescribed medications.
	(ii)  The physician's order, authorizing the resident's self-administration of medications, shall be documented and available for Departmental review.

R432-200-19.  Behavior Management and Restraint Policy.
	See R432-150-14.

R432-200-20.  Resident Care Equipment.
	(1)  The facility shall provide equipment, in good working order, to meet the needs of residents.
	(2)  Disposable and single-use items shall be properly disposed of after use.
	(3)  Resident care equipment shall include at least the following:
	(a)  Self-help ambulation devices such as wheelchairs, walkers, and other devices deemed necessary in the resident plan of care.  Facility policy may require that residents obtain their own equipment for long-term use;
	(b)  Blood pressure apparatus and stethoscopes, appropriate to the needs and number of residents;
	(c)  Thermometers appropriate to the needs of residents;
	(d)  Weight scales to weigh all residents;
	(e)  Bedpans, urinals, and equipment to clean them;
	(f)  Water pitchers, drinking glasses, and resident gowns;
	(g)  Drug service trays;
	(h)  Access to emergency oxygen including equipment for its administration;
	(i)  Emesis basins;
	(j)  Linens including sheets, blankets, bath towels, and wash cloths for not less than three complete changes for the facility's licensed bed capacity.  There shall be a bedspread for each resident bed;
	(k)  Personal items including toothbrush, comb, hair brush, soap for bathing and showering, denture cups, shaving apparatus, and shampoo;
	(l)  An individual chart for each resident;
	(m)  Gloves (sterile and unsterile);
	(n)  Ice bags.

R432-200-21.  Pharmacy Service.
	The facility shall make provision for pharmacy service.
	(1)  This service shall be under the direction of a qualified pharmacist currently licensed in the state of Utah.
	(2)  The pharmacist may be retained by contract.
	(3)  The pharmacist shall develop policies, direct, supervise and assume responsibility for any pharmacy services offered in the facility.
	(4)  Pharmacy services shall meet R432-150-19.

R432-200-22.  Dietary Services.
	(1)  Organization.
	(a)  There shall be an organized dietary service that provides safe, appetizing, and nutritional food service to residents.
	(b)  The service shall be under the supervision of a qualified dietetic supervisor or consultant.
	(c)  If a facility contracts with an outside food management company, the company shall comply with all applicable requirements of these rules.
	(2)  See R432-150-24.

R432-200-23.  Social Services.
	(1)  The facility shall provide social services which assist staff, residents, and residents' families to understand and cope with residents' personal, emotional, and related health and environmental problems.
	(2)  This service may be provided by a consultant.
	(3)  See R432-150-17.
	(4)  Responsibilities.
	Whether provided directly by the facility or by agreement with other agencies, social service personnel shall:
	(a)  Provide services to maximize each resident's ability to adjust to the social and emotional aspects of their condition, treatments, and continued stay in the facility;
	(b)  Participate in ongoing discharge planning to guarantee continuity of care;
	(c)  Initiate referrals to official agencies when the resident needs financial assistance;
	(d)  Maintain appropriate liaison with the family or other responsible person concerning the resident's placement and rights;
	(e)  Preserve the dignity and rights of each resident;
	(f)  Maintain records, including a social history and social-services-needs evaluation, (updated annually);
	(g)  Integrate social services with other elements of the resident-care plan.

R432-200-24.  Recreation Services.
	(1)  There shall be an organized resident activity program for the group and for each resident in the facility.
	(2)  See R432-150-20.

R432-200-25.  Laboratory and Radiology Services.
	(1)  The facility shall make provision for laboratory and radiology services.
	(2)  See R432-150-18, Laboratory Services, and R432-150-23, Ancillary Health Services.

R432-200-26.  Dental Services.
	The facility shall make provision for annual and emergency dental care for residents.  Such provisions shall include:
	(1)  Developing oral hygiene policies and procedures with input from dentists;
	(2)  Presenting oral hygiene in-service programs by knowledgeable persons to both staff and residents;
	(3)  Allowing resident's freedom of choice in selecting their own private dentists;
	(4)  Developing an agreement with a dental service for those residents who do not have a personal dentist;
	(5)  Arranging transportation to and from the dentist's office.

R432-200-27.  Specialized Rehabilitative Services.
	(1)  Organization.
	(a)  A facility that provides specialized rehabilitative services may offer these services directly or through agreements with outside agencies or qualified therapists.
	(b)  Services may be offered either on-site or off-site.
	(c)  If the facility does not provide specialized rehabilitative services, the facility shall neither admit nor retain residents in need of such services.
	(2)  Personnel.
	(a)  Specialized rehabilitative services shall be provided by qualified licensed therapists in accordance with Utah law and accepted practices.
	(b)  Therapists shall offer the full scope of services to the resident.
	(c)  All therapy assistants shall be qualified and shall work under the direct supervision of a licensed therapist at all times.
	(d)  Speech pathologists shall be licensed under Title 58, Chapter 41.
	(3)  Policies and Procedures.
	(a)  Services shall be provided only on the written order of an attending physician.
	(b)  Safe and adequate space and equipment shall be available commensurate with the needs of residents.
	(c)  An appropriate plan of treatment shall be initiated by an attending physician and developed by the therapist in consultation with the nursing staff.
	(d)  An initial progress report shall be submitted to the attending physician two weeks after treatment has begun or when specified by the physician.
	(e)  The physician and therapist shall review and evaluate the plan of treatment monthly, unless, the physician recommends an alternate schedule in writing.
	(f)  There shall be documentation in the resident's record of the specialized plan of treatment.

R432-200-28.  Medical Records.
	(1)  Organization.
	(a)  Medical records shall be complete, accurately documented, and systematically organized to facilitate retrieval and compilation.
	(b)  There shall be written policies and procedures to accomplish these purposes.
	(c)  The medical record service shall be under the direction of a registered record administrator (RRA) or an accredited record technician (ART).
	(d)  If an RRA or an ART is not employed at least part-time, the facility shall consult at least annually with an RRA or ART according to the needs of the facility.
	(e)  A designated individual in the facility shall be responsible for day-to-day record keeping.
	(2)  Retention and Storage.
	(a)  Provision shall be made for the filing, safe storage, and easy accessibility of medical records.
	(i)  The record and its contents shall be safeguarded from loss, defacement, tampering, fires, and floods.
	(ii)  Records shall be protected against access by unauthorized individuals.
	(b)  Medical records shall be retained for at least seven years after the last date of resident care.  Records of minors shall be retained until the minor reaches age 18 or the age of majority plus an additional two years.  In no case shall the record be retained less than seven years.
	(c)  All resident records shall be retained within the facility upon change of ownership.
	(d)  When a facility ceases operation, provision shall be made for appropriate safe storage and prompt retrieval of all medical records.
	(3)  Release of Information.
	(a)  There shall be written procedures for the use and removal of medical records and the release of information.
	(b)  Medical records shall be confidential.
	(i)  Information may be disclosed only to authorized persons in accordance with federal, state, and local laws.
	(ii)  Requests for other information which may identify the resident (including photographs) shall require the written consent of the resident or guardian if the resident is judged incompetent.
	(c)  Authorized representatives of the Department may review records to determine compliance with licensure rules and standards.
	(4)  Physician or Licensed Practitioner Documentation
	Rubber-stamp signatures may be used in lieu of the written signature of the physician or licensed practitioner if the facility retains the signator's signed statement acknowledging ultimate responsibility for the use of the stamp and specifying the conditions for its use.
	(5)  Medical Record.
	(a)  Records shall be permanent (typewritten or hand written legibly in ink) and capable of being photocopied.
	(b)  Records shall be kept for all residents admitted or accepted for treatment and care.
	(c)  Records shall be kept current and shall conform to good medical and professional practice based on the service provided to each resident.
	(d)  All records of discharged residents shall be completed and filed within 60 days of discharge.
	(e)  All entries shall be authenticated including date, name or identified initials, and title of persons making entries.
	(6)  Contents of the Medical Record
	A facility shall maintain an individual medical record for each resident which shall include:
	(a)  Admission record (face sheet) including the resident's name; social security number; age at admission; birth date; date of admission; name, address, telephone number of spouse, guardian, authorized representative, person or agency responsible for the resident; and name, address, and telephone number of the attending physician;
	(b)  Admission and subsequent diagnoses and any allergies;
	(c)  Reports of physical examinations signed and dated by the physician;
	(d)  Signed and dated physician orders for drugs, treatments, and diet;
	(e)  Signed and dated progress notes including but not limited to:
	(i)  Records made by staff regarding the daily care of the resident;
	(ii)  Informative progress notes by appropriate staff recording changes in the resident's condition.  Progress notes shall describe the resident's needs and response to care and treatment, and shall be in accord with the plan of care;
	(iii)  Documentation of administration of all "PRN" medications and the reason for withholding scheduled medications;
	(iv)  Documentation of use of restraints in accordance with facility policy including type of restraint, reason for use, time of application, and removal;
	(v)  Documentation of oxygen administration;
	(vi)  Temperature, pulse, respiration, blood pressure, height, and weight notations, when required;
	(vii)  Laboratory reports of all tests prescribed and completed;
	(viii)  Reports of all x-rays prescribed and completed;
	(ix)  Records of the course of all therapeutic treatments;
	(x)  Discharge summary including a brief narrative of conditions and diagnoses of the resident and final disposition;
	(xi)  A copy of the transfer form when the resident is transferred to another health care facility;
	(xii)  Resident-care plan.

R432-200-29.  Housekeeping Services.
	Organization.
	(1)  There shall be adequate housekeeping services to maintain a clean sanitary and healthful environment in the facility.
	(2)  See R432-150-26.

R432-200-30.  Laundry Services.
	(1)  There shall be adequate laundry service to provide clean linens and clothing for residents and staff.
	(2)  See R432-150-27.

R432-200-31.  General Maintenance.
	(1)  Each facility shall develop and implement maintenance policies and procedures that shall be reviewed and updated annually.
	(2)  See R432-150-28.

R432-200-32.  Penalties.
	Any person who violates any provision of this rule may be subject to the penalties enumerated in 26-21-11 and R432-3-6 and be punished for violation of a class A misdemeanor as provided in 26-21-16.

KEY:  health care facilities
Date of Enactment or Last Substantive Amendment:  October 1, 2011
Notice of Continuation:  September 15, 2016
Authorizing, and Implemented or Interpreted Law:  26-21-5; 26-21-6