TITLE 22 STAFFING REGULATIONS

TITLE 22. SOCIAL SECURITY

DIVISION 5. LICENSING AND CERTIFICATION OF HEALTH FACILITIES, HOME HEALTH

AGENCIES, CLINICS, AND REFERRAL AGENCIES

CHAPTER 3. SKILLED NURSING FACILITIES

ARTICLE 3. REQUIRED SERVICES

This database is current through 1/29/10 Register 2010, No. 5

§ 72315. Nursing Service -Patient Care.


(a) No patient shall be admitted or accepted for care by a skilled nursing facility except on the order of a physician.

(b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind.

(c) Each patient, upon admission, shall be given orientation to the skilled nursing facility and the facility's services and staff.

(d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails. The patient shall be free of offensive odors.

(e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by physician's orders.

(f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include:

(1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient.

 

(2) Encouraging, assisting and training in self-care and activities of daily living.

 

(3) Maintaining proper body alignment and joint movement to prevent contractures and deformities.

 

(4) Using pressure-reducing devices where indicated.

 

(5) Providing care to maintain clean, dry skin free from feces and urine.

 

(6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine.

 

(7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b).


(g) Each patient requiring help in eating shall be provided with assistance when served, and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating.

(h) Each patient shall be provided with good nutrition and with necessary fluids for hydration.

(i) Measures shall be implemented to prevent and reduce incontinence for each patient and shall include:

(1) Written assessment by a licensed nurse to determine the patient's ability to participate in a bowel and/or bladder management program. This is to be initiated within two weeks after admission of an incontinent patient.

 

(2) An individualized plan, in addition to the patient care plan, for each patient in a bowel and/or bladder management program.

 

(3) A weekly written evaluation in the progress notes by a licensed nurse of the patient's performance in the bowel and/or bladder management program.


(j) Fluid intake and output shall be recorded for each patient as follows:

(1) If ordered by the physician.

 

(2) For each patient with an indwelling catheter:

 

(A) Intake and output records shall be evaluated at least weekly and each evaluation shall be included in the licensed nurses' progress notes.

 

(B ) After 30 days the patient shall be reevaluated by the licensed nurse to determine further need for the recording of intake and output.


(k) The weight and length of each patient shall be taken and recorded in the patient's health record upon admission, and the weight shall be taken and recorded once a month thereafter.

( l) Each patient shall be provided visual privacy during treatments and personal care.

(m) Patient call signals shall be answered promptly.

 

TITLE 22. SOCIAL SECURITY

DIVISION 5. LICENSING AND CERTIFICATION OF HEALTH FACILITIES, HOME HEALTH

AGENCIES, CLINICS, AND REFERRAL AGENCIES

CHAPTER 3. SKILLED NURSING FACILITIES

ARTICLE 3. REQUIRED SERVICES

This database is current through 1/29/10 Register 2010, No. 5

§ 72319. Nursing Service -Restraints and Postural Supports.


(a) Written policies and procedures concerning the use of restraints and postural supports shall be followed.

(b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints.

(c) The only acceptable forms of physical restraints shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with spring release devices. Soft ties means soft cloth which does not cause abrasion and which does not restrict blood circulation.

(d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff.

(e) No restraints with locking devices shall be used or available for use in a skilled nursing facility.

(f) Seclusion, which is defined as the placement of a patient alone in a room, shall not be employed.

(g) Restraints shall be used in such a way as not to cause physical injury to the patient and to insure the least possible discomfort to the patient.

(h) Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency.

(i) The requirements for the use of physical restraints are:

(1) Treatment restraints may be used for the protection of the patient during treatment and diagnostic procedures such as, but not limited to, intravenous therapy or catheterization procedures. Treatment restraints shall be applied for no longer than the time required to complete the treatment.

 

(2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record.

 

(A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints.

 

(B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method.

 

(C) Patients shall be restrained only in an area that is under supervision of staff and shall be afforded protection from other patients who may be in the area.


(j) When drugs are used to restrain or control behavior or to treat a disordered thought process, the following shall apply:

(1) The specific behavior or manifestation of disordered thought process to be treated with the drug is identified in the patient's health record.

 

(2) The plan of care for each patient specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions.

 

(3) The data collected shall be made available to the prescriber in a consolidated manner at least monthly.

 

(4) PRN orders for such drugs shall be subject to the requirements of this section.


(k) "Postural support" means a method other than orthopedic braces used to assist patients to achieve proper body position and balance. Postural supports may only include soft ties, seat belts, spring release trays or cloth vests and shall only be used to improve a patient's mobility and independent functioning, to prevent the patient from falling out of a bed or chair, or for positioning, rather than to restrict movement. These methods shall not be considered restraints.

(1) The use of postural support and the method of application shall be specified in the patient's care plan and approved in writing by the physician or other person lawfully authorized to provide care.

 

(2) Postural supports shall be applied:

 

(A) Under the supervision of a licensed nurse.

 

(B) In accordance with principles of good body alignment and with concern for circulation and allowance for change of position.

 

TITLE 22. SOCIAL SECURITY

DIVISION 5. LICENSING AND CERTIFICATION OF HEALTH FACILITIES, HOME HEALTH

AGENCIES, CLINICS, AND REFERRAL AGENCIES

CHAPTER 3. SKILLED NURSING FACILITIES

ARTICLE 3. REQUIRED SERVICES

This database is current through 1/29/10 Register 2010, No. 5

§ 72329. Nursing Service-Staff.


(a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The Department may require a facility to provide additional staff as set forth in Section 72501(g).

(b) Facilities licensed for 59 or fewer beds shall have at least one registered nurse or a licensed vocational nurse, awake and on duty, in the facility at all times, day and night.

(c) Facilities licensed for 60 to 99 beds shall have at least one registered nurse or licensed vocational nurse, awake and on duty, in the facility at all times, day and night, in addition to the director of nursing services. The director of nursing service shall not have charge nurse responsibilities.

(d) Facilities licensed for 100 or more beds shall have at least one registered nurse, awake and on duty, in the facility at all times, day and night, in addition to the director of nursing service. The director of nursing service shall not have charge nurse responsibilities.

(e) Nursing stations shall be staffed with nursing personnel when patients are housed in the nursing unit.

(f) Each facility shall employ sufficient nursing staff to provide a minimum daily average of 3.0 nursing hours per patient day.

(1) Facilities which provide care for mentally disordered patients and in which licensed psychiatric technicians provide patient care shall meet the following standards:

 

(A) If patients are not certified for special treatment programs, facilities shall employ sufficient staff to provide a minimum daily average of 3.0 nursing hours per patient day.

 

(B) For patients certified for special treatment programs, facilities shall employ sufficient staff to provide a minimum daily average of 2.3 nursing hours per patient day for each patient certified to the special treatment program, exclusive of additional staff required to meet the staffing standards of the special treatment program.


(g) Staffing for a distinct part intermediate care unit in a skilled nursing facility:

(1) Units of less than 50 intermediate care beds shall not be required to provide licensed personnel in addition to those provided in the skilled nursing facility unless the Department determines through a written evaluation that additional licensed personnel are necessary to protect the health and safety of patients.

 

(2) Units of 50 or more intermediate care beds shall provide a registered nurse or licensed vocational nurse employed 8 hours on the day shift, 7 days per week in the unit.

 

(3) For purposes of this section intermediate care beds that are licensed as such by the Department shall not be included for establishing licensed nurse staffing as required in Section 72329(f)(1) if the unit is used exclusively for intermediate care patients.


(h) This section shall become inoperative upon the operative date of Section 72329.1.

 

TITLE 22. SOCIAL SECURITY

DIVISION 5. LICENSING AND CERTIFICATION OF HEALTH FACILITIES, HOME HEALTH

AGENCIES, CLINICS, AND REFERRAL AGENCIES

CHAPTER 3. SKILLED NURSING FACILITIES

ARTICLE 3. REQUIRED SERVICES

This database is current through 1/29/10 Register 2010, No. 5

§ 72329.1. Nursing Service-Staff.


(a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The staffing requirementsrequired by this section are minimum standards only. Skilled nursing facilities shall employ and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant state and federal staffing requirements. The Department may require a facility to provide additional staff as set forth in Section 72501(g).

(b) Facilities licensed for 59 or fewer beds shall have at least one registered nurse or a licensed vocational nurse, awake and on duty, in the facility at all times, day and night.

(c) Facilities licensed for 60 to 99 beds shall have at least one registered nurse or licensed vocational nurse, awake and on duty, in the facility at all times, day and night, in addition to the director of nursing services. The director of nursing services shall not have charge nurse responsibilities.

(d) Facilities licensed for 100 or more beds shall have at least one registered nurse, awake and on duty, in the facility at all times, day and night, in addition to the director of nursing services. The director of nursing services shall not have charge nurse responsibilities.

(e) Nursing stations shall be staffed with nursing personnel when patients are housed in the nursing unit.

(f) Each facility shall employ sufficient nursing staff to provide a minimum of 3.2 nursing hours per patient day.

(1) Facilities which provide care for mentally disordered patients and in which licensed psychiatric technicians provide patient care shall meet the following standards:

 

(A) If patients are not certified for special treatment programs, facilities shall employ sufficient staff to provide a minimum of 3.2 nursing hours per patient day.

 

(B) For patients certified for special treatment programs, facilities shall employ sufficient staff to provide a minimum of 2.3 nursing hours per patient day for each patient certified to the special treatment program, exclusive of additional staff required to meet the staffing standards of the special treatment program.


(g) Only direct caregivers as defined in Section 72038 shall be included in the staff-to-patient ratios. The ratios shall be based on the anticipated individual patient needs for the activities of each shift and shall be distributed throughout the day to achieve a minimum of 3.2 nursing hours per patient day.

(1) Skilled nursing facilities shall employ and schedule additional staff to ensure patients receive nursing care based on their needs.

 

(2) The calculation of the staff-to-patient ratio shall be based on the daily census of patients in the skilled nursing facility and not the total number of beds. Bedholds shall not be included in the calculations of the staff-to-patient ratio. If the census changes during a 24 hour period, the calculation shall be based upon the highest number of patients in the facility during the period.

 

(3) Unless granted a waiver pursuant to subsection (j), facilities shall use the following ratios:

 

(A) On the day shift, the ratio shall be at least one direct caregiver for every 5 patients or fraction thereof;

 

(B) On the evening shift, the ratio shall be at least one direct caregiver for every 8 patients or fraction thereof; and,

 

(C) On the night shift, the ratio shall be at least one direct caregiver for every 13 patients or fraction thereof.

 

(D) There shall be one licensed nurse for every 8 or fewer patients, based on the facility census for the 24 hour period. These are not in addition to the requirements in subparagraphs (A) through (C) above, and may be assigned to shifts as required by the facility, subject to other statutory and regulatory requirements.

 

(4) "Day shift" refers to the 8-hour period during which a facility's patients require the greatest amount of care. "Evening shift" refers to the 8-hour period when the facility's patients require more than minimal care. "Night shift" refers to the 8-hour period during which a facility's patients require the least amount of care. A facility that uses other than 8-hour shifts for its direct caregivers shall seek a waiver under subsection (j) to continue that practice.

 

(5) A "shift" is defined as the working period of one direct caregiver, or the full time equivalent of one direct caregiver, who performs eight hours of nursing services, as defined in section 72038. Other than time spent on normal rest periods required by section 11020 of Title 8 of the California Code of Regulations, or in the in-service training at the facility required by section 71847, time not spent providing nursing services, such as that spent at meal periods, may not be included in calculating a shift. A facility that uses fractions of a shift to meet the ratios must ensure that the posting required by subsection (i) contains this information in a form that will enable all interested persons to verify that the required staffing is provided and the ratios are met.

 

(6) A citation for a class "AA", class "A" or class "B" violation may be issued for a violation of this section that meets the requirements specified in Section 1424 of the Health and Safety Code.


(h) The facility shall retain the staff assignment record that it employs to comply with subsection (i) for each shift, the licensing and/or certification status of the staff, and the patient census for each shift. Records documenting staffing, including staff assignment records and payroll records, shall be retained for a minimum of three years. Unless the request is made by Department staff who are present at the facility, in which case it must be provided immediately, documentation of staffing shall be provided to the Department within ten days of the Department's request for the documentation. If the facility is unable to provide the documentation requested by the Department, it shall cease admitting new patients until it demonstrates to the Department that it has the staff necessary to provide the care needed by the patients by submitting the requested documentation. The facility shall also comply with the provisions of Section 1429.1 of the Health and Safety Code.

(i) The facility shall post the patient census and staffing information daily. The posting shall include the actual number of licensed and certified nursing staff directly responsible for the care of patients for that particular day on each shift. The facility may use the form it currently uses to comply with the requirements of section 483.30 of title 42 of the Code of Federal Regulations, but, in addition to the information the federal regulation requires it to contain, it shall also designate the patient assignment by specifying each room and each bed to which each certified nurse assistant is assigned during his or her shift, and shall additionally specify the assignment of each licensed nurse and any other direct caregiver not assigned to a specific room or beds. This posting shall be publicly displayed in a clearly visible place.

(j) The facility may request a waiver for the staff-to-patient ratio in accordance with Section 1276.65 of the Health and Safety Code as long as the facility continues to meet the 3.2 nursing hours per patient day requirement.

(1) The facility shall submit a written request for a waiver with substantiating information to the Department. The facility shall request the waiver by using the program flexibility procedures specified in Section 72213, and the Department shall process the request as required by Section 1276 of the Health and Safety Code.

 

(2) The facility shall notify the Department if there has been a change in the substantiating information. A request for a waiver with substantiating information included shall be updated and resubmitted annually.


(k) Staffing for a distinct part intermediate care unit in a skilled nursing facility:

(1) Units of less than 50 intermediate care beds shall not be required to provide licensed personnel in addition to those provided in the skilled nursing facility unless the Department determines through a written evaluation that additional licensed personnel are necessary to protect the health and safety of patients.

 

(2) Units of 50 or more intermediate care beds shall provide a registered nurse or licensed vocational nurse employed 8 hours on the day shift, 7 days per week in the unit.

 

(3) For purposes of this section intermediate care beds that are licensed as such by the Department shall not be included for establishing licensed nurse staffing as required in subsection (f)(1) if the unit is used exclusively for intermediate care patients.


(l) Initial implementation of this section shall be contingent on an appropriation in the annual Budget Act or another statute, in accordance with Health and Safety Code Section 1276.65(i).

 

TITLE 22. SOCIAL SECURITY

DIVISION 5. LICENSING AND CERTIFICATION OF HEALTH FACILITIES, HOME HEALTH

AGENCIES, CLINICS, AND REFERRAL AGENCIES

CHAPTER 3. SKILLED NURSING FACILITIES

ARTICLE 3. REQUIRED SERVICES

This database is current through 1/29/10 Register 2010, No. 5

§ 72379. Activity Program -General.


An activity program means a program which is staffed and equipped to encourage the participation of each patient, to meet the needs and interests of each patient and to encourage self-care and resumption of normal activities.

 

TITLE 22. SOCIAL SECURITY

DIVISION 5. LICENSING AND CERTIFICATION OF HEALTH FACILITIES, HOME HEALTH

AGENCIES, CLINICS, AND REFERRAL AGENCIES

CHAPTER 3. SKILLED NURSING FACILITIES

ARTICLE 3. REQUIRED SERVICES

This database is current through 1/29/10 Register 2010, No. 5

§ 72381. Activity Program -Requirements.


(a) Patients shall be encouraged to participate in activities planned to meet their individual needs. An activity program shall have a written, planned schedule of social and other purposeful independent or group activities. The program shall be designed to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, to enable the patient to maintain the highest attainable social, physical and emotional functioning but not necessarily to correct or remedy a disability.

(b) The activity program shall consist of individual, small and large group activities which are designed to meet the needs and interests of each patient and which include, but are not limited to:

(1) Social activities.

 

(2) Indoor and out-of-doors activities, which may include supervised daily walks.

 

(3) Activities away from the facility.

 

(4) Religious programs.

 

(5) Opportunity for patient involvement for planning and implementation of the activity program.

 

(6) Creative activities.

 

(7) Educational activities.

 

(8) Exercise activities.


(c) Activities shall be available on a daily basis.

(d) The activity leader, at a minimum, shall:

(1) Develop, implement and supervise the activity program.

 

(2) Plan and conduct in-service training of the staff of the facility at least annually.

 

(3) Coordinate the activity schedule with other patient services.

 

(4) Maintain a current list of patients from the nursing service who are not physically able to participate in activities.

 

(5) Post the activity schedule conspicuously, in large visible print, for the information of patients and staff.

 

(6) Request and maintain equipment and supplies.

 

(7) Develop and maintain contacts with community agencies and organizations.

 

(8) Develop and implement activities for patients unable to leave their rooms.

 

(9) Maintain progress notes specific to the patient's activity plan which are recorded at least quarterly, and more frequently if needed, in the patient's health record.

 

(10) Maintain a current record of the type f frequency of activities provided and the names of patients participating in each activity.


(e) Where appropriate, the activity leader may recruit, train and supervise a volunteer program to assist with and augment the services of the activity program.

 

TITLE 22. SOCIAL SECURITY

DIVISION 5. LICENSING AND CERTIFICATION OF HEALTH FACILITIES, HOME HEALTH

AGENCIES, CLINICS, AND REFERRAL AGENCIES

CHAPTER 3. SKILLED NURSING FACILITIES

ARTICLE 3. REQUIRED SERVICES

This database is current through 1/29/10 Register 2010, No. 5

§ 72383. Activity Program -Activity Plan.


(a) An activity plan shall:

(1) Be developed and implemented for each patient and shall be integrated with the individual interdisciplinary patient care plan.

 

(2) Be reviewed quarterly and approved, in writing, by the attending physician as not in conflict with the treatment plan.

 

TITLE 22. SOCIAL SECURITY

DIVISION 5. LICENSING AND CERTIFICATION OF HEALTH FACILITIES, HOME HEALTH

AGENCIES, CLINICS, AND REFERRAL AGENCIES

CHAPTER 3. SKILLED NURSING FACILITIES

ARTICLE 3. REQUIRED SERVICES

This database is current through 1/29/10 Register 2010, No. 5

§ 72385. Activity Program -Staff.


(a) Activity program personnel with appropriate training and experience shall be available to meet the needs and interests of patients.

(b) An activity program leader shall be designated by and be responsible to the administration. An activity program leader shall meet one of the following requirements:

(1) Have two years of experience in a social or recreational program within the past five years, one year of which was full-time in a patient activities program in a health care setting.

 

(2) Be an occupational therapist, art therapist, music therapist, dance therapist, recreation therapist or occupational therapy assistant.

 

(3) Have satisfactorily completed at least 36 hours of training in a course designed specifically for this position and approved by the Department and shall receive regular consultation from an occupational therapist, occupational therapy assistant or recreation therapist who has at least one year of experience in a health care setting.

 

 


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