Neb. Admin. Code tit. 175 — Health Care Facilities and Services Licensure

Chapter 1 General Facility and Services Regulations

Neb. Admin. Code tit. 175, ch. 1 General Facility and Services Regulations {#sec-175-nac-1 omnilex-key=us-ne-regs-official--title-175--175 NAC 1}

TITLE 175 HEALTH CARE FACILITIES AND SERVICES LICENSURE

CHAPTER 1 GENERAL FACILITY AND SERVICES REGULATIONS

001. SCOPE AND AUTHORITY. These regulations govern credentials issued to health care facilities and health care services set out in Nebraska Revised Statute (Neb. Rev. Stat.) §§ 71-401 to 71-479, except for assisted-living facilities and pharmacies.

002. DEFINITIONS. The definitions in the Nebraska Health Care Facility Licensure Act and the following are adopted for this title.

002.01 ADJOINING. Areas located in a manner to allow access without having to enter a general corridor area or area used by other consumers are adjoining.

002.02 ADMINISTRATOR. The operating officer for the facility or service which may include individuals with titles such as administrator, chief executive officer, manager, director, or other similar designation is an administrator.

002.03 BED CAPACITY. The total number of licensed beds in a facility or service for use by the consumer excluding beds intended for ancillary usage.

002.04 BIOLOGICAL. Any virus, therapeutic serum, toxin, antitoxin, or product used for the prevention, treatment or cure of disease or injuries to humans.

002.05 BY LAWS. A set of rules adopted by the facility or service used to govern the facility or service’s operation.

002.06 CARDIOPULMONARY RESUSCITATION (CPR). A procedure to restore breathing and heart function through clearance of air passages, artificial respiration, and manual external cardiac massage.

002.07 CARE PLAN. A written plan based on an individual assessment identifying the needs of the consumer and the strategy for meeting those needs. These may also be referred to as treatment plans.

002.08 COMPLAINT. An expression of a concern or dissatisfaction.

002.09 COMPLETE APPLICATION. An initial application or renewal application which contains all of the requested information, with attestation to its truth and completeness, signatures of the applicant(s), submitted with all required fees and documentation.

002.10 CONSUMER. Consumer has the same definition as defined in Neb. Rev. Stat. § 38-111.

002.11 DEHYDRATION. A lack of sufficient water in the body of a consumer.

002.12 DESIGNEE. A person authorized by law or the consumer to act on the consumer’s behalf.

002.13 DIAGNOSIS. The act or process of identifying or determining the nature of a disease or injury.

002.14 EXISTING FACILITY OR SERVICE. A facility or service with a current license or whose construction was approved by the Department prior to the effective date of this chapter.

002.15 FOREIGN CORPORATION. A corporation created by authority outside the state of Nebraska.

002.16 GOVERNING AUTHORITY. The person or persons that control the facility or service license on behalf of the licensee.

002.17 GRIEVANCE. A written expression of dissatisfaction is a grievance.

002.18 HEMODIALYSIS. The mechanical process of removing unwanted waste and fluid from the blood in consumers whose kidneys no longer perform this function.

002.19 INDELIBLE. Documentation that cannot be erased.

002.20 LICENSED CAPACITY. The total number of consumers the facility or service is licensed to serve at one time.

002.21 LICENSEE. The person or entity to whom the Department has issued a license.

002.22 MEDICAL PRACTITIONER. A person credentialed under the Uniform Credentialing Act whose scope of practice includes prescribing medications, diagnosing, and treating is a medical practitioner. For the purpose of this chapter, this includes: physician, physician assistant, advanced practice registered nurse, optometrist, podiatrist, dentist, certified nurse midwife and certified registered nurse anesthetist.

002.23 MEDICAL SERVICES. Address the medical concerns, health concerns or needs of the consumer.

002.24 MEDICALLY RELATED SOCIAL SERVICES. Assist the consumer to maintain or improve the ability to manage everyday physical, mental, and psychosocial needs.

002.25 NEBRASKA FOOD CODE. Nebraska Food Code has the same definition as set out in Neb. Rev. Stat. § 81-2,244.01.

002.26 NEW CONSTRUCTION. Changes to the structure of a facility or part of a facility which is enlarged, altered, or built from the ground up. New construction does not include remodeling.

002.27 NEW FACILITY OR SERVICE. A facility or service not currently licensed or a new service to be provided by the licensee at an already licensed facility or service.

002.28 PARENT. The legal parent or stepparent who is legally responsible for a consumer under the age of 19 years.

002.29 PREMISES. The structure which houses the facility or service, the grounds, and each building where care and treatment is provided to the consumer.

002.30 RANGE OF MOTION. The degree of motion a joint can be moved.

002.31 QUALIFIED DIETICIAN. A registered dietician or a licensed medical nutrition therapist.

002.32 QUALIFIED INSPECTOR. A Nebraska licensed architect or engineer, an official or employee of a local jurisdiction or a person authorized by a local jurisdiction to make inspections of a building, part of a building, equipment, or systems.

002.33 REMODELING. The repair or replacement of existing items which does not affect the physical structure of the building and does not require moving electrical wiring, plumbing, gas, heating, or cooling systems.

002.34 RESTRAINT.

(A) Chemical restraint. A drug that is used to manage behavior of a consumer, which restricts freedom of movement and is not a standard treatment for the consumer’s medical or psychiatric condition.

(B) Mechanical or physical restraint. A device attached or adjacent to the consumer’s body which the consumer cannot remove that restricts freedom of movement or normal access to the body.

(C) Personal restraint. The use of physical force for the purpose of restraining free movement of a consumer which does not include briefly holding the consumer in order to calm or comfort them or holding the hand of the consumer to escort them from one area to another.

002.35 SCHEMATIC PLAN. A basic diagram of the facility.

002.36 SCREENING TOOL. A simple interview or testing procedure to collect basic information regarding the consumer’s health status.

002.37 SECLUSION. The involuntary confinement of the consumer in a room or area which prevents the consumer from freely moving about the facility or interacting with others and is used for other than therapeutic purposes. Seclusion is only allowed in mental health substance use treatment facilities and hospitals when it is ordered by a medical practitioner to ensure the safety of the consumer or others.

002.38 SIGNIFICANT CHANGE. A major change in the consumer’s status that is not self-limiting and impacts more than one area of their health or status.

002.39 SIGNIFICANT MEDICATION ERROR. A medication error that has the potential to or jeopardizes the health and safety of the consumer.

002.40 SKIN INTEGRITY. The skin condition of the consumer.

002.41 SUBSTANCE USE DISORDER. A condition in which the use of one or more substances leads to a clinically significant impairment and which may have negative social consequences for the consumer.

002.42 THERAPEUTIC DIET. A diet that is provided to the consumer to treat a medical diagnosis.

002.43 TIME OUT ROOM. A room where the consumer is placed under staff observation when they engage in specified inappropriate behaviors.

002.44 UNCREDENTIALED DIRECT CARE STAFF. Personnel who are not credentialed under the Uniform Credentialing Act or other state laws governing the practice of health care and whose primary responsibility is to provide direct care to the consumer.

002.45 VERMIN. Small animals and insects that can be harmful, may transmit diseases or are difficult to control.

002.46 VOLUNTEER. An unpaid individual who performs duties at the facility or service.

003. LICENSING REQUIREMENTS. For all applications for initial licensure, renewal and reinstatement, an applicant or licensee must submit documentation that the applicant or licensee meets the requirements set out in the Neb. Rev. Stat. §§ 4-108 through 4-111. No applicant or licensee may initiate construction of a facility or service prior to obtaining written approval from the Department to begin the construction process and may not utilize a facility or service for the consumer prior to obtaining written approval from the Department after the conclusion of the construction process and obtaining any required license.

003.01 INITIAL LICENSE. Applicants must submit a complete application provided by the Department, meet all requirements of the statutes, of this chapter, and the chapter in 175 Nebraska Administrative Code (NAC) for the type of license being requested. An applicant for an initial facility or service license must comply with all applicable codes, guidelines, and standards specified in regulations pertaining to each specific individual facility or service type.

003.02 INITIAL APPLICATION REQUIREMENTS AND DOCUMENTATION. The applicant must submit:

(A) Schematic plans;

(B) Documentation approving occupancy and operation issued by the State Fire Marshal or the State Fire Marshal’s delegated authority;

(C) Current proof of registration and status with the Nebraska Secretary of State Office if operated by a foreign corporate entity;

(D) Current zoning permit; and

(E) For facilities or services completing construction only:

(i) Architect or engineer certification and a detailed project description; and

(ii) A completion certificate; or

(F) For facilities or services having no construction or structural changes:

(i) Operational permit issued by the local building authority; or

(ii) Signed and dated statement that the building is structurally safe for use and occupancy from a Nebraska licensed architect or engineer.

003.03 RENEWAL LICENSE. To renew a license, a license holder must, prior to the expiration date, submit a complete application for renewal, and the following:

(A) Documentation as set out in 175 NAC 1-003.02 for initial licensure in this chapter, except for 003.02(A), (C), (D), (E), and (F); and

(B) Any specific documentation in the chapter in 175 NAC applicable to the specific facility or service type.

003.04 REINSTATEMENT FROM EXPIRED STATUS. A licensee can request reinstatement of an expired license within 90 days of the expiration date. A letter must be submitted to the Department requesting reinstatement which contains all of the information requested in an application for an initial license, and the chapter in 175 NAC pertaining to the specific facility or service type, and any required fee. The facility or service may not operate during this time.

004. INSPECTIONS. To determine compliance with operational care, treatment and physical plant standards, the Department inspects the facility or service prior to and following licensure.

004.01 INITIAL INSPECTION. An announced initial onsite inspection will be conducted after receipt of a completed application for an initial license.

004.02 COMPLIANCE INSPECTION. An unannounced inspection may be conducted of the facility or service anytime the Department deems necessary, including, the passage of 5 years without an inspection.

005. GENERAL REQUIREMENTS. These requirements pertain to all applicants and licensees governed by Neb. Rev. Stat. §§ 71-401 to 71-479.

005.01 NOTIFICATIONS. An applicant or licensee must notify the Department electronically, in writing, or via facsimile of the following:

(A) At least 30 calendar days before a facility or service is sold, leased, discontinued, or moved to a new location;

(B) A change in the use, location of beds, or both;

(i) Increase the number of beds for which the facility or service is currently licensed;

(ii) Change the usage of beds or rooms; or

(iii) Change the type of services provided;

(D) To request a single license document;

(E) To request simultaneous facility or service licensure inspections for all types of licensure held or sought;

(F) Prior to the start of the construction process if a facility is having construction done; and

(G) Within 24 hours of the following:

(i) When the licensee has reason to believe abuse, neglect or exploitation of a consumer has occurred;

(ii) When the death of a consumer at the facility or service occurred due to:

(1) Suicide;

(2) A violent act;

(3) Drowning; or

(4) The use of restraint or seclusion; and

(iii) When a consumer who needs supervision, leaves a facility or service without staff knowledge;

(iv) A fire in the facility or service; or

(v) Any natural disaster or accident resulting in damage to the physical plant which has a direct or immediate effect on a consumer in the facility or service. Notification must include the steps included to assure the consumer’s safety.

005.02 CAPACITY AND USAGE. The licensee must ensure:

(A) When providing beds for the consumer, the licensee must not utilize more beds than are licensed and approved by the Department and must not exceed the maximum occupancy approval of the State Fire Marshal or their delegated authority; and

(B) The total number of consumers receiving care, treatment, or services at one time from the facility or service must not exceed the licensed capacity approved by the Department and must not exceed the maximum occupancy approval of the State Fire Marshal or their delegated authority.

005.03 PUBLIC INFORMATION. The licensee must make licenses, the most recent inspection reports, and any disciplinary action notices that are currently in effect, if any, available for public inspection upon request. All facility or service licenses must be displayed on the licensed premises.

005.04 COMPLAINTS AND GRIEVANCES. A licensee must establish, implement, and revise as necessary, written policies and procedures to promptly address complaints or grievances filed verbally or in writing. The policies and procedures must include:

(A) Information regarding how the consumer or designee may submit a complaint or grievance;

(B) Timeframes for investigative review and for a response to the consumer or designee;

(C) How the licensee will utilize information from complaints and grievances to improve the quality of care and treatment provided; and

(D) How the licensee will maintain records of complaints and grievances received, actions taken and resolution.

005.05 QUALITY ASSURANCE AND IMPROVEMENT. The licensee must have a quality assurance and improvement program to collect data and assess care and treatment provided to the consumer, both concurrently and retrospectively. The program must include involvement by all disciplines. Results must be recorded quarterly and reported to the licensee’s governing authority or licensee annually. The program must address:

(A) Goals and objectives;

(B) How problems or issues to be addressed will be identified;

(D) How recommendations will be implemented;

(E) How changes made will be monitored for effectiveness;

(F) A plan to review and revise actions, policies, and recommendations as necessary; and

(G) Identification, by job title, of the person responsible for the effectiveness of the program.

005.06 INFECTION CONTROL. The licensee must have an infection control program to minimize sources and transmissions of infections and communicable diseases. The program must address:

(A) How the licensee will identify, report, investigate and control infections;

(B) How trends will be tracked and identified;

(C) How treatment of any infections or communicable diseases will be monitored for appropriateness and for alteration of treatment when necessary;

(D) Hand hygiene techniques and how the licensee will ensure compliance;

(E) Use of safe work practices and personal protective equipment;

(F) Handling, cleaning, and disinfection of equipment, supplies and linens used to provide care and treatment to the consumer;

(G) How the licensee will educate staff, volunteers, and the consumer regarding infections, modes of transmission, hygienic practices, and methods of infection prevention; and

(H) Identification of the person, by job title, who is responsible for the effectiveness of the overall program.

005.07 DISASTER PREPAREDNESS AND MANAGEMENT. The licensee must have a disaster preparedness program to ensure the safety, well-being and continuity of care and treatment for the consumer, visitors, and staff during natural or other disasters, disease outbreaks, or other similar situations. The program must address:

(A) How consumer identification will be maintained;

(B) How communication will be maintained;

(D) How consumers, staff and visitors will be protected from the threat of exposure, ingestion, absorption, or inhalation of hazardous substances or materials;

(E) How food, water, medicine, medical supplies, and other necessary items will continue to be provided to the consumer, staff, and visitors;

(F) How the consumer will be provided with necessary care and treatment; and

(G) How the facility will educate staff, visitors and consumers on the disaster preparedness plans.

005.08 COMMUNICATION. Each licensee must implement interventions to ensure communication with consumers or their designee occurs in a manner and format the consumer or designee can understand.

006. CONSTRUCTION. The applicant or licensee is responsible to ensure that the facility or service is designed, constructed, and maintained in a manner that is safe and functional for the care and treatment provided. The applicant or licensee must comply with all current applicable Building, Plumbing, Electrical, Elevator, Boiler, Energy, Food, and Accessibility statutory codes and standards, and all new construction must be designed in accordance with the requirements in Neb. Rev. Stat. § 71-439 for the type of facility or service being designed. The applicant or licensee must:

(A) Ensure the facility or service is designed and completed in accordance with the Nebraska Architect and Engineers Act;

(B) Submit the following to the Department, prior to the start of construction:

(i) Project description documentation including the purpose and use of the area, street address, contact persons and anticipated completion date;

(ii) Construction risk assessment (if the construction will take place in an area currently occupied or used by the consumer) outlining and identifying the plan to ensure the area is safe for the consumer during the construction process;

(iii) Certification from a Nebraska licensed architect or engineer that the schematic plans, construction plans and any revisions thereof meet the regulatory requirements for that specific facility or service type; and

(iv) Completion certificate containing the following:

(1) Name, signature and license number of a Nebraska licensed architect or engineer;

(2) Name and address of the facility or service;

(3) Documentation of an inspection completed by qualified inspectors having jurisdiction;

(4) Occupancy approval by the State Fire Marshal’s office or delegated authority; and

(5) Bed Capacity Worksheet, if applicable to the type of facility or service.

006.01 CONSTRUCTION WAIVER. A waiver of any physical plant requirement, other than those set by statute, may be requested, in writing, by the applicant or licensee pursuant to Neb. Rev. Stat. § 71-439.

006.02 WAIVER TERMS AND CONDITIONS. A construction waiver may be granted under the terms and conditions and for such period of time as are applicable and appropriate to the waiver. The terms, conditions and period of waiver may include but are not limited to:

(A) Waivers that are granted to meet the special needs of a patient remain in effect as long as required by the patient; or

(B) A limited period of time as determined by the Department.

006.03 APPLICATION. An applicant or licensee must submit a request for waiver of any construction or physical plant requirements set forth in 175 NAC on a form provided by the Department.

007. PHYSICAL PLANT. A licensee must maintain the facility or service it operates in a manner that is safe, clean, and functional for the type of care and treatment provided to the consumer.

007.01 SHARING SPACE. A licensee may share physical space with another licensed or unlicensed entity when:

(A) Spaces are clearly identified so the consumer or his or her designee is aware of the specific licensed facility or service where they are receiving care and treatment;

(B) Current medical records are clearly separated and not shared by the other entities;

(C) Staffing and administration is clearly separated and not shared by the other entities. An individual cannot be on duty in both entities at the same time; and

(D) The facilities or services are not sharing the same space for care and treatment for the consumer at the same time.

008. RECORDKEEPING. The licensee must maintain complete and accurate records which document the operation of the facility or service and the care and treatment provided to the consumer. Records may be created and maintained in written or electronic format, or a combination of both. Records must:

(A) Contain dated, legible, and indelible entries;

(B) Ensure entries are dated, timed, and signed by the author;

(D) Be transferred to another facility or service, if the consumer is transferred, to assure continuity of care;

(E) Contain the following:

(i) Identification data, including name, date of birth, gender;

(ii) Physical description of the consumer and or a photograph;

(iii) A signed Service Agreement or Consent to Treatment;

(iv) Allergies;

(v) Plan of care and treatment;

(vi) Advanced directives, if available;

(vii) Dates of admission and discharge, including transfer information and a discharge summary, as applicable;

(viii) Medical practitioner’s orders, when applicable;

(ix) Name and contact information of the medical practitioner;

(x) Emergency contact information;

(xi) An assessment to determine the mental, physical, and psychological ability of the consumer to protect themselves from injury;

(xii) Documentation of all diagnoses, care and treatment provided, and the results or response; and

(xiii) Documentation of education of rights for the consumer.

008.01 CONFIDENTIALITY. Records must be kept confidential and available only for use by authorized persons or as otherwise permitted by law. Records must be available for copying and examination by an authorized representative of the Department.

008.02 ACCESS TO RECORDS. Records will be released only with the consent of the consumer or their designee or as required by law.

008.03 RETENTION AND PRESERVATION. All records for the consumer must be preserved in original, microfilm, electronic, or other similar form. The licensee must retain these records for a minimum of 7 years beginning with each service date, protect the confidentiality of all information contained, regardless of the form or storage method of the records; and safeguard the records against loss, destruction, or unauthorized use.

008.04 DESTRUCTION. When a consumer record is destroyed, such destruction must be by shredding, incineration, electronic deletion, or by other similar protective measures in order to preserve the confidentiality of the information in the record. Documentation of record destruction must be maintained permanently.

008.05 DISCONTINUATION OF OPERATIONS. When a licensee discontinues operation of a facility or service the licensee must transfer consumer records to the facility or service chosen by the consumer or designee. All records that are not transferred per the consumer or designee, which have not reached the time permitted for destruction of the record, must be stored to assure confidentiality, and the Department must be notified in writing, via email or facsimile, of the address where these records are stored prior to the close of business.

009. ENVIRONMENTAL SERVICES. Every building or space utilized for the care and treatment of the consumer must comply with the following:

009.01 HOUSEKEEPING. Housekeeping services to protect the health and safety of the consumer in accordance with acceptable standards of practice and manufacturer’s instructions must be provided, including the following:

(A) Spaces must be constructed utilizing smooth, washable materials and maintained in a clean condition. Abrasive surfaces may be used to reduce or prevent accidents where wet or slippery surfaces present a hazard;

(B) Equipment, fixtures, furniture, and furnishings, including windows, draperies, curtains, flooring, and carpeting must be kept clean and free of contaminants;

(C) All garbage must be disposed of to prevent the attraction of vermin, to minimize odors and the potential transmission of diseases;

(D) Cleaning equipment and supplies must be available; and

(E) Hazardous materials must be secured to prevent accidental or intentional ingestion, inhalation, or consumption by the consumer.

009.02 MAINTENANCE. All parts of a facility or service, and all equipment, fixtures and furnishings are to be maintained in good working order and meet the following standards:

(A) Surfaces must be smooth, free of sharp edges, splinters, or potential safety risks;

(B) Doors, stairways, passageways, aisles, and other means of exit must be maintained to prevent hazards which might pose a potential safety risk;

(C) Routine and preventative maintenance must be performed in accordance with manufacturer’s instructions and documentation of maintenance must be maintained;

(D) Sound and lighting levels must be conducive to the care and treatment provided;

(E) Maintenance equipment and supplies must be available; and

(F) Hazardous materials must be secured to prevent accidental or intentional ingestion, inhalation, or consumption by the consumer.

009.03 ANIMALS. Any animal at a facility or service, whether owned by the facility, a consumer, or a visitor, must not jeopardize consumer health and safety. A licensee that allows animals to be on the premises must implement written policies and procedures to ensure:

(A) Animals are examined annually and have received all vaccinations, as recommended by a licensed veterinarian annually;

(B) Provisions have been implemented to prevent the presence and spread of fleas, ticks, and other parasites;

(C) Animals are prohibited from being in food preparation, storage, or serving areas during food preparation and serving times, with the exception of service animals;

(D) Identification of a staff person, identified by job title, who is designated to be responsible for care and supervision of a facility owned animal while the animal is at the facility or service and designated to oversee a non-facility owned animal while the animal is at the facility or service;

(E) Compliance with state, local, or other ordinances regarding animals or specific breeds identified by those laws or ordinances; and

(F) Any animal that has bitten or attacked any person without provocation or has been determined by the local health authority to be dangerous is not allowed in the facility or used by the service.

009.04 OTHER SAFETY MEASURES. The licensee must ensure a facility or service maintains the environment in a manner to minimize accidents and to promote safety. This includes:

(A) Restricting access to mechanical equipment which may pose a danger to the consumer;

(B)Safety outlets must be installed and used for a facility or service that provides care or treatment to consumers under the age of 6; and

(C)Providing water for bathing and hand hygiene at safe temperatures to accommodate the comfort and preferences of the consumer and to prevent the potential of thermal injury.

(i) Water temperatures must not exceed:

(1) 110 degrees Fahrenheit at bathing and therapy fixtures; and

(2) 120 degrees Fahrenheit at hand washing fixtures.

009.05 SWIMMING POOLS, THERAPY POOLS AND HOT TUBS. When provided, a licensee must ensure safe operation in accordance with current standards of practice, state, and federal law, including:

(A) Designation of a staff member pool operator responsible to oversee operation and maintenance;

(B) Supervision requirements;

(D) Method of summoning assistance in the event of an emergency;

(E) Methods to reduce the potential transmission of disease; and

(F) Maintaining documentation of daily and weekly water quality and water temperature checks.

History

Effective 2025-01-20

Chapter 3 Regulations Governing Centers for the Developmentally Disabled

Neb. Admin. Code tit. 175, ch. 3 Regulations Governing Centers for the Developmentally Disabled {#sec-175-nac-3 omnilex-key=us-ne-regs-official--title-175--175 NAC 3}

001. SCOPE AND AUTHORITY . These regulations govern the licensing of Centers for the Developmentally Disabled facilities under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479.

002. DEFINITIONS . Definitions set in the Health Care Facility Licensure Act, 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.

002.01 GROUP RESIDENCE. Any group of rooms located within a building or structure forming a habitable unit with living, sleeping, cooking, and eating facilities for four (4) or more, developmentally disabled persons, operated by the same or identical lessee, owner, or management is a group residence.

002.02 AMBULATORY. The ability to walk without assistance is ambulatory.

002.03 BARRIER. A circumstance or obstacle that prevents a client from making progress toward their goals is a barrier.

002.04 HABILITATION. A process aimed at helping disabled people attain, keep, or improve skills and functioning for daily living is habilitation.

002.05 NON-AMBULATORY. Inability to walk without assistance is non-ambulatory.

002.06 USABLE FLOOR AREA. The floor area in a room exclusive of space used for entrance, vestibules, closets, toilet areas, and bathing areas is usable floor area.

003. LICENSING . To receive a license, an applicant must submit a complete application and meet the requirements for a license set out in the Health Care Facility Licensure Act, 175 NAC 1, and this chapter.

004. GENERAL REQUIREMENTS . The following requirements are applicable to all licenses.

004.01 EFFECTIVE DATES AND TERM OF LICENSE. The license of a Center for the Developmentally Disabled expires annually on November 30.

004.02 INITIAL LICENSURE AND RENEWAL FEES. Initial licensure and renewal fees for Centers for the Developmentally Disabled are $150.

005. INSPECTIONS . Requirements for inspections are set out in 175 NAC 1.

006. PHYSICAL PLANT STANDARDS . Each building where services are provided must be maintained by licensee in a manner that is safe, clean, and functional for the clients who reside there.

006.01 CLIENT BEDROOMS. Single bedrooms for ambulatory clients must provide at least 80 square feet of usable floor area with a side dimension of not less than 7 feet - 0 inches. All client bedrooms must have windows which provide an unobstructed view of not less than 15 feet - 0 inches in at least 1 horizontal direction.

006.02 MULTI-BEDROOMS. Ambulatory clients must be provided at least 60 square feet of usable floor space for each client. There must be at least 3 feet - 0 inches between beds placed side-to-side and not less than 3 feet - 0 inches between the heads of the beds. The amount of usable floor space in a client bedroom is determined after taking adjustments into account as stated in this chapter. A bedroom must have no more than 4 beds.

006.03 WINDOWS. Bedrooms must be exterior rooms with at least 1 window which is easily opened to the outside. The minimum total area of the window or windows measured between stops -- clear width when opened, must be at least 10 percent of the usable floor area. All windows must be provided with screens which are maintained in good repair. Combination storm window screens are acceptable. Full length storm windows may be used during the winter months. Windowsills must not be more than 36 inches above the finished floor. All exterior windows and doors must have serviceable screens except for doors with panic hardware.

006.04 CLOSETS. There must be accessible private and adequate storage space for clothing and personal belongings in the bedroom area for each client. Built-in closets or wardrobes with doors or curtains are acceptable.

006.05 CEILING HEIGHTS. Level ceilings in sleeping rooms must not be less than 7 feet - 0 inches high. In sleeping rooms with sloped ceilings, only the areas with vertical wall heights of 5 feet or more must be included in the required usable floor area. At least half of the usable floor space must have a ceiling not less than 7 feet -0 inches.

006.06 PARTITIONS. Partitions defining each bedroom must run from floor to ceiling.

006.07 CLIENT BEDROOMS. All client bedrooms must be located at or above natural grade level. Non-ambulatory clients must not be housed in bedrooms located above the first floor level.

006.08 DOORS. Doors in a building may be lockable by the occupant if they can be unlocked by a master key from the opposite side. Master keys are to be carried by staff at all times.

006.08(A) INTERIOR DOORS. Excluding time out room doors, interior doors must not have vision panels.

006.08(B) DOOR LOCKS. Door locks installed on sleeping room doors must be lockable from the corridor side only, except where such doors open directly to the outside of the building. Sleeping room doors leading directly to the outside of the building may be lockable on the room side. All locks must permit exit from a room by a simple operation without the use of a key.

006.08(C) DOOR WIDTHS. Door widths must not be less than 3 feet wide to allow a minimum clear opening of 32 inches in the fully opened position.

006.08(D) DOOR ALARMS. Door alarms must be provided for exterior doors when clients requiring such supervision is established by the Individual Program Plan.

006.09 CORRIDORS. Corridor widths must not be less than 3 feet - 0 inches.

006.10 BEDS. Each client must have an individual bed. Adult beds must be at least 36 inches wide. Adult size beds must be provided for individuals 14 years of age and older. Each bed must have a clean, firm, comfortable mattress. Beds must be of suitable construction and dimensions to accommodate persons using them. Bunk beds, roll-aways and trundles are not permitted.

006.10(A) BEDDING. All beds provided for clients must be supplied with suitable pillowcases and bottom and top sheets. All bedding, including mattresses, mattress pads, quilts, blankets, pillows, sheets, spreads, and all bath linen must be kept clean. Bedding, including mattresses, mattress pads, quilts, blankets, pillows, and bed and bath linen which is worn out or unfit for further use must not be used. Bedding must be appropriate to the season. Pillowcases, sheets, and bath linen, after being used by one client, must be washed before they are used by other clients.

006.10(B) BED LINEN. Clean bed linen must be furnished at least once each week, or more frequently, to maintain cleanliness and a clean washcloth, towel or appropriate paper service must be available to each client.

006.11 ROOM FURNISHINGS. All equipment, fixtures, furniture, and furnishings, including windows, draperies, curtains, and carpets must be kept clean and free of dust, dirt, vermin, and other contaminants and must be maintained in good order and repair. Each client must be provided with appropriate individual furniture, including at a minimum a chest of drawers, an individual wardrobe with clothes racks and shelves unless built-in closet space is provided, and a mirror, and at least one chair per bedroom will be provided. Tilted mirrors or mirrors located at a height for wheelchair use must be provided for clients where appropriate. There must be accessible private storage space for clothing in the bedroom area for each client. Each client must have individual racks or other drying space for washcloths and towels.

006.12 TOILETS AND BATHING FACILITIES. Toilet and bathing areas and fixtures must approximate normal patterns found in residential construction and must meet the following requirements:

(A) If there are wheelchair clients in the home, the toilet and bath areas must be large enough for wheelchair use and also to include appropriate fixtures and appurtenances for the wheelchair clients’ use; (B) Shower curbs must be omitted to permit access by wheelchairs. An accessible restroom shall provide at least the following fixtures and appurtenances for the wheelchair clients’ use; (C) No bathroom must open directly into a food preparation area; (D) Toilets must provide bar soap or a soap dispenser to be located no higher than 48 inches from the floor; (E) All toilet and bathing area facilities and fixtures must be kept clean and in good repair; (F) Each bathroom and toilet area must be well-lighted with a mirror over each lavatory; and (G) Wherever there is a bathroom, there must be an easily accessible toilet.

006.13 BATHROOMS. Client bathrooms must be provided as follows:

(A) One sink and one toilet for each 6 clients; (B) One sink when mounted, allows 29 inches clearance from the floor to the bottom of the apron and a maximum rim height of 34 inches; (C) One toilet with the seat 15 inches to 20 inches from the floor, or 13 inches to 15 inches for children; (D) Grab bars near each side or one side attached and the back of the toilet stool securely attached 32 inches to 34 inches above the parallel to the floor. Grab bars at the side must not be less than 24 inches in front of the toilet. Grab bars must have an outside diameter of not less than 1 1/2 inches and must provide a clearance of 1 1/2 inches between grab bars and adjacent surface. For children's restrooms grab bars must be securely attached 15 inches above the floor and be positioned to extend 16 inches beyond the toilet seat; and (E) Toilet tissue must be provided within reach of the toilet seat and at a height of no more than 48 inches from the floor.

006.14 BATHING FACILITIES. Bathing facilities must be provided as follows:

(A) One bathing facility (tub or shower) for each eight clients; (B) Bathtubs and showers must be provided with stable grab bars to assist clients; and (C) Towels or warm air hand dryers must be provided with the operating mechanism no higher than 48 inches from the floor and not mounted directly above the sinks.

006.15 DINING AND RECREATION. All facilities must have minimum areas for clients’ dining and recreation which must be at least 10 and 20 square feet respectively per client, or 30 square feet total per client when the area is used for a combination thereof. Space for non-ambulatory mobile clients must be increased by 50 percent. Under no circumstances must the combined recreation and dining space be less than 150 square feet. In residential units that have 8 beds or less, space in the kitchen may be used for dining if the kitchen was laid out to accommodate table space for eating purposes; the space must be located apart from the food preparation area, and 10 square feet per client must be allocated for dining purposes. Furnishings in the dining recreation room must include a couch, chair(s), end tables, dining table and chairs or similar furniture to provide a comfortable setting.

006.16 FOOD SERVICE. The kitchen may be residential in nature in both layout and equipment.

006.17 DISHWASHING. Utilizing an automatic dishwasher or a three compartment sink is adequate if it meets the following requirements:

(A) When automatic dishwashers are used, the final rinse cycle temperature must not be less than 150 degrees Fahrenheit; and (B) For chemical sanitization of dishes in a three compartment sink, the following procedure is followed:

(i) Immersion for a minimum of one minute in sanitizing solution containing: at least 50 parts per million of available chlorine in water at a temperature not less than 75 degrees Fahrenheit (one-half tablespoon of laundry bleach or similar product containing 5 1/4 percent of available chlorine to each gallon of water provides minimum concentration; (ii) Use another commercial chemical sanitizer which has the equivalent bacterial effect at this level of chlorine. The quantity required will need to be determined on an individual basis. For some, quantity will depend on the hardness or mineral content of the local water supply; or (iii) At least a 2-compartment sink must be available in each kitchen. It is recommended that, when made up, the strength of sanitizing solutions be at least twice the minimum strength required for the particular sanitizing solution used. One tablespoon of laundry bleach or other solution containing 5 1/4 percent available chlorine to each gallon of water provides 100 parts per million.

006.18 FOOD STORAGE. Dry or staple foods must be stored at least 4-6 inches above the floor in a ventilated room not subject to sewage or wastewater backflow, contamination leakage, water overflow, rodents, or vermin. This requirement does not preclude the use of dry or staple food stored in cabinets in the kitchen if these requirements are met.

006.19 HANDWASHING. There must be a conveniently located handwashing facility in the kitchen.

006.20 COUNTER SPACE. There is cleanable work counter space for the preparation of meals. Formica, vinyl, or resilient type work counter coverings which are free of crevices or cracks are permitted.

006.21 REFRIGERATION. Refrigerators are provided for perishable foods and are kept clean and in good working order and maintain refrigerated foods at from 33 degrees Fahrenheit to 45 degrees Fahrenheit.

006.22 ADMINISTRATION. A room must be provided for the house manager or house parents. If the house manager or family live in the facility, their numbers must be counted in determining the number of toilets and baths, and space allocated for dining and recreation, unless a separate apartment is provided.

006.23 OUTSIDE RECREATION AREA. The lot must be large enough for an outside recreation area commensurable with the number and type of clients in order to effectively promote normalization. In areas where public recreation is not available within one city block of the block where the facility is located, at least 25 square feet of outdoor recreation area per client must be provided.

006.24 GENERAL STORAGE. General storage in addition to linen closets and clients’ room closets must be provided at the ratio of 60 cubic feet per bed.

006.25 VENTILATION. If areas used as kitchens, bathrooms, toilet areas, or laundries are located in rooms without windows, or windows that cannot be opened to the outside air, these areas must be provided with mechanical ventilation with vents leading directly to the outside. If these areas have windows that can be opened to the outside air, mechanical ventilation is not required.

006.26 PLUMBING. Hot and cold water must be piped to all fixtures in the building except cold water shall be piped to the toilet. Hot water at fixtures used by clients for bathing and sinks must at a minimum be 110 degrees Fahrenheit and must not exceed 115 degrees Fahrenheit. In order to prevent a hazard to the clients, mixing valves must be utilized in cases where a client’s Individual Program Plan specifies training in temperature adjustment. Water temperature may not exceed 115 degrees Fahrenheit.

006.27 HEATING AND COOLING. The building must be equipped with a heating system and have a radiator, convertor, or register in each room used by clients that does not constitute a burn hazard. The heating system must be capable of maintaining a temperature of 70-75 degrees Fahrenheit during severe cold weather conditions at an elevation of 30 inches above the floor in all areas used by clients. For all facilities a cooling system is required which is capable of maintaining an indoor temperature of a range from 68 degrees Fahrenheit to 78 degrees Fahrenheit during hot weather conditions at an elevation of 30 inches above the floor in all areas used by clients. Indoor relative humidity must be maintained within the 30-70% range throughout the year. If hot water or steam radiators are used, they must be provided with covers to prevent inadvertent burns.

006.27(A) MECHANICAL ROOMS. Mechanical equipment rooms housing gas-fired heating and hot water equipment must have positive outside combustion air supplied for the equipment.

006.27(B) HEATING APPLIANCES. Every gas-fired or oil-fired heating appliance and hot water and other heating appliance must be vented to the outside air.

006.28 ARTIFICIAL LIGHTING. Each room or area, including storerooms must be provided with light fixtures to provide the following minimum foot candles or lumen per square foot rating at an elevation of 30 inches above the floor. Extension cords and temporary outlets are prohibited. Bare, incandescent bulbs are prohibited in client areas.

006.29 LAUNDRY. Laundry services or facilities for clients must be provided in accordance with the developmental needs of the clients. Separate storage space for soiled and clean laundry must be located in the residence. All damp soiled linen such as bed linen, towels, and washcloths must be maintained in covered waterproof containers.

006.29(A) LAUNDRY EQUIPMENT. Domestic type equipment must be provided for the laundry. Laundry equipment must not be located in the kitchen.

006.30 ELEVATORS. All elevators in a Center for the Developmentally Disabled must be inspected for safety at least once a year by the Nebraska State Department of Labor.

006.31 FLOORS, WALLS, AND CEILINGS. The floors of all rooms, hallways, bathrooms, storerooms, and all other spaces used or traversed by clients and staff must be of such construction as to be easily cleaned, shall be smooth, and shall be kept clean and in good repair. Cleaning of floors must be so done as to minimize the raising of dust and exposure of clients thereto. Ceilings in areas where food is stored or prepared and in which dishes and utensils are washed must be of such construction as to be easily cleaned, must be smooth, and must be kept clean and in good repair. The safe use of rugs, carpets, or natural stone which can be kept clean is permitted. Abrasive strips to reduce or prevent slipping shall be used where slippery surfaces present a hazard.

006.31(A) DIRT FLOORS. Dirt floors in a basement area are prohibited. Basement floors must be concrete with proper drainage.

006.31(B) WALLS. Walls must be free from spaces which may harbor vermin. Walls in other areas of the facility must have a cleanable finish. Lead based paints are not permitted in any area of the facility.

006.31(C) CEILINGS. Enamel-painted plaster, gypsum board, concrete and vinyl-coated suspended ceiling panels, or equally washable surfaces are adequate.

006.32 FOOD SERVICE. Each licensee must comply with the provisions of the Nebraska Food Code.

006.33 MENU PLANNING. Menus must be planned at least a week in advance and must be reviewed and approved by a dietician before service.

006.33(A) MEAL SUBSTITUTIONS. Records of substitutions of planned food items must be made and must be of equal nutritional value.

006.33(B) DOCUMENTATION OF MENUS. Records of menus must be filed for 6 months in the facility.

006.34 DINING ROOMS. All clients, including the mobile non-ambulatory must eat or be fed in dining areas except where contraindicated for health reasons. Table service must be provided for all who can and will eat at a table.

006.34(A) DINING EQUIPMENT. Dining areas must be equipped with tables, chairs, eating utensils and dishes to meet the developmental needs of the clients.

006.34(B) DINING SUPERVISION. Dining areas must be adequately supervised and staffed for the direction of self-help eating procedures and to assure that each client receive an adequate amount and variety of food.

006.35 WATER AND SEWER SYSTEMS. Each building must have and maintain an accessible and safe supply of potable water. Where an authorized public water supply of satisfactory quality, quantity and pressure is available, the building must be connected to it and must use it exclusively. All water distribution systems must be protected with anti-siphon devices and airgaps to prevent contamination.

006.35(A) PRIVATE WELLS. The licensee must ensure that any building with a private well or wells as the source of the water supply must have this water supply tested quarterly for coliform bacteria and a chemical analysis every 3 years by the Department or a laboratory approved by the same.

006.36 CLOTHING. Each client must have an adequate allowance of neat, clean, fashionable, and seasonable clothing.

006.36(A) CLOTHING IDENTIFICATION. Each client must have her or his own clothing which is properly marked with her or his name, and he or she shall use this clothing.

006.36(B) APPROPRIATE CLOTHING. Such clothing must make it possible for clients to go out of doors in inclement weather, to go on trips or visits appropriately dressed and to make a normal appearance in the community.

006.36(C) NON-AMBULATORY CLIENTS. Non-ambulatory clients must be dressed daily in their own clothing, including shoes, unless contraindicated in a written, medical order which is reviewed periodically.

006.36(D) CLOTHING MAINTENANCE. An ongoing wardrobe check should be kept on each client's personal and clothing items to assure proper maintenance.

007. STANDARDS OF OPERATION, CARE, AND TREATMENT . A Center for the Developmentally Disabled must be organized, managed, and administered by the licensee to ensure each client receiving services at the facility received necessary care and treatment in a safe manner, in accordance with current standards of practice, and in accordance with the Health Care Facility Licensure Act, 175 NAC 1, and this chapter.

007.01 ADMINISTRATION. The licensee may be the administrator or may appoint a person to be the administrator. If the administrator is not the licensee, the administrator is directly responsible to the licensee in all matters related to the maintenance, operation, and management of the facility. The administrator is the contact person for the facility. The licensee’s responsibilities include:

(A) Designating a house manager in writing; (B) Being available or ensuring the administrator is available to the house manager at all times; (C) Ensuring the health, safety and protection of clients residing at the facility; (D) Maintaining compliance with all applicable state statutes, codes, rules, and regulations; (E) Notifying the Department in writing within 5 working days when:

(i) A vacancy in the administrator position occurs including the name of who will be responsible for the position until another administrator is appointed; and (ii) A vacancy in the administrator position is filled including the effective date and name of person appointed to that position; and

(F) Establishing, implementing, and revising as necessary, written policies and procedures governing the facility operations.

007.02 STAFFING. The licensee must maintain a sufficient number of staff with the required experience, orientation, training, and competency necessary to meet the care and treatment needs of clients and the operations needs of the facility.

007.02(A) PERSONNEL POLICIES. Written personnel policies and procedures must be established and made available to each employee. Personnel policies and procedures must be read by each employee upon employment and as revisions are made. Documentation of this must be maintained in the employee's personnel file. Personnel policies must address hiring, assignment, and promotion of employees; grievance procedures; suspension or dismissal of an employee; and ensure that employees with symptoms or signs of communicable disease are not permitted to work.

007.02(B) JOB DECRIPTIONS. Job descriptions for each consultant and staff position must be established and made available to each consultant and staff person upon employment. Each job description must include but not necessarily be limited to a description of the person's duties and responsibilities and the person's role, if any, in implementing the individual program, plan job descriptions for consultants must be included as a part of the contract with a consultant.

007.02(C) VOLUNTEERS. Policies and procedures must be implemented which specify the training and supervision to be given to volunteers. A volunteer must never be left in charge of the facility.

007.02(D) TRAINING. Policies and procedures must be available which specify the training to be received during the 3 months orientation period and provide for in-service training and staff development on a regular basis thereafter.

007.02(D)(i) INITIAL TRAINING. Staff orientation for new employees must take place during the first 3 months of employment and must begin on the first day of employment. Orientation during the first 3 months must be consistent with the job description for the individual and the needs of the clients served. Training during the first 3 months must include: basic first aid and cardiopulmonary resuscitation, drug administration, (in-service must be completed prior to administration of drugs), Individual Program Plan development and implementation, client rights, and facility policies and procedures.

007.02(D)(ii) ONGOING TRAINING. In-service training and staff development must be available to and attended by all staff on a regular basis. Training must be consistent with the job description for the individual and the needs of the clients to be served. A plan of in-service training and staff development must be established for a 3 month period and must provide for ongoing in-service training and staff development.

007.02(D)(iii) TRAINING DOCUMENTATION. Documentation of all staff training and in-services attended must be kept in each employee's personnel record. In-service records must include topic and content, actual training time and date of training.

007.02(E) STAFFING. Regardless of the organization or design of living units, the staff- client ratios, must be, morning, awake and present, afternoon and evening, awake and present, and overnight sleeping. For time periods when clients are not present in the facility, staff-ratios will not apply.

007.02(E)(i) STAFFING RATIOS FOR DISABLED. For any unit within a facility that includes clients who are children under the age of 6 years, disabled, physically handicapped, or who are aggressive, assaultive, security risks, or who manifest severely hyperactive or psychotic-like behavior, or who require considerable adult guidance and supervision, the following minimum staff-client ratio must be met:

(1) Morning - 1:4; (2) Afternoon and evening - 1:4; and (3) Overnight - 1:8.

007.02(E)(ii) STAFFING RATIOS FOR BASIC INDEPENDENT SKILLS. For any unit within a facility that includes clients in basic independent living skills, who do not attend vocational training programs but may attend prevocational training programs, the following minimum staff client ratios must be met:

(1) Morning - 1:8; (2) Afternoon and evening - 1:8; and (3) Overnight - 1:10.

007.02(E)(iii) STAFFING RATIOS FOR TRAINING PROGRAMS. For any unit serving clients in vocational training programs and adults who work in sheltered employment situations, the following minimum staff client ratios must be met:

(1) Morning - 1:8; (2) Afternoon and evening - 1:8; and (3) Overnight - 1:10.

007.02(E)(iv) ADDITIONAL STAFFING. Additional staff coverage must be provided on call as necessary during emergencies, including illness of a client or clients. Additional staff coverage must be provided on call during emergencies in accordance with the previously stated ratios. These individuals and their phone numbers must be listed near the main telephone for the facility. Volunteers are not included in meeting the staff client ratios. A licensee that accepts any client whose needs require awake overnight care must provide awake and present staff in the prescribed ratios.

007.03 EMERGENCY MEDICAL SERVICES. Each licensee must establish, implement, and revise as necessary policies and procedures regarding the handling of emergency situations. All employees and volunteers must have immediate access to such information along with the names, telephone numbers, location, and type of medical services available. Emergency information must be maintained in the facility at a location known to all facility employees.

007.03(A) MEDICAL INFORMATION. All staff must have immediate access to clients' medical information including, name of physician(s), person to notify in case of emergency, current medications, and known allergies. Medical information must be maintained in the facility at a location known to all facility employees.

007.03(B) EMERGENCY SITUATIONS. The licensee must maintain a first aid kit adequate to deal with possible emergency situations at each location. This kit must be checked on at least an annual basis and restocked as needed.

007.04 PERSONNEL. Personnel files must be maintained in a centralized system and must be subject to inspection by authorized representatives of the Department at any time. Personnel files must be maintained for all personnel and must include:

(1) Job description; (2) Documentation of completed training and in-service attended; (3) Documentation of annual performance evaluation; (4) Pre-employment physical; (5) Job application; (6) Credential verification; (7) Date of hiring; and (8) Disciplinary actions, if any.

007.04(A) INDIVIDUAL LICENSE REQUIREMENTS. The licensee must ensure all persons who provide a service to clients meet applicable state laws. The licensee must ensure that all persons for whom a license, certification or registration is required hold the license, certification, or registration in accordance with applicable state laws.

007.04(A)(i) REPORTING. Each licensee must ensure that any incident where there is reason to believe that abuse, neglect, or exploitation of a client has occurred are reported to:

(1) The Adult and Child Abuse and Neglect Hotline via telephone immediately; and (2) Local law enforcement as required by state and federal laws.

007.04(B) INVESTIGATION. A licensee must ensure any incident where there is reason to believe that abuse, neglect, or exploitation of a client has occurred is thoroughly investigated and the investigation documented in a written report. Within 5 working days of the incident, the facility must submit the written investigative report to the Department.

007.04(C) PROTECTION. A licensee must ensure that clients are protected throughout the investigation. Actions must be taken as a result of the investigation to ensure patient safety and to prevent the potential for recurrence.

007.04(D) CRIMINAL BACKGROUND AND REGISTRY CHECKS. A licensee must complete and maintain documentation of pre-employment criminal background and registry checks on each unlicensed direct care staff member.

007.04(D)(i) CRIMINAL BACKGROUND CHECKS. A licensee must complete criminal background checks through a governmental law enforcement agency or a private entity that maintains criminal background information.

007.04(D)(ii) REGISTRY CHECKS. A licensee must check for adverse findings on the following registries:

(1) Nurse Aide Registry; (2) Adult Protective Services Central Registry; (3) Central Register of Child Protection Cases; and (4) Nebraska State Patrol Sex Offender Registry.

007.04(D)(iii) NURSE AIDE REGISTRY CHECKS. A licensee must not employ staff with adverse findings on the Nurse Aide Registry regarding abuse or neglect of clients served, or misappropriation of the property of clients served. The licensee must:

(1) Determine how to use the criminal background and registry information, except for the Nurse Aide Registry, in making hiring decisions; (2) Decide whether employment can begin prior to receiving the criminal background information; and (3) Document any decision to hire a person with a criminal background or adverse registry findings, except for the Nurse Aide Registry. The documentation must include the basis for the decision and how it will not pose a threat to clients’ safety or property.

007.05 CLIENT RECORDS. The licensee must establish, implement, and revise as necessary policies and procedures regarding the confidentiality, maintenance, storage, and destruction of client records. Client records must include:

(A) Documentation of all current evaluations; (B) Documentation of incident reports; (C) Documentation of clothing and personal possession inventory; (D) Documentation of medication histories and response profiles; (E) Documentation of client consent forms; and (F) If vocational services are offered to the clients of the facility, the records of the facility must indicate whether or not such services have been approved by the state.

007.06 POST-ADMISSION INDIVIDUAL PROGRAM PLAN. A post-admission Individual Program Plan must include measurable goals and objectives, must be developed, and implemented within 30 days after admission of any client, and be completed by the interdisciplinary team. Continued placement and programs must be determined, by the interdisciplinary team, in accordance with developmental needs as identified in comprehensive assessments and must not be contingent on age or time restrictions.

007.07 RESTRAINT DOCUMENTATION. Documentation of monitoring of restraints and time-out rooms which includes extent of time in time-out, reason for use, 15 minute checks of the restraint, release from restraints and exercise every 2 hours, and signature of the individual documenting monitoring of restraints. If a time-out room is used for behavior modification programs the room must provide a minimum of 60 square feet of floor space and have a ceiling height of 9 feet. There must be a means of observing the client while in the time-out room. Appropriate furniture, at least a bed or chair and a light must be provided. The door must be lockable from only the outside.

007.08 CLIENT RIGHTS. Each licensee must establish, implement, and revise as necessary policies and procedures assuring that each client has the same civil rights unless specific rights have been removed by a court of law after the client has been afforded his or her full due process rights, or for the particular circumstances and with specific safeguards outlined.

007.08(A) HUMAN RIGHTS COMMITTEE. The licensee must have a Human Rights Committee for each facility. Policies and procedures regarding Clients’ Rights must be reviewed by the Human Rights Committee at least annually. Any compromise of these rights must be documented with justification. Clients must have a right to treatment, services and habilitation designed to maximize developmental potential of the person and provided in a setting that is least restrictive of the client’s personal liberty. A Human Rights Committee must be established for each facility. Reports of the Committee meetings must be available in each facility served or locale and must specify what occurred during the Committee meetings.

007.08(B) PROTECTIVE SAFEGUARDS OF THE CLIENT’S RIGHTS. The Human Rights Committee must review and take action in accordance with written policies and procedures, with respect to alleged instances of mistreatment, neglect, abuse, exploitation, and situations where restraints, psychotropic medication or aversive conditioning are used. Documentation of reviews and actions by the Human Rights Committee must be maintained in the facility for clients. Composition of the Human Rights Committee must be as follows:

(i) Administrative staff representative; (ii) Residential and service staff; (iii) Client; (iv) Indirect consumer, i.e., the parents or guardian of a client; and (v) Representatives from community concerned with rights of individuals with developmental disabilities.

007.08(C) INFORMATION REGARDING CLIENT RIGHTS. Each client must be informed, by an appropriate communication system, of his or her rights and responsibilities as a client, and of all rules and regulations governing client conduct and responsibilities. Receipt of such information must be acknowledged in writing by the client or his or her family, guardian, or representative, where applicable, and maintained in the client’s record in the facility. If written acknowledgement cannot be obtained, information regarding client’s rights must be sent to his or her family, guardian, or representative by certified mail.

007.08(C)(i) RECOGNITION OF HUMAN DIGNITY. Each client must be treated with consideration, respect, truthfulness, and full recognition of his or her dignity and individuality, including privacy in treatment and in care of his or her personal needs. Clients’ individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, and entertainments must be elicited and respected by the facility. Privacy of a client’s body must be maintained during toileting, bathing, and other activities of personal hygiene, except as needed for client safety or assistance.

007.08(C)(ii) INPUT INTO DECISION MAKING. There must be documentation that each client is afforded maximum opportunity to participate in any decisions concerning his or her person, including those decisions involving medical care and treatment, residency, and the development and implementation of the Individual Program Plan. If it is determined that informing clients of their condition is medically contraindicated, this decision and reasons for it must be documented in the facility in the client’s record by the physician.

007.08(C)(iii) FREEDOM FROM RESTRAINTS. Physical restraints, psychotropic medications or aversive conditioning techniques must be employed only in accordance with policies and procedures approved by the Human Rights Committee and must be employed only after approval by the same. Physical restraints, psychotropic medication, and aversive conditioning techniques, such as using noxious or aversive stimuli, must never be used as a punishment, for the convenience of staff, or as a substitute for programs, and must be applied only after other means of controlling behavior have been tried and have failed. Documentation of the failure of these alternative techniques must be included in a client’s record and reviewed by the Human Rights Committee. Prior to the incorporation of physical restraints, psychotropic medications, or aversive conditioning techniques in a client’s habilitation plan, except when absolutely necessary in an emergency situation to prevent a client from seriously injuring himself or others:

(1) It must be documented in the client’s record in the facility that physical restraints, psychotropic medications, or aversive conditioning techniques, or any or all of them, are essential for the client’s habilitation and that less restrictive techniques have been attempted and have failed; and (2) Incorporation of aversive conditioning techniques, physical restraints, or psychotropic medications in the client’s habilitation plans has been with the informed consent of the client, or his or her family, guardian, or representative, when applicable, and documented in the client’s record in the facility. The written policies and procedures of the facility governing the use of restraints must delineate the following:

(a) Physician's orders must indicate the specific reasons for the use of restraints and must specify the type of restraints used; (b) The use of restraints must be temporary and the client must not be restrained for an indefinite amount of time; (c) Orders for restraints must not be enforced for longer than 12 hours, unless the client’s condition warrants and must be reordered every 12 hours by the physician; (d) A client placed in the restraint must be checked at least every 15 minutes by appropriately trained staff and an account must be kept of this surveillance; (e) Reorders shall be issued only after a review of the client’s condition; (f) The use of restraints must not be employed as punishment, for the convenience of the staff, or as a substitute for supervision; (g) Mechanical restraints must avoid physical injury to the client and provide a minimum of discomfort; (h) The opportunity for motion and exercise must be provided for a period of not less than 10 minutes during each 2 hours in which restraints are employed, except at night, if the client is asleep; and

(i) The following documentation is required before incorporation in the client’s habilitation plan of more restrictive methods of managing behavior, i.e., psychotropic medication, restraint, and a complete description of the maladaptive behavior must include: (i) The form of the behavior; (ii) Where and when the behavior occurred; (iii) The frequency of the occurrence of the behavior; (iv) The results of this occurrence; (v) The previous intervention approaches tried; (vi) The description of the teaching procedures; (vii) The persons responsible; (viii) The setting; (ix) The time spent per day and week; (x) The results of the alternative approaches; (xi) The proposed procedure; (xii) The description of the proposed procedure; (xiii) The persons responsible; (xiv) The setting; (xv) The rationale for choosing this specific procedure; (xvi) The evaluation of the program (data collection); (xvii) Who will review it; (xviii) The proposed length of the implementation; (xix) Who can terminate the procedure; and (xx) Who will monitor and how frequently will monitoring occur.

007.08(C)(iv) FREEDOM FROM SECLUSION. Seclusion is prohibited.

007.08(C)(v) FREEDOM FROM ABUSE AND NEGLECT. Mistreatment, neglect, physical, mental, or verbal abuse, or exploitation of clients in any form is prohibited. The licensee must have a written policy that defines use of behavior modification programs, the staff members who may authorize their use, and a mechanism for monitoring and controlling their use.

007.08(C)(vi) BEHAVIOR MANAGEMENT CONSENT. For discontinuation of a behavior management program associated with the use of psychotropic medication(s), the client record must contain documentation that the cessation of psychotropic medication does not interfere with a client’s habilitation program and that there is documentation of no problematic behavior. Once a maintenance dose for psychotropic medication has been established, there must be provision in the client’s Individual Program Plan for quarterly review of the client’s status and documentation of the review maintained in the facility’s records for the client.

007.08(C)(vii) DISCIPLINE OF CLIENTS. Clients must not discipline other clients, except as, part of an organized self-government program which is conducted in accordance with written policy of the facility.

007.08(C)(viii) FREEDOM OF ASSOCIATION AND COMMUNICATION. Each client must be afforded the right to communicate, associate, and meet privately with persons of his or her own choice; to send and receive his or her personal mail unopened; and to participate in activities of social, religious, and community groups at his or her discretion. There will be documentation of the rationale for the restriction of any of these rights. A decision to restrict a visitor is reviewed and re-evaluated each time the client’s Individual Program Plan is reviewed by the Interdisciplinary Team and medical orders are reviewed by the physician or at the client’s request. Close relatives must be permitted to visit clients at reasonable hours without prior notice.

007.08(C)(ix) CONFIDENTIAL TREATMENT OF CLIENT INFORMATION. Each client must be assured of confidential treatment of all information contained in his or her records and his or her written, informed consent, or the written, informed consent of his or her family, guardian, or representative, if applicable, must be required for the release of information to persons not authorized under law to receive it.

007.08(C)(x) FREEDOM FROM INTERFERENCE WITH PERSONAL FINANCIAL AFFAIRS. Each client must be afforded the right to manage his or her personal financial affairs. In the event a client has had a conservator appointed by a court of law, the conservator must be free to manage the client’s personal financial affairs within the bounds of the court order appointing the conservator. Each client and his or her parent(s), or conservator, if applicable, shall be informed orally and in writing of all financial responsibilities involved in being a client.

007.08(D) AUTHORIZATION. Written authorization from the client or his or her conservator, if applicable, must be obtained when the licensee is handling the client's funds and the authorization must be in the client's record in the facility.

007.08(D)(i) CLIENT FUNDS. Licensee must maintain a written account of all clients’ funds received by or deposited with the facility. The facility may, at the client’s request, keep on deposit personal funds over which the client has control. Should the client or conservator, where applicable, request these funds, they must be given to him or her on request with receipts maintained by the facility and a copy to the client.

007.08(D)(ii) FINANCIAL TRANSACTIONS. If the licensee makes financial transactions on a client’s behalf, the client or his or her representative must receive, or acknowledge that he or she has seen, an itemized accounting of disbursements and current balances at least quarterly. A copy of this statement must be maintained in the client’s financial or business record.

007.08(D)(iii) FREEDOM FROM INVOLUNTARY SERVITUDE. No client must ever be required to perform labor which involves the operation and maintenance of the facility or the regular care, treatment, or supervision of other clients. Clients may voluntarily perform any work available to them. Clients may be required however, to perform tasks of a housekeeping nature (such as the making of their own beds) without compensation.

007.08(D)(iv) TRANSFER OR DISCHARGE OF CLIENTS. When the client is transferred or discharged, the reason for the transfer or discharge and a summary of findings, progress and plans must be recorded and made available to both the transferring facility and the facility to which the client is transferred. Except in an emergency, the client or his or her parents, guardian, or representative, if applicable, must be informed in writing at least 30 days in advance of transfer and at least 60 days in advance of discharge, and his or her written consent obtained. The Interdisciplinary Team must convene prior to transfer or discharge of a client and must review the move.

007.08(D)(v) FEE SCHEDULE. Each client has the right to a copy and to view a fee schedule of charges for services to the client.

007.09 CLIENT SERVICES. A licensee must not admit any client to a facility if the individual need for that client cannot be met. An evaluation by a physician, a psychologist, a social worker, and residential staff must be completed prior to admission for each client.

007.09(A) INTERDISCIPLINARY TEAM. The interdisciplinary team is responsible for development of a preliminary program plan at the time of admission, complete Individual Program Plan with 30 days, after the date of admission and must complete an annual review of each client’s program plan. The Interdisciplinary Team must include:

(i) The client’s case manager; (ii) The client’s parent or guardian, if applicable; (iii) The client to be served, or reason for nonattendance; (iv) A representative from the residential program staff; and (v) Professionals from those disciplines for which the individual has specialized needs, including vocational staff, if applicable and school system representatives, if applicable.

007.09(B) NONPARTICIPATION IN INTERDISCIPLINARY TEAM. If any member(s) of the previous team are not involved in the development or review of the program plan, the reasons for their nonparticipation must be documented in the minutes of the Interdisciplinary Team meeting. Program Plans must include signatures of the individual or the individual’s legal representative participation, in the Interdisciplinary Team meeting.

007.09(C) PROFESSIONALS WHO PARTICIPATE ON THE INTERDISCIPLINARY TEAM. Professionals who participate on the Interdisciplinary Team must meet the following requirements:

(i) A psychologist must have a current active license in Nebraska; (ii) Social Services Workers must have a bachelor’s degree in social work, developmental or intellectual disabilities, or a related field; (iii) Physicians must have a current active license in Nebraska; (iv) Dentists must have an active license in Nebraska; (v) Licensed Medical Nutrition Therapists must have a current active license in Nebraska; (vi) Speech pathologists or audiologists must have a current active license in Nebraska; (vii) Physical Therapists must have a current active license in Nebraska; and (viii) Occupational Therapists must be:

(1) Graduates of an occupational therapy curriculum accredited jointly by the Council on Medical Education of the American Medical Association and the American Occupational Therapy Association; or (2) Eligible for certification by the American Occupational Therapy Association under its requirements in effect on the effective date of these regulations; or (3) Have 2 years of competent experience as an occupational therapist.

007.10 CLIENT EVALUATIONS. Client evaluations conducted by the disciplinary areas must include:

(A) Summary of progress towards meeting the current Individual Program Plan's goal and objectives and assessments of continuing need for care; (B) Identification of the tools or methods used for assessment; (C) Needs, strengths, and weaknesses (barriers); (D) Recommendations if the client has habilitative needs; and (E) Written in language clearly understandable by all.

007.11 INDIVIDUAL PROGRAM PLAN. The Individual Program Plan must include:

(A) Long term goals and short term objectives, that are stated separately, and each objective is stated in terms of a single behavioral outcome; (B) Projected completion dates; (C) Measurable indicators of progress expressed in behavioral terms inclusive of a pass or fail criteria; (D) Be sequenced within a developmental progression appropriate to the individual; and (E) Assigned priorities.

007.11(A) INDIVIDUAL PROGRAM PLAN OBJECTIVES. The Individual Program Plan objectives must include a description of the manner in which objectives will be achieved and possible barriers to the achievement of them in common language understandable by all concerned; a training plan shall be written for the implementation of each objective specifying:

(i) Data collection procedures; (ii) Training procedures; (iii) Staff responsible for training; (iv) Conditions or (environment) and materials needed; and (v) Method by which effectiveness of program will be evaluated.

007.11(B) INDIVIDUAL PROGRAM PLAN SPECIFICATIONS. The Individual Program Plan must include statements (in readily understandable form) of specific habilitation services to be provided, containing the identity of the client (by name and title) or agency which will deliver each service, and specifying the date of the initiation of each service to be provided and the proposed duration of each service.

007.11(C) ACTIVITY SCHEDULES. Activity schedules are an active extension of the Individual Program Plan. The schedule must be recorded and must include:

(i) Client’s schedules on a weekly basis; (ii) Time periods in which staff are working with clients on their Individual Program Plans; (iii) Time periods clients are working alone or together on skill attainment; (iv) Times for the client to choose activities that interest him or her; (v) Ongoing staff services (responsible persons); (vi) Restrictions of client rights; (vii) Barriers to programming, i.e., blind, non-ambulatory; (viii) Guardianship status; (ix) Admission date; and (x) Primary relative, guardian or advocate.

007.11(C)(1) INDIVIUALIZED SERVICE PLAN. At the time of admission, a preliminary program plan shall be developed by an Interdisciplinary Team which may provide for the continuation of existing programs from previous facility. Comprehensive evaluations of a client’s developmental must be completed within 30 days following admission. Reassessments must be completed annually or more frequently if needed as determined by the needs of the client. Comprehensive evaluations must include:

(a) Medical evaluation, upon admission and thereafter as needed, must address physical and mental health, and include a medication history; (b) Dental evaluation, upon admission and thereafter as needed, must include complete extra and intra-oral examinations; (c) Sensorimotor Development evaluation; (d) Communicative Development evaluation; (e) Social Development evaluation; upon admission and thereafter as needed; (f) Affective Development evaluation; (g) Cognitive Development evaluation; (h) Adaptive behaviors or independent living skills evaluation; (i) Dietary, if applicable. Dietary evaluations must address eating skills; adaptive equipment; modified diets; edible reinforcers, and nutritional inducements; (j) Speech, if applicable. Speech evaluations must include appraisal of articulation, voice, rhythm, and language; (k) Audiology, if applicable. Audiology evaluations must include tests of pure tone air and bone conduction, speech audiometry, and other procedures as necessary, and include assessment of the use of visual cues, and use of amplification; (l) Physical therapy, if applicable. Physical therapy evaluations must address the preservation and improvement of abilities for independent function such as range of motion, strength tolerance, coordination, and activities of daily living; and prevention, insofar as possible of irreducible or progressive disabilities through means such as the use of orthotic and prosthetic appliances, assistive and adaptive devices, positioning, behavior adaptations, and sensory stimulation; (m) Occupational therapy, if applicable. Occupational therapy evaluations must address the preservation and improvement of abilities for independent function such as range of motion, strength, tolerance, coordination, and activities of daily living; and prevention, insofar as possible of irreducible or progressive disabilities through means such as the use of orthotic and prosthetic appliances, assistive and adaptive devices, positioning, behavior adaptations, and sensory stimulation; (n) Psychological initial evaluation upon admission and bi-annually. Psychological evaluations must address perceptual skills, social skills, self-direction, emotional stability, and effective use of time, including leisure time. Full-scale must include non-adaptive and adaptive behavior scale; and (o) Vocational, if applicable. Vocational evaluations must address client aptitudes, abilities, interests, work attitudes, work habits, work tolerances, community, and social skills.

007.11(C)(2) POST-ADMISSION INDIVIDUAL PROGRAM PLAN. The post-admission Individual Program Plan, which must include measurable goals and objectives, is developed, and implemented within 30 calendar days after admission by the Interdisciplinary Team.

(a) Continued placement and programs must be determined in accordance with developmental needs as identified by comprehensive assessments and not be contingent on age or time restrictions.

007.11(D) PROGRAMS. Programs must be implemented as specified on the Individual Program Plan. The frequency of implementation of a program must be in accordance with normal life activities.

007.11(E) ONGOING IMPLEMENTATION AND CONTINUING APPROPRIATENESS. The Individual Program Plan must be reviewed at least quarterly by the client’s Interdisciplinary Team for assuring implementation and whether it continues to be appropriate for the client.

007.11(F) MODIFICATION AND REVIEW OF THE INDIVIDUAL PROGRAM PLAN. The Individual Program Plan itself must also be reviewed and modified as necessary by the client’s Interdisciplinary Team at intervals determined by the team, and at least annually.

007.11(G) LEISURE TIME ACTIVITIES. Clients must be provided with leisure time activities and must be directed at keeping the client both physically and mentally alert and active.

007.11(H) GENERIC SERVICES AND RESOURCES. The licensee must utilize, as extensively as possible, generic services and resources appropriate to the needs of the clients served, including introducing clients into the environments available in the community that are most appropriate to addressing their needs. There must be written policies and procedures to utilize these resources within the scope of availability.

007.11(I) COMMUNITY ACTIVITIES. Services must be provided in settings that are appropriate for and that encourage disabled clients to experience relationships with non-disabled persons in community activities.

007.11(J) STAFF PERSON RESPONSIBILITY FOR SERVICES. The Interdisciplinary Team must identify one staff person as responsible for coordinating all services provided to the client by the facility. This person must be designated on the client’s Individual Program Plan.

007.12 MEDICATIONS. Each licensee must establish, implement, and revise as necessary policies and procedures governing the handling, storage and administration of medications that must be in compliance with current standards of practice and state and federal law.

007.12(A) MEDICATION STORAGE AND HANDLING. All medications must be prescribed for the client by a licensed medical practitioner and dispensed by a licensed pharmacist.

007.12(B) ADMINISTRATION OF MEDICATION. The licensee must ensure clients receive medications only as legally prescribed by a medical practitioner in accordance with the prescription and prevailing professional standards.

007.12(B)(i) METHODS OF ADMINISTRATION. When the licensee is responsible for the administration of medication, it must be accomplished by the following methods:

007.12(B)(i)(1) SELF ADMINISTRATION. The licensee must allow clients to self-administer medication, with or without supervision, unless an Interdisciplinary Team has determined the client is not capable of doing so safely.

007.12(B)(i)(2) LICENSED HEALTH CARE PROFESSIONAL. When the licensee utilizes licensed health care professionals for whom medication administration is included in their scope of practice, the licensee must ensure the medications are properly administered in accordance with prevailing professional standards.

007.12(B)(i)(3) PERSONS OTHER THAN A LICENSED HEALTH CARE PROFESSIONAL. When the licensee utilizes persons other than licensed health care professionals in the provision of medications, the licensee must follow 172 NAC 95, Regulations Governing the Provision of Medications by Medication Aides and Other Unlicensed Persons, and 172 NAC 96, Regulations Governing the Medication Aide Registry.

007.12(C) FACILITY RESPONSIBILITY. When the licensee is not responsible for medication administration or provision of medication, the licensee maintains responsibility for the overall supervision, safety, and welfare of the client.

007.12(D) DISPOSAL OF MEDICATIONS. Medications that are discontinued by the medical practitioner, and those medications which are beyond their expiration date, must be destroyed. The licensee must identify who will be responsible for disposal of medications and the method to dispose of medications in a timely and safe manner. Documentation of the disposal should be documented, and such documentation should be retained for a minimum of 5 years.

History

Effective 2024-03-17

Chapter 4 Assisted-Living Facilities

Neb. Admin. Code tit. 175, ch. 4 Assisted-Living Facilities {#sec-175-nac-4 omnilex-key=us-ne-regs-official--title-175--175 NAC 4}

4-001 SCOPE AND AUTHORITY : These regulations govern licensure of assisted-living facilities. The regulations are authorized by and implement the Assisted-Living Facility Act, Neb. Rev. Stat. §§ 71-5901 to 71-5908 and the Health Care Facility Licensure Act, Neb. Rev. Stat. §§ 71-401 to 71-459.

4-001.01 Assisted-living facility does not include a home, apartment, or facility where:

Casual care is provided at irregular intervals; or
A competent person residing in such home, apartment or facility provides for or contracts for his or her own personal or professional services if no more than 25% of persons residing in such home, apartment or facility receive such services.

4-002 DEFINITIONS : For the purposes of these regulations, the following definitions apply:

Abuse means any knowing, intentional or negligent act or omission on the part of a person which results in physical, sexual, verbal, or mental abuse, unreasonable confinement, cruel punishment, exploitation, or denial of essential care, treatment, and services to a resident.

Activities of daily living. (See definition of Care.)

Adjoining means located to allow access without having to enter a general corridor area used or observed by other facility occupants.

Administrator means the operating officer of an assisted-living facility and includes a person with a title such as administrator, chief executive officer, manager, superintendent, director, or other similar designation.

Apartment means portion of a building that contains living and sleeping areas, storage room(s), separate room(s) containing a toilet, lavatory, and bathtub or shower; and a kitchen area with a sink and cooking and refrigeration appliances.

Applicant means the individual, government, corporation, partnership, limited liability company, or other form of business organization who applies for a license.

Assisted-living facility means a facility where shelter, food, and care are provided for remuneration for a period of more than 24 consecutive hours to four or more persons residing at such facility who require or request such services due to age, illness, or physical disability.

This definition does not include a home, apartment or facility where:

Casual care is provided at irregular intervals, or
A competent person residing in such home, apartment or facility provides for or contracts for his or her own personal or professional services if no more than 25% of persons residing in such home, apartment, or facility receive such services.

Authorized representative means:

A person holding a durable power of attorney for health care;
A guardian; or
A person appointed by a court to manage the personal affairs of a resident of an assisted-living facility other than the facility. (See definition of Power of Attorney for Health Care.)

Bed capacity means the total number of beds which can be set up in an assisted-living facility for use by residents.

Biological means any virus, therapeutic serum, toxin, antitoxin, or analogous product applicable to the prevention, treatment, or cure of disease or injuries of humans.

Care means the exercise of concern or responsibility for the comfort, welfare, and habilitation of persons, including a minimum amount of supervision and assistance with or the provision of personal care, activities of daily living, health maintenance activities, or other supportive services. For purposes of this chapter:

Activities of daily living means transfer, ambulation, exercise, toileting, eating, self-administration of medication, and similar activities;
Health maintenance activities means noncomplex interventions which can safely be performed according to exact direction, which do not require alteration of the standard procedure, and for which the results and resident responses are predictable; and
Personal care means bathing, hair care, nail care, shaving, dressing, oral care, and similar activities.

Chemical restraint means a psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms.

Complaint means an expression of a concern or dissatisfaction.

Completed application means an application that contains all the information specified in 175 NAC 4-003 and includes all required attachments and documentation and the licensure fee.

Complex nursing interventions means interventions which require nursing judgment to safely alter standard procedures in accordance with the needs of the resident, which require nursing judgment to determine how to proceed from one step to the next, or which require a multidimensional application of the nursing process. Complex nursing interventions does not include a nursing assessment.

Department means the Department of Health and Human Services Regulation and Licensure.

Device means an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is prescribed by a medical practitioner and dispensed by a pharmacist or other person authorized by law to do so.

Direct care staff means staff who provide assistance with activities of daily living, health maintenance activities, and personal care and does not include housekeeping, maintenance, dietary, laundry, administrative or clerical staff if they do not provide any of the above mentioned assistance.

Direction and monitoring means for the purpose of medication administration, the acceptance of responsibility for observing and taking appropriate action regarding any desired effects, side effects, interactions, and contraindications associated with the medication. Direction and monitoring can be done by a:

Competent individual for himself or herself,
Caretaker; or
Licensed health care professional.

Director means the Director of Regulation and Licensure.

Drug means substances as defined in Neb. Rev. Stat. § 71-1,142.

Dwelling means a building that contains living and sleeping areas, storage room(s), separate room(s) containing a toilet, lavatory, and bathtub or shower; and a kitchen area with a sink and cooking and refrigeration appliances.

Existing facility means a licensed health care facility or a facility whose construction or remodeling plans were approved by the Department prior to the effective date of 175 NAC 4.

Facility means an assisted-living facility as defined.

Five rights means getting the right drug to the right recipient in the right dosage by the right route at the right time.

Food code means the Nebraska Food Code as defined in Neb. Rev. Stat. § 81-2,244.01 and as published by the Nebraska Department of Agriculture, except for compliance and enforcement provisions.

Foreign when applied to corporations means all those created by authority other than that of the State of Nebraska.

Grievance means a written expression of dissatisfaction which may or may not be the result of an unresolved complaint.

Health care facility means an ambulatory surgical center, an assisted-living facility, a center or group home for the developmentally disabled, a critical access hospital, a general acute hospital, a health clinic, a hospital, an intermediate care facility, an intermediate care facility for the mentally retarded, a long-term care hospital, a mental health center, a nursing facility, a pharmacy, a psychiatric or mental hospital, a public health clinic, a rehabilitation hospital, a skilled nursing facility, or a substance abuse treatment center.

Health care service means an adult day service, a home health agency, a hospice or hospice service, or a respite care service.

Health maintenance activities (see definition of Care).

Licensed health care professional means an individual for whom administration of medication is included in the scope of practice.

Licensee means the individual, government, corporation, partnership, limited liability company, or other form of business organization to whom the license is issued. The licensee has the primary responsibility for the overall operation of the assisted-living facility.

Medical practitioner means any licensed physician, osteopathic physician, dentist, podiatrist, optometrist, chiropractor, physician assistant, certified registered nurse anesthetist, advanced practice registered nurse, or certified nurse midwife.

Medication means any prescription or nonprescription drug intended for treatment or prevention of disease or to affect body function in humans.

Medication administration includes, but is not limited to:

Providing medications for another person according to the five rights;
Recording medication provision; and
Observing, monitoring, reporting, and otherwise taking appropriate actions regarding desired effects, side effects, interactions, and contraindications associated with the medication.

Medication aide means an individual who is listed on the medication aide registry operated by the Department as provided for in 172 NAC 95 and 172 NAC 96.

Medication provision means the component of the administration of medication that includes giving or applying a dose of a medication to an individual and includes helping an individual in giving or applying such medication to himself or herself.

Mental abuse means humiliation, harassment, threats of punishment, deprivation, or other actions causing mental anguish.

Misappropriation of money or property means the deliberate misplacement, exploitation, or use of a resident’s belongings or money without the resident’s consent.

NAC means Nebraska Administrative Code.

Neglect means a failure to provide goods or services necessary to avoid physical harm or mental anguish of a resident.

New construction means a facility or a distinct part of a facility in which care and treatment is to be provided and which is enlarged, remodeled or altered in any fashion or is built from the ground up on or after the effective date of 175 NAC 4.

New facility means a facility or a distinct part of a facility in which care and treatment is to be provided and which is not currently licensed. New facility also includes those facilities, which were previously licensed for care and treatment in another licensure category, and which now intend to seek licensure in a different category.

Personal care (See definition of Care.)

Physical abuse means hitting, slapping, pinching, kicking, or other actions causing injury to the body.

Physical restraint means any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that he or she cannot remove easily and that restricts freedom of movement or normal access to his or her own body.

Power of attorney for health care means a power of attorney executed in accordance with Neb. Rev. Stat. §§ 30-3401 to 30-3432 which authorizes a designated attorney in fact to make health care decisions for the principal when the principal is incapable. A person holding the power of attorney for health care can make health care decisions to the extent allowed by the terms of the health care power of attorney.

Premises means a facility, the facility’s grounds and each building or grounds on contiguous property used for administering and operating a facility.

PRN means an administration scheme, in which a medication is not routine, is taken as needed and requires assessment for need and effectiveness.

Qualified inspector means a professional architect or engineer licensed to practice in Nebraska, an official or employee of a local jurisdiction authorized by that jurisdiction to make inspections of particular building equipment or systems, or an individual certified by a nationally recognized organization to make such inspections.

Resident means a person residing and receiving care at an assisted-living facility.

Schematic plans means a diagram of the facility or service which describes the number and location of beds; the location of care and treatment rooms, Life Safety Code construction and occupancy classifications locations, fire compartments, and Fire Marshal approved points of safety.

Sexual abuse means sexual harassment, sexual coercion, or sexual assault.

Shelter means to provide lodging for compensation.

Stable or predictable means that a resident’s clinical and behavioral status and nursing care needs are determined to be nonfluctuating and consistent or fluctuating in an expected manner with planned interventions, including an expected deteriorating condition.

Supplement means a product meant to satisfy dietary needs.

Supportive services means those services which support personal care, provision of medications, activities of daily living and health maintenance activities.

Treatment means a therapy, modality, product, device, or other intervention used to maintain well being or to diagnose, assess, alleviate, or prevent a disability, injury, illness, disease, or other similar condition.

Unlicensed direct care staff means personnel who are not licensed or certified under the Uniform Licensing Law or other state laws governing the practice of health care and whose primary responsibility is to manage, supervise, and/or provide direct care to residents. Unlicensed direct care staff includes nursing assistants, medication aides, and other personnel with this responsibility and with job titles designated by the facility.

Verbal abuse means the use of oral, written or gestured language including disparaging and derogatory terms to residents or within their hearing distance.

4-003 LICENSING REQUIREMENTS AND PROCEDURES : Any person intending to establish, operate, or maintain an assisted-living facility must first obtain a license from the Department. A facility must not hold itself out as an assisted-living facility or as providing health care services unless licensed under the Assisted-Living Facility Act and the Health Care Facility Licensure Act. An applicant for an initial or renewal license must demonstrate that the assisted-living facility meets the care, treatment, and operational and physical plant standards contained in 175 NAC 4.

4-003.01 Initial License: The initial license process occurs in two stages. The first stage consists of the applicant’s submission of affirmative evidence of the ability to comply with the operational and physical plant standards contained in 175 NAC 4-006 and 175 NAC 4-007. The application is not complete until the Department receives documents specified in 175 NAC 4-003.01.

The second stage consists of the Department’s review of the completed application together with an inspection of the assisted-living facility. The Department determines whether or not the applicant for an initial license meets the standards contained in 175 NAC 4, the Assisted-Living Facility Act and the Health Care Facility Licensure Act.

4-003.01A Applicant Responsibilities: An applicant for an initial assisted-living facility license must:

Intend to provide assisted-living services as defined;
Comply with the applicable codes, guidelines, and standards specified in 175 NAC 4-007;
Submit a written application to the Department as provided in 175 NAC 4-003.01B;
Receive approval in writing, from the Department, of schematic plan and, if new construction, of construction plans; and
Notify the Department at least 30 days prior to planned occupancy so the Department can conduct an on-site inspection.

4-003.01B Application Requirements: The applicant may construct an application or obtain an application form from the Department. The application must include:

Full name of the assisted-living facility to be licensed, street and mailing address, telephone and facsimile number, if any;
Type of assisted-living facility to be licensed;
Name of the administrator;
Name and address of the assisted-living facility owner(s);
Ownership type;
Mailing address for the owner(s);
The preferred mailing address for the receipt of official notices from the Department;
List of names and addresses of all persons in control of the assisted-living facility. The list must include all individual owners, partners, limited liability company members, parent companies, in any, and members of boards of directors owning or managing the operations and any other persons with financial interests or investments in the assisted-living facility. In the case of publicly held corporations, the individual owners listed must include any stockholders who own 5% or more of the company’s stock;
The legal name of the individual or business organization (government, corporation, partnership, limited liability company or other type) to whom the license should be issued and a statement that the individual or organization accepts the legal responsibility for compliance with these regulations;
Applicant’s federal employer identification number, if not an individual;
Applicant’s social security number if the applicant is an individual. To ensure social security numbers are not part of public records and are used only for administrative purposes, applicants may submit social security numbers in a separate document;
Number of beds;
Signature(s) of:

a. The owner, if the applicant is an individual or partnership;

b. Two of its members, if the applicant is a limited liability company;

c. Two of its officers, if the applicant is a corporation; or

d. The head of the governmental unit having jurisdiction over the assisted-living facility to be licensed, if the applicant is a governmental unit;

Copy of the registration as a foreign corporation filed with the Nebraska Secretary of State, if applicant is a foreign corporation;
Schematic plans;
For new construction, plans completed in accordance with the Engineers and Architects Regulation Act, Neb. Rev. Stat. §§ 81-3401 to 81-3455. An applicant may construct a project description and/or certification document, or obtain a form from the Department. Construction plans must include the following:

a. Project name, description of the project with quantity and floor area information on bed, care, treatment, bathing, toileting, dining, and activity locations, building systems, medical equipment, street address, and contact person;

b. Site plan, floor plans, elevations, wall and building sections, construction details, plumbing and electrical diagrams, construction component schedules;

c. Complete list of names, titles and telephone numbers of other authorities reviewing or inspecting the construction;

d. Upon Department request, such additional information that may be required for review, such as structural and mechanical calculations, electrical system calculations, and product and equipment information; and

e. Certification, if any, from a licensed architect or engineer that the schematic plans, construction plans, and any revisions thereof meet the requirements of 175 NAC 4-007;

Planned occupancy date;
Copies of zoning approval from the relevant jurisdiction;
Occupancy certificates issued by the State Fire Marshal or delegated authority;
The required licensure fee specified in 175 NAC 4-004.09; and
If applicable, the disclosure information required by Neb. Rev. Stat. §§71-516.01 to 71-516.04, the Alzheimer’s Special Care Disclosure Act. The following information must be submitted:

a. The Alzheimer’s special care unit’s written statement of its overall philosophy and mission which reflects the needs of residents afflicted with Alzheimer’s disease, dementia, or a related disorder;

b. The process and criteria for placement in, transfer to, or discharge from the unit;

c. The process used for assessment and establishment of the plan of care and its implementation, including the method by which the plan of care evolves and is responsible to changes in condition;

d. Staff training and continuing education practices;

e. The physical environment and design features appropriate to support the functioning of cognitively impaired adult residents;

f. The frequency and types of resident activities;

g. The involvement of families and the availability of family support programs; and

h. The costs of care and any additional fees.

4-003.01C Department Responsibilities: The Department will:

Review the application for completeness;
Provide notification to the applicant of any information needed to complete the application;
Confirm, either by Department review or by accepting certification from an architect or engineer, that the schematic plans and, if new construction, the construction plans meet the standards of 175 NAC 4-007;
Upon receipt of the requested information, conduct an on-site inspection in accordance with 175 NAC 4-005 prior to the issuance of an assisted-living facility license; and
Issue or deny a license based on the results of the initial inspection.

4-003.01D Denial of License: See 175 NAC 4-008.01 and 4-008.02 for grounds and procedures for the Department’s denial of an initial license.

4-003.02 Renewal Licenses

4-003.02A Licensee Responsibilities: Licensees must submit a written application to the Department. The licensee may construct an application or obtain an application form from the Department. The licensure application must include:

Full name of the assisted-living facility to be licensed, street and mailing address, telephone and facsimile number, if any;
Type of assisted-living facility to be licensed;
Name of the administrator;
Name and address of the assisted-living facility owner(s);
Ownership type;

6.Mailing address for the owner(s);

The preferred mailing address for the receipt of official notices from the Department;
List of names and addresses of all persons in control of the assisted-living facility. The list must include all individual owners, partners, limited liability company members, parent companies, if any, and members of boards of directors owning or managing the operations and any other persons with financial interests or investments in the assisted-living facility. In the case of publicly held corporations, the individual owners listed must include any stockholders who own 5% or more of the company’s stock;
The legal name of the individual or business organization (government, corporation, partnership, limited liability company or other type) to whom the license should be issued and a statement that the individual or organization accepts the legal responsibility for compliance with these regulations;
Applicant’s federal employer identification number, if not an individual;
Applicant’s social security number if the applicant is an individual. To ensure social security numbers are not part of public records and are used only for administrative purposes, applicants may submit social security numbers in a separate document;
Number of beds;
Signature(s) of:

a. The owner, if the applicant is an individual or partnership;

b. Two of its members, if the applicant is a limited liability company;

c. Two of its officers, if the applicant is a corporation; or

d. The head of the governmental unit having jurisdiction over the assisted-living facility to be licensed, if the applicant is a governmental unit;

Occupancy certificates issued by the State Fire Marshal or delegated authority dated within the 18 months prior to the license expiration date;
Required licensure fee specified in 175 NAC 4-004.09; and
If applicable, the disclosure information required by Neb. Rev. Stat. §§71-516.01 to 71-516.04, the Alzheimer’s Special Care Disclosure Act. The following information must be submitted:

b. The process and criteria for placement in, transfer to, or discharge from the unit;

c. The process used for assessment and establishment of the plan of care and its implementation, including the method by which the plan of care evolves and is responsible to changes in condition;

d. Staff training and continuing education practices;

e. The physical environment and design features appropriate to support the functioning of cognitively impaired adult residents;

f. The frequency and types of resident activities;

g. The involvement of families and the availability of family support programs; and

h. The costs of care and any additional fees.

4-003.02B Department Responsibilities: The Department will:

Send a notice of expiration and an application for renewal to the licensee’s preferred mailing address not later than 30 days prior to the expiration date. The licensure renewal notice specifies:

a. Date of expiration;

b. Fee for renewal;

c. License number; and

d. Name and address of the assisted-living facility.

Issue a renewal when it determines that the licensee has submitted a completed application;
Send to each licensee that fails to renew its license a second notice, which is the final notice and specifies that:

a. The licensee failed to pay the renewal fee or submit an application or both;

b. The license has expired;

c. The Department will suspend action for 30 days following the date of expiration;

d. Upon receipt of the renewal fee and completed renewal application, the Department will issue the renewal license; and

e. Upon failure to receive the renewal fee and completed renewal application, the license will be lapsed.

Place the assisted-living facility license on lapsed status for nonpayment of fees if the licensee fails to renew the license. During this time, the assisted-living facility may not operate. The license remains in lapsed status until it is reinstated.

4-003.02C Refusal to Renew: See 175 NAC 4-008.01 and 4-008.02 for grounds and procedures for the Department’s refusal to renew a license.

4-003.03 Reinstatement from Lapsed Status: An assisted-living facility requesting reinstatement of its lapsed license must submit to the Department an application for reinstatement and pay the required licensure fee specified in 175 NAC 4-004.09. The application must conform to the requirements specified in 175 NAC 4-003.02.

4-003.03A The Department will review the application for completeness and decide if an onsite inspection is needed to determine compliance with the operation, care, treatment, and physical plant requirements of 175 NAC 4-006 and 4-007. The decision is based on the following factors:

The length of time that has transpired from the date the license was placed on lapsed status to the date of the reinstatement application; and
Whether the assisted-living facility has provided care from the site under a license that is different from the lapsed license.

4-003.03B When the Department decides that a reinstatement inspection is warranted, it will conduct the inspection in accordance with 175 NAC 4-005.

4-003.03C When the Department decides that a reinstatement inspection is not warranted, it will reinstate the license.

4-003.03D Refusal to Reinstate: See 175 NAC 4-008.01 and 4-008.02 for grounds and procedures for the Department’s refusal to reinstate a lapsed license.

4-004 GENERAL REQUIREMENTS

4-004.01 Separate License: An applicant must obtain a separate license for each type of health care facility or health care service that the applicant seeks to operate. All buildings in which care and treatment is provided must comply with 175 NAC 4-006 and if applicable, 175 NAC 4-007. A single license may be issued for:

An assisted-living facility operating in separate buildings or structures on the same premises under one management;
An inpatient facility that provides services on an outpatient basis at multiple locations; or
A health clinic operating satellite clinics on a intermittent basis within a portion of the total geographic area served by such health clinic and sharing administration with such clinics.

4-004.02 Single License Document: The Department may issue one license document that indicates the various types of health care facilities or health care services for which the entity is licensed.

4-004.03 Effective Date and Term of License: An assisted-living facility license expires on April 30 of each year.

4-004.04 License Not Transferable: A license is issued only for the premises and persons named in the application and is not transferable or assignable. Change of ownership (sale, whether of stock, title, or assets, lease, discontinuance of operations) or premises terminates the license. If there is a change of ownership and the assisted-living facility remains on the same premises, the inspection in 175 NAC 4-005 is not required. If there is a change of premises, the assisted-living facility must pass the inspection specified in 175 NAC 4-005.

4-004.05 Bed Capacity, Usage and Location: The licensee must not put into use more beds than the total number of beds for which the assisted-living facility is licensed. Changes in the use and location of beds may occur at any time without prior Departmental approval for licensure purposes. A licensee must not locate more residents in a resident room than the capacity for which the room was originally approved.

4-004.06 Change of Ownership or Premises: The licensee must notify the Department in writing ten days before an assisted-living facility is sold, leased, discontinued, or moved to new premises.

4-004.07 Notification: An applicant or licensee must notify the Department in writing by electronic mail, facsimile, or regular mail:

At the time of licensure renewal, of any change in the location of beds;
At least 30 working days prior to the date it wishes to increase the number of beds for which the assisted-living facility is licensed;
To request a single license document;
To request simultaneous facility or service licensure inspections for all types of licensure held or sought;
If new construction is planned, and submit construction plans for Department approval prior to any new construction affecting resident care and treatment areas of the assisted-living facility. The Department may accept certification from an architect or engineer in lieu of Department review;
Within 24 hours of any resident death that occurred due to suicide, a violent act, or the resident’s leaving the facility without staff knowledge when departure presented a threat to the safety of the resident or others;
Within 24 hours if a facility has reason to believe that a resident death was due to abuse or neglect by staff;
Within 24 hours of any facility fire requiring fire department response; or
Within 24 hours of an accident or natural disaster resulting in damage to the physical plant and having a direct or immediate adverse effect on the health, safety, and security of residents. This must include a description of the well-being of the facility’s residents and the steps being taken to assure resident safety, well-being, and continuity of care and treatment. The notification may be made by telephone if the accident or natural disaster has affected the facility’s capacity to communicate.

4-004.08 Information Available to Public: The licensee must make available for public inspection upon request licenses, license record information, and inspection reports. This information may be displayed on the licensed premises.

4-004.09 Fees: The licensee must pay fees for licensure as set forth below:

Initial and Renewal Licensure fees:

a. 1 to 10 Beds $ 950

b. 11 to 20 Beds $1,450

c. 21 to 50 Beds $1,650

d. 51 or more Beds $1,950

Duplicate original license: $10
Refunds for denied applications:

a. If the Department did not perform an inspection, the license fee is refunded except for an administrative fee of $25.

b. If the Department performed an inspection, the license fee is not refunded.

4-004.10 Deemed Compliance

4-004.10A Accreditation: The Department may deem a licensee in compliance with 175 NAC 4-006 based on acceptance of accreditation as an assisted-living facility by a recognized independent accreditation body or public agency, which has standards that are at least as stringent as those of the State of Nebraska, as evidence that the assisted-living facility complies with rules and regulations adopted and promulgated under the Assisted-Living Facility Act.

4-004.10A1 A licensee must request the Department to deem its facility in compliance with 175 NAC 4-006 based on accreditation. The request must be:

Made in writing;
Submitted within 30 days of receipt of a report granting accreditation; and
Accompanied by a copy of the accreditation report.

4-004.10A2 Upon receipt of the request and acceptance of accreditation, the Department will deem the facility in compliance with 175 NAC 4-006 and will provide written notification of the decision to the facility within ten working days of receipt of the request.

4-004.10A3 The Department will exclude an assisted-living facility that has been deemed in compliance with 175 NAC 4-006 from the random selection of up to 25% of assisted-living facilities for compliance inspections under 175 NAC 4-005.04A. The assisted-living facility may be selected for a compliance inspection under 175 NAC 4-005.04B.

4-004.10A4 To maintain deemed compliance, the licensee must maintain the accreditation on which the license was issued. If the accreditation is sanctioned, modified, terminated, or withdrawn, the licensee must, within 15 days of receipt of notification of an action, notify the Department in writing of the action and the cause for the action. If the cause for action indicates possible regulatory violation, the Department will inspect the assisted-living facility within 90 days of receipt of notice. The assisted-living facility may continue to operate unless the Department determines that the assisted-living facility no longer meets the requirements for licensure under the Assisted-Living Facility Act and Health Care Facilities Licensure Act. If the Department determines the facility no longer qualifies for deemed compliance, the facility is subject to inspections under 175 NAC 4-005.

4-005 INSPECTIONS : To determine compliance with operational, care, treatment, and physical plant standards, the Department inspects an assisted-living facility prior to and following licensure. The Department determines compliance through on-site inspections, review of schematic and construction plans, and reports of qualified inspectors.

4-005.01 Initial Inspection: The Department will conduct an announced initial on-site inspection to determine compliance with 175 NAC 4-006 and 4-007. The inspection will be conducted within 30 working days, or later if requested by the applicant, of receipt of a completed application for an initial license. The Department will provide a copy of the inspection report to the assisted-living facility within 10 working days after completion of an inspection.

4-005.02 Results of Initial Inspection

4-005.02A When the Department finds that the applicant fully complies with the requirements of 175 NAC 4-006 and 4-007, the Department will issue a license.

4-005.02B When the Department finds that the applicant had complied substantially but has failed to comply fully with the requirements of 175 NAC 4-006 and 4-007 and the failure(s) would not pose an imminent danger of death or physical harm to persons residing in the assisted-living facility, the Department may issue a provisional license. The provisional license:

Is valid for up to one year; and
Is not renewable.

4-005.02C When the Department finds the applicant has one or more violations that create no imminent danger of death or serious physical harm and no direct or immediate adverse relationship to the health, safety, or security of the persons residing in the facility, the Department may send a letter to the facility requesting a statement of compliance. The letter will include:

A description of each violation;
A request that the facility submit a statement of compliance within ten working days; and
A notice that the Department may take further steps if the statement of compliance is not submitted.

4-005.02D The statement of compliance must indicate any steps that have been or will be taken to correct each violation and the estimated time to correct each violation. Based on the statement of compliance, the Department will take one of the following actions:

If the facility submits and implements a statement of compliance that indicates a good faith effort to correct the violations, the Department will issue either a regular license or a provisional license; or
If the facility fails to submit and implement a statement of compliance that indicates a good faith effort to correct the violations, the Department may deny the license.

4-005.02E When the Department finds the applicant fails to meet the requirements of 175 NAC 4-006 and 4-007 and the failure(s) would create an imminent danger of death or serious physical harm, the Department will deny the license.

4-005.03 Physical Plant Inspections: The Department will conduct inspections for conformity with construction plans and compliance with 175 NAC 4-007 at new facilities or new construction prior to use or occupancy.

4-005.03A On-site progress inspections of the physical plant by qualified inspectors for conformity to construction documents and compliance with code requirements may occur at any time after construction has begun and prior to the concealment of essential components.

4-005.03B The Department will conduct an on-site final inspection of the physical plant prior to use or occupancy. In lieu of an on-site final inspection by the Department, the Department may accept a certification from a licensed architect or engineer that the physical plant meets the requirements of the Assisted-Living Facility Act, the Health Care Facility Licensure Act and 175 NAC 4, and that the facility is complete and ready for occupancy in accordance with Department-approved plans. The architect or engineer may construct a certification form or obtain a certification form from the Department.

4-005.03B1 The certification must state:

Name of the architect or engineer;
Name of the professional entity with which he or she is affiliated, if any;
Address and telephone number;
Type of license held, the state in which it is held, and the license number;
Name and location of the facility;
Name(s) of the owner(s) of the facility;
New construction had the building structure and plumbing rough-in inspected by a qualified inspector prior to the time these would be concealed and preclude observation;
All new construction, care and treatment room sizes, bedroom sizes, handrails, grab bars, hardware, building systems, protective shielding, privacy curtains, appropriate room finishes, and other safety equipment are completed in accordance with approved construction plans; and
The facility is furnished, cleaned, and equipped for the care and treatment to be performed in compliance with 175 NAC 007, and approved for use and occupancy.

4-005.03B2 The certification must have attached to it:

Copies of documents from other authorities having jurisdiction verifying that the facility meets the codes specified in 175 NAC 4-007.03A, and approved for use and occupancy;
Copies of certifications and documentation from equipment and building system installers verifying that all equipment and systems installed are operating and approved for use and occupancy; and
Schematic floor plans documenting actual room numbers and titles, bed locations, capacity, and life safety information.

4-005.04 Compliance Inspections: The Department may, following the initial licensure of an assisted-living facility, conduct an unannounced onsite inspection at any time as it deems necessary to determine compliance with 175 NAC 4-006 and 4-007. The inspection may occur based on random selection or focused selection.

4-005.04A Random Selection: Each year the Department may inspect up to 25% of the assisted-living facilities based on a random selection of licensed assisted-living facilities.

4-005.04B Focused Selection: The Department may inspect an assisted-living facility when the Department is informed of one or more of the following:

An occurrence resulting in resident death or serious physical harm;
An occurrence resulting in imminent danger to or the possibility of death or serious physical harm to residents;
An accident or natural disaster resulting in damage to the physical plant and having a direct or immediate adverse effect on the health, safety, and security of residents;
The passage of five years without an inspection;
A complaint alleging violation of the Assisted-Living Facility Act, the Health Care Facility Licensure Act or 175 NAC 4;
Complaints that, because of their number, frequency, or type, raise concerns about the maintenance, operation, or management of the facility;
Financial instability of the licensee or of the licensee’s parent company;
Outbreaks or recurrent incidents of physical health problems at an assisted-living facility such as dehydration, pressure sores, or other illnesses;
Change of services, management or ownership; or
Any other event that raises concerns about the maintenance, operation, or management of the assisted-living facility.

4-005.05 Results of Compliance Inspections

4-005.05A When the inspection reveals violations that create imminent danger of death or serious physical harm or have a direct or immediate adverse effect on the health, safety, or security of residents residing in the assisted-living facility, the Department will review the inspection findings within 20 working days after the inspection. If the evidence from the inspection supports the findings, the Department will impose discipline in accordance with 175 NAC 4-008.03.

4-005.05B When the inspection reveals one or more violations that create no imminent danger of death or serious physical harm and no direct or immediate adverse effect on the health, safety, or security of residents residing in the assisted-living facility, the Department may request a statement of compliance from the facility. The statement of compliance must indicate any steps that have been or will be taken to correct each violation and the estimated time to correct each violation. Based on the statement of compliance, the Department will take one of the following actions:

If the assisted-living facility submits and implements a statement of compliance that indicates a good faith effort to correct the violations, the Department will not take any disciplinary action against the license; or
If the assisted-living facility fails to submit and implement a statement of compliance, the Department will initiate disciplinary action against the assisted-living facility license, in accordance with 175 NAC 4-008.

4-005.06 Re-Inspections

4-005.06A The Department may conduct re-inspections to determine if the assisted-living facility fully complies with the requirements of 175 NAC 4-006 and 4-007. Re-inspection occurs:

After the Department has issued a provisional license;
Before a provisional license is converted to a regular license;
Before a disciplinary action is modified or terminated; or
After the Department receives a statement of compliance for cited violations.

4-005.06B Following a re-inspection, the Department may:

Convert a provisional license to a regular license;
Affirm that the provisional license is to remain effective;
Modify a disciplinary action in accordance with 175 NAC 4-008.02. ; or
Grant full reinstatement of the license.

4-006 STANDARDS OF OPERATION, CARE AND TREATMENT : To provide adequate protection to assisted-living residents and compliance with state statutes, an assisted-living facility must meet the following:

4-006.01 Licensee Responsibilities: The licensee of each assisted-living facility must assume the responsibility for the total operation of the facility. The licensee responsibilities include:

Monitoring policies to assure the appropriate administration and management of the assisted-living facility;
Maintaining the assisted-living facility’s compliance with all applicable state statutes and relevant rules and regulations;
Providing quality care to residents whether care is furnished by assisted-living facility staff or through contract with the facility;
Designating an administrator who is responsible for the day to day management of the assisted-living facility and defining the duties and responsibilities of the administrator in writing;
Notifying the Department in writing within five working days when a vacancy in the administrator position occurs including who will be designated as the administrator until another administrator is appointed;
Notifying the Department in writing within five working days when the vacancy is filled including effective date and name of person appointed administrator; and
Assuring that after January 1, 2005, any person designated as administrator of the assisted-living facility meets the initial training requirements specified in 175 NAC 4-006.02A within the first six months of employment as the administrator.

4-006.02 Administration: Each assisted-living facility must have an administrator who is responsible for the overall operation of the facility. The administrator is responsible for planning, organizing, and directing the day to day operation of the assisted-living facility. The administrator must report all matters related to the maintenance, operation, and management of the assisted-living facility and be directly responsible to the licensee or to the person or persons delegated governing authority by the licensee. The administrator must:

Be responsible for the facility’s compliance with rules and regulations;
Be responsible for the facility’s promotion of resident self-direction and participation in decisions which incorporate independence, individuality, privacy and dignity;
Be on the premises a sufficient number of hours to permit adequate attention to the management of the facility;
Maintain staff with appropriate training and skills and sufficient in number to meet resident needs as defined in resident service agreements;
Designate a substitute to act in his or her absence who must be responsible and accountable for management of the facility;
Monitor that resident service agreements are established and implemented;
Monitor that facility staff identify and review incidents and accidents, resident complaints and concerns, patterns and trends in overall facility operation such as provisions of resident care and service and take action to alleviate problems and prevent recurrence;
Develop and implement procedures that require the reporting of any evidence of abuse, neglect, or exploitation of any resident residing in the assisted-living facility in accordance with Neb. Rev. Stat. §§ 28-372 of the Adult Protective Services Act or in the case of a child, in accordance with Neb. Rev. Stat. § 28-711;
Complete an investigation on suspected abuse, neglect, or misappropriation of money or property and take action to prevent reoccurrence until the investigation is completed;
Be at least 21 years of age; and
Meet the administrator training requirements as specified in 4-006.02A.

4-006.02A Initial Administrator Training Requirements: After January 1, 2005, the administrator must have completed training consisting of a total of at least 30 hours, including, but not limited to:

Resident care and services;
Social services;
Financial management;
Administration;
Gerontology; and
Rules, regulations, and standards relating to the operation of an assisted-living facility.

4-006.02B Verification of Initial Administrator Training: Verification of initial training completed must be submitted to the Department for approval. Training documentation may include but is not limited to:

Evidence of completion of training including documentation of date of training, number of hours, description of training, and trainer qualifications;
Evidence of successful completion of college courses and/or degree which includes topics in 4-006.02A; or
Evidence of completion of a Department approved training course.

4-006.02B1 Initial training requirements do not apply to an assisted-living facility administrator who also holds an active nursing home administrator license or who is currently employed as a hospital administrator. Verification of nursing home or hospital administrator status must be submitted to the Department. Such verification includes:

Proof of current licensure as a nursing home administrator in Nebraska or other jurisdiction; or
A statement from the governing authority of the hospital or other authorizing entity that could verify administrator status.

4-006.02C Department Responsibilities for Approval of Initial Administrator Training Programs: The Department will:

Determine whether the administrator training program meets the course requirements of 175 NAC 4-006.02A and provide written notification of program approval within 90 days of receipt of application; and
Establish and maintain a registry of persons who have met the initial training requirements. The registry will contain information the Department deems necessary.

4-006.02D Initial Administrator Training Waiver: Persons employed as assisted-living administrators on January 1, 2005 were allowed to apply within 90 days of that date for a Department waiver of the initial administrator training requirements.

4-006.02E Ongoing Administrator Training: Each year of employment, a facility administrator must complete 12 hours of ongoing training in areas related to care and facility management of the population served. The record of such training must be available for Department review and include topic of training, date and length of training and name and title of person providing training. Nursing home and hospital administrators verified under 175 NAC 4-006.02B1 are not required to fulfill the annual training requirement.

4-006.03 Staff Requirements: The facility must maintain a sufficient number of staff with the required training and skills necessary to meet the resident population’s requirements for assistance or provision of personal care, activities of daily living, health maintenance activities, supervision and other supportive services, as defined in Resident Service Agreements.

4-006.03A Employment Eligibility: Each assisted-living facility must ensure and maintain evidence of the following:

4-006.03A1 Criminal Background Check: The facility must complete criminal background checks on each member of the unlicensed direct care staff of the facility.

4-006.03A1a Such checks must be done on all new unlicensed direct care staff hired.

4-006.03A1b Such checks must be made through a governmental law enforcement agency or a private entity that maintains criminal background information.

4-006.03A1c It is the responsibility of the facility to:

Determine how to use this criminal background information in making hiring decisions;
Decide whether employment can begin prior to receiving the criminal background information; and
Document any decision to hire a person with a criminal background. The documentation must include the basis for the decision and how it will not pose a threat to resident safety or resident property.

4-006.03A2 Registry Checks: The facility must check each unlicensed direct care staff for adverse findings on the following registries:

Nurse Aide Registry;
Adult Protective Services Central Registry;
Central Register of Child Protection Cases; and
Nebraska State Patrol Sex Offender Registry.

4-006.03A2a Each facility must determine whether to employ or continue employment of any person as direct care staff with adverse registry findings, except for the Nurse Aide Registry.

4-006.03A2b The facility must document any decision to hire as direct care staff a person with adverse registry findings, except for the Nurse Aide Registry. The documentation must include the basis for the decision and how it will not pose a threat to resident safety or resident property.

4-006.03A2c Each facility must not employ or continue employment of any person as direct care staff who has adverse findings on the Nurse Aide Registry regarding resident abuse, neglect, or misappropriation of resident property.

4-006.03A3 Health Status: Each assisted-living facility must establish and implement policies and procedures regarding the health status of staff to prevent the transmission of disease to residents.

4-006.03A3a A health history screening for each staff person must be completed prior to assuming job responsibilities. A physical examination is at the discretion of the employer based on results of the health history screening.

4-006.03B Direct Care Staff Training: Each assisted-living facility must ensure direct care staff receive training in order to perform job responsibilities. The facility must provide for and maintain evidence of the following training;

4-006.03B1 Orientation: Orientation must be given within two weeks of employment to each direct care staff person of the facility and must include as a minimum, but is not limited to:

Resident’s rights;
Resident service agreement;
Infection Control practices including handwashing techniques, personal hygiene and disposal of infectious material;
The facility’s emergency procedures and information regarding advance directives;
Information on any physical and mental special care needs of the residents in the facility;
Information on abuse, neglect and misappropriation of money or property of a resident and reporting procedures; and
Disaster preparedness plans.

4-006.03B2 Ongoing Training: Ongoing training must be given to each direct care staff person and must consist of at least 12 hours per year on topics appropriate to the employee’s job duties including meeting the physical and mental special care needs of residents in the facility. The record of such training must include topic of training, name of staff, date and length of training and name of person providing the training.

4-006.03C Staffing Resources: The assisted-living facility must ensure that staffing resources and training are sufficient to meet the level of supervision and assistance with activities of daily living, personal care and health maintenance activities that are required by the residents as defined in the resident service agreements.

4-006.03C1 The facility must have at least one staff person on the premises at all times when necessary to meet the needs of the residents as required in the resident service agreements.

4-006.03C2 Registered Nurse: Each assisted-living facility must provide for a registered nurse to review medication administration policies and procedures and to provide or oversee the training of medication aides at such facility. Training of medication aides must include, but is not limited to:

Facility procedures for storing, handling and providing medications;
Facility procedures for documentation of medications;
Facility procedures for documentation and reporting medication errors and adverse reactions;
Identification of person(s) responsible for direction and monitoring of medication aides; and
Other resident-specific training on providing medications in accordance with the limits and conditions of the Medication Aide Act.

4-006.03D General Staff: The assisted-living facility must provide staffing to ensure that services to residents are provided in a safe and timely manner to meet the resident needs as required in the resident service agreements.

4-006.03E Employment Record: A current employment record must be maintained for each staff person. The record must contain at a minimum, information on orientation, in-services, credentialing and health history screening.

4-006.04 Resident Rights: The assisted-living facility must provide residents their rights in writing upon admission and for the duration of their stay. The operations of the facility must afford residents the opportunity to exercise their rights. At a minimum, the resident must have the right to:

Be treated with dignity and provided care by competent staff;
Be an equal partner in the development of the resident service agreement while retaining final decision making authority;
Be informed in advance about care and treatment and of any changes in care and treatment that may affect the resident’s well-being;
Be informed in writing of the pricing structure and/or rates of all facility services;
Self direct activities, participate in decisions which incorporate independence, individuality, privacy and dignity and make decisions regarding care and treatment;
Choose a personal attending physician;
Voice complaints and grievances without discrimination or reprisal and have those complaints/grievances addressed;
Examine the results of the most recent survey of the facility conducted by representatives of the Department;
Refuse to perform services for the facility;
Refuse to participate in activities;
Privacy in written communication including sending and receiving mail;
Receive visitors as long as this does not infringe on the rights and safety of other residents in the facility;
Have access to the use of a telephone with auxiliary aides where calls can be made without being overheard;
Have the right to have a telephone in his/her room at the resident’s expense;
Retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights and safety of other residents;
Share a room with a person of his or her choice upon consent of that person;
Self-administer medications if it is safe to do so;
Be free of chemical and physical restraints;
Exercise his or her rights as a resident of the facility and as a citizen or resident of the United States;
Form and participate in an organized resident group that functions to address facility issues;
Review and receive a copy, within two working days, of their permanent record, as referred to in 175 NAC 4-006.12;
Be free from abuse, neglect, and misappropriation of their money and personal property; and
Be free from involuntary transfer or discharge without 30 days advance written notice except in situations where the transfer or discharge is necessary to protect the health and safety of the resident, other residents or staff.

4-006.04A Grievances: Each assisted-living facility must establish and implement a process for addressing all grievances received from residents, employees and others. The process includes, but is not limited to:

A procedure on submission of grievances available to residents, employees and others;
Documentation of efforts to address grievances received from residents, employees and others; and
The telephone number and address of the Department is readily available to residents, employees and others who wish to lodge complaints or grievances.

4-006.05 Consumer Satisfaction/Improvement: Each assisted-living facility must develop and implement a process to measure consumer satisfaction.

4-006.06 Resident Service Agreements: The assisted-living facility must evaluate each resident and must have a written service agreement negotiated with the resident and authorized representative, if applicable, to delineate the services to be provided to meet the needs identified in the evaluation.

4-006.06A The agreement must contain the following basic components:

Services to be provided by the assisted-living facility and from other sources, how often and when the services are provided and by whom, to meet the needs of individuals including those for special populations as specified in 175 NAC 4-006.11E. Such services must not exceed those which are defined in these regulations as shelter, food, activities of daily living, personal care, health maintenance, other supportive services or those which involve complex nursing interventions that are allowed by 175 NAC 4-006.07B;
Rights and responsibilities of the facility and of the resident;
Costs of services and terms of payment; and
Terms and conditions of continued residency.

4-006.06B The Resident Service Agreement must be reviewed and updated as the resident’s needs change.

4-006.07 Admission and Retention Requirements: The assisted-living facility must ensure that the resident admission and retention practices conform with the following:

4-006.07A Eligibility Criteria: To be eligible for admission to an assisted-living facility, a person must be in need of or wish to have available shelter, food, assistance with or provision of personal care, activities of daily living, or health maintenance activities or supervision due to age, illness, or physical disability. The administrator has the discretion regarding admission or retention of residents subject to the Assisted-Living Facility Act and rules and regulations adopted and promulgated under the act.

4-006.07A1 The assisted-living facility must establish and implement procedures to request that:

On and after January 1, 2005, every person seeking admission to an assisted-living facility or the authorized representative of such person must, upon admission and annually thereafter, provide the facility with a list of drugs, devices, biologicals, and supplements being taken or being used by the person, including dosage, instructions for use, and reported use; and
Every person residing in an assisted-living facility on January 1, 2005, or the authorized representative of such person must, within 60 days after January 1, 2005, and annually thereafter, provide the facility with a list of drugs, devices, biologicals, and supplements being taken or being used by such person, including dosage, instructions for use, and reported use.

4-006.07B Restrictions on Eligibility Criteria: Residents requiring complex nursing interventions or whose conditions are not stable or predictable must not be admitted, readmitted, or retained by the assisted-living facility unless:

4-006.07B1 The resident, if the resident has sufficient mental ability to understand the situation and make a rational decision as to his or her needs or care and is not a minor, or the resident’s authorized representative, and the resident’s physician or the registered nurse agree that admission or retention of the resident is appropriate;

4-006.07B2 The resident or his or her authorized representative assumes responsibility for arranging for the resident’s care through appropriate private duty personnel, a licensed home health agency, or a licensed hospice agency; and

4-006.07B3 The resident’s care does not compromise the assisted-living facility operations or create a danger to others in the facility.

4-006.07C Assisted-living facility staff while on duty must not provide complex nursing interventions for facility residents, except that a registered nurse assessment to determine the suitability of the resident or potential resident for admission to and/or continued residence in the assisted-living facility is permitted.

4-006.08 Activities: The assisted-living facility must plan and provide activities designed to meet the interests and promote the physical, mental, and psychosocial well-being of residents. Such activities must be on-going and all residents informed of the opportunity to participate. Information about activities must be posted and made available to residents.

4-006.09 Provision of Medication: Provision of medications may be provided by the assisted-living facility as requested by the resident and in accordance with licensed health care professional statutes and the statutes governing medication provision by unlicensed personnel.

4-006.09A Self-Administration of Medications: The following requirements apply in those instances when residents self-administer medications. Residents must:

Be at least 19 years of age;
Have cognitive capacity to make informed decision about taking medication;
Be physically able to take or apply a dose of medication;
Have capability and capacity to take or apply a dose of medication according to specific directions for prescribed medications or according to a recommended protocol for nonprescription medication; and

5.Have capability and capacity to observe and take appropriate action regarding any desired effects, side effects, interactions, and contraindications associated with a dose of medication.

4-006.09A1 In the event self-administration could potentially result in adverse health consequences, the facility must counsel the resident and the authorized representative, if applicable.

4-006.09A2 Medications may be stored in a resident’s room if the resident keeps the room locked when not present; or the medications are stored in a secure location or locked container.

4-006.09A3 Residents who self-medicate must be encouraged to have their medications reviewed on a regular basis by a licensed health care professional.

4-006.09B Administration of Medication: The assisted-living facility must establish and implement policies and procedures to ensure residents receive medications only as legally prescribed by a medical practitioner, in accordance with the Five Rights and prevailing professional standards. The assisted-living facility must ensure that a registered nurse reviews and documents the review of medication administration policies and procedures at least annually.

4-006.09B1 Methods of Administration: When the facility is responsible for the administration or provision of medications, it must be accomplished by the following methods:

4-006.09B1a Self-Administration of Medication: The facility must allow residents of the facility to self-administer medications, with or without supervision, when assessment determines resident is capable of doing so.

4-006.09B1b Licensed Health Care Professional: When the facility utilizes licensed health care professionals for whom medication administration is included in the scope of practice, the facility must ensure the medications are properly administered in accordance with prevailing professional standards.

4-006.09B1c Provision of Medication by a Person Other Than a Licensed Health Care Professional: When the facility utilizes persons other than a licensed health care professional in the provision of medications, the facility must follow 172 NAC 95 Regulations Governing the Provision of Medications by Medication Aides and Other Unlicensed Persons and 172 NAC 96 Regulations Governing the Medication Aide Registry. Each facility must establish and implement policies and procedures:

To ensure that medication aides who provide medications are trained and have demonstrated the minimum competency standards specified in 172 NAC 95 004;
To ensure that competency assessments and/or courses for medication aides have been completed in accordance with the provisions of 172 96-005;
That specify how direction and monitoring will occur when the facility allows medication aides to perform the routine/acceptable activities authorized by 172 NAC 95-005 and as follows:

a. Provide routine medication; and

b. Provision of medications by the following routes:

(1) Oral, which includes any medication given by mouth including sublingual (placing under the tongue) and buccal (placing between the cheek and gum) routes and oral sprays;

(2) Inhalation, which includes inhalers and nebulizers, including oxygen given by inhalation;

(3) Topical application of sprays, creams, ointments, and lotions, and transdermal patches; and

(4) Instillation by drops, ointments and sprays into the eyes, ears and nose.

That specify how direction and monitoring will occur when the assisted-living facility allows medication aides to perform the additional activities authorized by 172 NAC 95-009, which include, but are not limited to:

a. Provision of PRN medications;

b. Provision of medications by additional routes, including, but not limited to, gastrostomy tube, rectal, and vaginal; and/or

c. Participation in monitoring.

That specify how competency determinations will be made for medication aides to perform routine and additional activities pertaining to medication provision;
That specify how written direction will be provided for medication aides to perform the additional activities authorized by 172 NAC 95-009;
That specify how records of medication provision by medication aides will be recorded and maintained; and
That specify how medication errors made by medication aides and adverse reactions to medications will be reported. The reporting must be:

a. Made to the identified person responsible for direction and monitoring;

b. Made immediately upon discovery; and

c. Documented in resident medical records.

4-006.09C Handling of Medications: Each assisted-living facility must have procedures to ensure that residents receive medications as prescribed by a medical practitioner including a method for verifying the identity of each resident.

4-006.09C1 Medications sent with a resident for temporary absences from the assisted-living facility must be in containers identified for the resident.

4-006.09C2 Medications must be sent with a resident upon discharge upon resident request.

4-006.09C3 Medications authorized for one resident must not be used for another resident or staff.

4-006.09C4 Any errors in administration or provision of prescribed medications must be reported to the resident’s licensed health care professional in a timely manner upon discovery and a written report of the error prepared.

4-006.09C5 Any adverse reaction to a medication must be reported immediately upon discovery to the resident’s licensed health care professional and recorded in the resident’s record.

4-006.09D Medication Record: The assisted-living facility must maintain records in sufficient detail to assure that residents receive the medications authorized by a medical practitioner and maintain records to protect medications against theft and loss.

4-006.09D1 When facility staff administer or provide medication, each resident must have an individual medication administration record which includes:

The identification of the resident;
The name of the medication given;
The date, time, dosage, method of administration or provision for each medication, the identification of the person who administered or provided the medication and any refusal by the resident; and
The resident’s medication allergies and sensitivities, if any.

4-006.09E Storage: All medications must be stored in locked areas and stored in accordance with the manufacturer’s or dispensing pharmacist’s instructions for temperature, light, humidity, or other storage instructions. Only authorized personnel who are designated by the facility responsible for administration or provision of medications must have access to the medications.

4-006.09E1 Medications for external use must be stored separately from other medications.

4-006.09F Disposal of Medications: Medications that are discontinued by the medical practitioner, those medications leftover at the time of death or those medications which are beyond their expiration date, must be destroyed in accordance with facility policy.

4-006.10 Food Service: The assisted-living facility must provide food service as specified in the resident service agreement and may include special diets if offered by the facility.

4-006.10A Menus: When the facility provides food service, meals and snacks must be appropriate to the resident’s needs and preferences and must meet daily nutritional requirements.

4-006.10A1 Menus must be planned and written based on the Food Guide Pyramid or equivalent and modified to accommodate special diets and texture adaptations as needed by the resident and specified in the resident services agreement. Menus are made accessible to residents.

4-006.10A2 Menus should reflect the food preferences of the resident population to the extent possible.

4-006.10A3 Records of menus with food actually served must be maintained for a period not less than 14 days.

4-006.10B Nutritional Supervision: The facility must monitor residents for potential problems involving nutritional status as follows:

Weigh each resident at the time of admission and record the weight in the resident’s record; and
Weigh each resident identified as having potential problems with nutritional status at least quarterly and record the weight in the resident’s record. The facility must follow up to address or rectify any weight gains or losses that equal or exceed: 7.5% gain or loss in three months or 10% gain or loss in 6 months.

4-006.10C Food Safety: The assisted-living facility must store, prepare, protect, serve and dispose of food in a safe and sanitary manner and in accordance with the Food Code.

4-006.11 Resident Care: Each assisted-living facility must provide residents care and services in accordance with their established resident service agreements which maximize the residents’ dignity, autonomy, privacy and independence.

4-006.11A Evidence that the facility is meeting each resident’s needs for personal care, assistance with activities of daily living and health maintenance include the following outcomes for residents:

4-006.11A1 Physical well-being of the resident:

Clean and groomed hair, skin, teeth and nails;
Nourished and hydrated;
Free of pressure sores, skin breaks, chaps and chafing;
Appropriately dressed for the season in clean clothes;
Protected from accident, injury and infection; and
Receives prompt emergency care for the following but not limited to: illnesses, injuries, and life threatening situations.

4-006.11A2 Behavioral/emotional well-being of the resident:

Opportunity to participate in age appropriate activities that are meaningful to the resident, if desired;
Sense of security and safety;
Reasonable degree of contentment; and
Feeling of stable and predictable environment.

4-006.11A3 In agreement that the resident:

Is free to go to bed at the time desired;
Is free to get up in the morning at the time desired;
Is free to have visitors;
Has privacy;
Is free to self direct his/her own care and treatment and change their plan at any time;
Is assisted to maintain a level of self-care and independence;
Is assisted as needed to have good oral hygiene;
Has been made as comfortable as possible by the facility;
Is free to make choices and assumes the risk of those choices;
Is fully informed of the services he/she can expect to be provided by the facility;
Is free of abuse, neglect and exploitation;
Is treated with dignity; and
Has the opportunity to participate in activities, if desired.

4-006.11B Health Maintenance Activities: All health maintenance activities must be performed in accordance with the Nurse Practice Act and the rules and regulations adopted and promulgated under the act.

4-006.11C Other Supportive Services: A assisted-living facility may provide other supportive services to assist residents. These services could include, but are not limited to: transportation, laundry, housekeeping, financial assistance/management, behavioral management, case management, shopping, beauty/barber and spiritual services.

4-006.11D Special Populations Services: Each assisted-living facility that provides services to special populations such as, but not limited to, those individuals with disabilities, mental impairments, dementia, or other disorders must:

Evaluate each resident to identify the abilities and special needs;
Ensure the administrator and staff assigned to provide care are trained to meet the special needs of those residents. Such training must be done by a person(s) qualified by experience and knowledge in the area of special services being provided;
Prepare and implement each resident service agreement to address the special needs; and
Provide a physical environment that maintains the safety and dignity of residents and accommodates residents’ special needs, such as physical limitations, and visual and cognitive impairments.

4-006.11E Requirements for Facilities or Special Care Units for Persons with Alzheimer’s Disease, Dementia or a Related Disorder: Each assisted-living facility or special care unit that specializes in providing care for persons who have Alzheimer’s disease, dementia or a related disorder must meet the following requirements:

Care and services must be provided in accordance with the resident service agreement and the stated mission and philosophy of the facility.
Prior to admission, the facility must inform the resident or authorized representative in writing of the facility’s criteria for admission, discharge, transfer, resident conduct and responsibilities.
The facility or unit must maintain a sufficient number of direct care staff with the required training and skills necessary to meet the resident population’s requirements for assistance or provision of personal care, activities of daily living, health maintenance activities, supervision and other supportive services. Such staff must remain awake, fully dressed and be available in the facility or unit at all times to provide supervision and care to the residents.
The administrator and direct care staff must be trained in:

a. The facility or unit’s philosophy and approaches to providing care and supervision for persons with Alzheimer’s disease;

b. The Alzheimer’s disease process; and

c. The skills necessary to care for, and intervene and direct residents who are unable to perform activities of daily living, personal care, or health maintenance and who may exemplify behavior problems or wandering tendencies.

The facility must not admit or retain residents if any one of the following conditions exists, unless the criteria in 4-006.07B are met:

a. The resident poses a danger to self or to others; or

b. The resident requires complex nursing interventions.

4-006.12 Record Keeping Requirements: Each assisted-living facility must maintain records and reports in such a manner to ensure accuracy.

4-006.12A Resident Records: Each assisted-living facility must ensure a permanent record of all assisted-living services is established for each resident. The record must be established within five working days of admission.

4-006.12A1 Content: Entries in the permanent resident record must be dated, legible and indelible. The author of each entry must be identified and authenticated. Authentication must include signature, written initials or computer entry. Resident records must contain information that includes, but is not limited to:

Date of admission;
Name of resident;
Gender and date of birth;
Physical description or photo of resident;
Resident Services Agreement;
Licensed practitioner’s orders where applicable;
Significant medical conditions;
Medications and any special diet;
Allergies;
Any unusual event or occurrence;
Person to contact in emergency situations;
Designated physician or registered nurse;
Advance directives if available;
Monthly documentation of assistance with activities of daily living, personal care, health maintenance activities or supervision, if such is required or requested by the resident; and
Date and destination of discharge or transfer.

4-006.12A2 Retention: Each assisted-living facility must maintain and preserve all resident records in original, microfilm, electronic or other similar form, for a period of at least two years from date of resident’s discharge. If a resident is transferred to another licensed health care facility or service, a copy of the record or abstract must be sent with the resident. When an assisted-living facility ceases operation, all resident records must be transferred to the licensed health care facility or health care service to which the resident is transferred. All other resident records that have not reached the required time for destruction must be stored to assure confidentiality and the Department must be notified of the address where stored.

4-006.12A3 Confidentiality: The facility must keep such records confidential and available only for use by authorized persons or as otherwise permitted by law. Records must be available for examination by authorized representatives of the Department.

4-006.12A4 Access: Resident information and/records will be released only with consent of the resident or authorized representative, if applicable, or as permitted by law.

4-006.12A5 Destruction: Resident records may be destroyed only when they are in excess of retention requirements specified in 175 NAC 4-006.12A2. In order to ensure the resident’s right of confidentiality, resident records must be destroyed or disposed of by shredding, incineration, electronic deletion or another equally effective protective measure.

4-006.13 Environmental Services: An assisted-living facility must provide a safe, clean, comfortable and homelike environment, allowing residents to use personal belongings to the extent possible. Every detached building on the same premises used for care and treatment must comply with these regulations.

4-006.13A Housekeeping and Maintenance: The assisted-living facility must provide the necessary housekeeping and maintenance to protect the health and safety of residents.

4-006.13A1 The facility’s buildings and grounds must be kept clean, safe and in good repair.

4-006.13A2 The facility must take into account resident habits and lifestyle preferences when housekeeping services are provided in the resident bedrooms/living area.

4-006.13A3 All garbage and rubbish must be disposed of in such a manner as to prevent the attraction of rodents, flies, and all other insects and vermin. Garbage must be disposed in such a manner as to minimize the transmission of infectious diseases and minimize odor.

4-006.13A4 The facility must maintain adequate lighting, environmental temperatures and sound levels in all areas that are conducive to the care provided.

4-006.13A5 The facility must maintain and equip the premises to prevent the entrance, harborage, or breeding of rodents, flies, and all other insects and vermin.

4-006.13B Equipment, Fixtures, Furnishings: The assisted-living facility must provide and maintain all facility owned equipment, fixtures, and furnishings clean, safe and in good repair.

4-006.13B1 Any specialized assistive devices or equipment needed to meet resident needs must be provided as specified in each resident service agreement.

4-006.13B2 Common areas and resident sleeping areas must be furnished with beds, chairs, sofas, tables, and storage items that are comfortable and reflective of resident needs and preferences. Furnishings may be provided by either the resident or the facility.

4-006.13B3 A process must be established and implemented for routine and preventative maintenance of facility-owned equipment and furnishings to ensure that such equipment and furnishings are safe and function to meet the intended use.

4-006.13C Laundry Services: Bed and bath linens must be provided as specified in the resident service agreement by either the resident or the facility. The resident service agreement must also address if the facility or the resident will be responsible for laundering of resident personal items.

4-006.13C1 When bed and bath linens are provided by the facility, the facility must maintain an adequate supply of clean linens in good repair.

4-006.13C2 The facility must establish and implement procedures for the storage and handling of soiled and clean linens.

4-006.13C3 When the facility launders bed and bath linens and items for more than one resident together, water temperatures to laundry equipment must exceed 140 degrees Fahrenheit or the laundry may be appropriately sanitized or disinfected by another acceptable method in accordance with manufacturer’s instructions.

4-006.13D Pets: The assisted-living facility must assure any facility owned pet does not negatively affect residents. The assisted-living facility must have policies and procedures regarding pets that include:

An annual examination by a licensed veterinarian;
Vaccinations as recommended by the licensed veterinarian that include, at a minimum, current vaccination for rabies for dogs, cats and ferrets;
Provision of pet care necessary to prevent the acquisition and spread of fleas, ticks and other parasites; and
Responsibility for care or supervision of the pet by facility staff.

4-006.13E Environmental Safety: The assisted-living facility is responsible for maintaining the facility in a manner that minimizes accidents.

4-006.13E1 The facility must maintain the environment to protect the health and safety of residents by keeping surfaces smooth and free of sharp edges, mold or dirt; keeping floors free of objects and slippery or uneven surfaces and keeping the environment free of other conditions which may pose a potential risk.

4-006.13E2 The facility must maintain all doors, stairways, passageways, aisles or other means of exit in a manner that provides safe and adequate access for care.

4-006.13E3 The facility must provide and maintain water for bathing and handwashing at safe and comfortable temperatures to protect residents from potential for burns or scalds. The water temperature at resident bathing fixtures must not exceed 115 degrees Fahrenheit, except in existing and new facilities where the resident is capable of managing water temperatures.

4-006.13E4 The facility must ensure hazardous/poisonous materials utilized by the facility are properly handled and stored to prevent accidental ingestion, inhalation, or consumption of the hazardous/poisonous materials by residents.

4-006.13E5 The facility must restrict access to mechanical equipment which may pose a danger to residents.

4-006.13F Disaster Preparedness and Management: The assisted-living facility must establish and implement disaster preparedness plans and procedures to ensure that resident care, safety, and well-being are provided and maintained during and following instances of natural (tornado, flood, etc.) or other disasters, disease outbreaks, or other similar situations. Such plans and procedures must address and delineate:

How the facility will maintain the proper identification of each resident to ensure that care coincides with the resident’s needs;
How the facility will move residents to points of safety or provide other means of protection when all or part of the building is damaged or uninhabitable due to natural or other disaster;
How the facility will protect residents during the threat of exposure to the ingestion, absorption, or inhalation of hazardous substances or materials;
How the facility will provide food, water, medicine, medical supplies, and other necessary items for care in the event of a natural or other disaster; and
How the facility will provide for the comfort, safety, and well-being of residents in the event of 24 or more consecutive hours of:

a. Electrical or gas outage;

b. Heating, cooling, or sewer system failure; or

c. Loss or contamination of water supply.

4-007 PHYSICAL PLANT STANDARDS : Assisted-living facilities must be designed, constructed and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided. The physical plant standards for assisted-living facilities, which include support services, care and treatment areas, construction standards, building systems and waivers, are set forth below.

4-007.01 Support Areas: The assisted-living facility may share the following support service areas among detached structures, care and treatment areas, or with other licensed facilities.

4-007.01A Dietary: If food preparation is provided on site, the assisted-living facility must dedicate space and equipment for the preparation of meals. Food service physical environment and equipment must comply with the Food Code. Locations providing food services for 16 or fewer residents, or used only for training or activity purposes, must comply with the Food Code, except that:

Instead of a three compartment food preparation and handwashing sink, a two-compartment sink may used for clean-up, dishwashing, and handwashing;
Instead of a final rinse cycle temperature of not less than 160 degrees Fahrenheit, an automatic dishwasher may have a final rinse cycle temperature not less than 150 degrees Fahrenheit;
Instead of storage space for food items and cooking and serving utensils no less than six inches above the floor, such space may be no less than four inches above the floor; and
Service sink and indirect waste plumbing connections are optional.

4-007.01B Laundry: If the assisted-living facility provides laundry services, such service may be provided by contract or on-site by the facility.

4-007.01B1 Contract: If contractual services are used, the facility must provide and utilize areas for soiled linen awaiting pickup and separate areas for storage and distribution of clean linen.

4-007.01B2 On-site: If on-site services are provided, the facility must have areas dedicated to laundry.

4-007.01B2a If personal laundry areas are provided, the areas must be equipped with a washer and dryer for use by residents. In new construction, the facility must provide a conveniently located sink for soaking and hand washing of laundry.

4-007.01B2b When the facility launders items for more than one resident together, the bulk laundry area must be divided into separate soiled (sort and washer areas) and clean (drying, folding and mending areas) rooms. In new construction, the facility must provide a conveniently located sink for soaking and hand washing of laundry and a housekeeping room.

4-007.01C Waste Processing: The assisted-living facility must provide areas to collect, contain, process, and dispose of waste produced within the facility in such a manner as to prevent the attraction of rodents, flies, and all other insects and vermin, and to minimize the transmission of infectious diseases.

4-007.01D Cosmetology and Barber: When provided, cosmetology and barber services must be in conformance with the Nebraska Cosmetology Act, Neb. Rev. Stat. §§ 71-340 to 71-3,238, and the Barber Act, Neb. Rev. Stat. §§ 71-201 to 71-248.

4-007.01E Pharmaceutical: When provided, pharmacy services must be in conformance with Neb. Rev. Stat. §§ 71-1,142 to 71-1,147.61.

4-007.02 Care and Treatment Areas: The assisted-living facility must not share the following care and treatment areas among detached structures or with other facilities operated by another licensee:

4-007.02A Equipment and Supplies: The facility must have space for equipment and supplies required for the care of residents as specified in the resident service agreements.

4-007.02B Alzheimer’s, Dementia, and Related Disorders: In a facility or a distinct part of a facility that provides services to residents with Alzheimer’s, dementia, and related disorders there must be personalized resident bedrooms, private and group activity areas, separate dining areas, features that support resident orientation to their surroundings, secured storage for equipment and supplies, call and security systems, and an area for medication storage and distribution.

4-007.02C Outpatient Areas: Areas for the care and treatment of residents not residing in the facility must:

Not interfere with residents living in the facility; and
Have a toilet room that is easily accessible from all program areas.

4-007.03 Construction Standards: All assisted-living facilities must be designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided. The standards for such facilities are set forth below.

4-007.03A Codes and Guidelines

4-007.03A1 New Construction: New construction must comply with the following codes and guidelines to provide a safe and accessible environment that is conducive to the care and treatment to be provided:

Building: Building Construction Act, Neb. Rev. Stat. §§ 71-6401 to 71-6407;
Plumbing: Plumbing Ordinance or Code, Neb. Rev. Stat. § 18- 1915;
Electrical: State Electrical Act, Neb. Rev. Stat. §§ 81-2101 to 81-2143;
Elevators: Nebraska Elevator Code, Neb. Rev. Stat. § 48-418.12 and Department of Labor Regulations, 230 NAC 1;
Boiler: Boiler Inspection Act, Neb. Rev. Stat. §§ 48-719 to 48-743;
Accessibility: Nebraska Accessibility Requirements, State Fire Marshal Regulations, 156 NAC 1 to 12; and
Energy: Nebraska Energy Code, Neb. Rev. Stat. §§ 81-1608 to 81-1626, for construction initiated on or after July 1, 2005.

4-007.03A2 All Facilities: All facilities must comply with the following applicable codes and standards to provide a safe environment.

Fire Codes: Nebraska State Fire Code Regulations State Fire Marshal, 153 NAC 1; and
Food Code: Neb. Rev. Stat. § 81-2,244.01, as published by the Nebraska Department of Agriculture, except for compliance and enforcement provisions.

4-007.03A3 Existing and New Facilities: Existing and new facilities must comply with the physical plant standards contained in 175 NAC 4-007. The facility must maintain all building materials and structural components so that total loads imposed do not stress materials and components more than one and one-half times the working stresses allowed in the building code for new buildings of similar structure, purpose or location.

4-007.03B Conflicts in Standards: In situations where the referenced codes and guidelines conflict with these regulations, the adopted rules and regulations of the Department and the Nebraska State Fire Marshal will prevail.

4-007.03C Interpretations: Floor area means dimension, sizes, and quantities; noted herein must be determined by rounding fractions to the nearest whole number.

4-007.03D Floor Area: Floor area means space with ceilings at least seven feet in height and does not include areas such as enclosed storage, toilets and bathing rooms, corridors and halls. The space beyond the first two feet of vestibules and alcoves less than five feet in width must not be included in the required floor area. In rooms with sloped ceilings, at least half of the ceiling must be at least seven feet in height with areas less than five feet in height, not included in the required floor area.

4-007.03E Dining Areas: Dining areas for residents must have an outside wall with windows for natural light and ventilation.

4-007.03E1 Dining areas must be furnished with tables and chairs that accommodate or conform to resident’s needs.

4-007.03E2 Dining areas must have a floor area of 15 square feet per resident in existing facilities and 20 square feet per resident in new construction.

4-007.03E3 Dining areas must allow for group dining at the same time in either separate dining areas or a single dining area, or dining in two shifts, or dining during open dining hours.

4-007.03E4 Dining areas must not be used for sleeping, offices or corridors.

4-007.03F Activity Areas: An assisted-living facility must have space for resident socialization and leisure time activities.

4-007.03F1 Activity areas must have furnishings to accommodate group and individual activities.

4-007.03F2 Activity areas must not be used for sleeping, offices, or as a corridor.

4-007.03G Bathing Rooms: An assisted-living facility must provide a bathing room consisting of a tub and/or shower adjacent to each bedroom or provide a central bathing room. Tubs and showers regardless of location must be equipped with hand grips or other assistive devices as needed or desired by the bathing resident.

4-007.03G1 In new construction where a central bathing room is provided, the room must open off the corridor and contain a toilet and sink or have an adjoining toilet room. A bathing room must not directly open into a dining/kitchen area.

4-007.03G2 Bathing Fixtures: The facility must have the following minimum number of bathing fixtures:

One fixture per 16 licensed beds in existing facilities; and
One fixture per eight licensed beds in new facilities and new construction.

4-007.03H Toilet Rooms: The assisted-living facility must provide toilet rooms with handwashing sinks for resident use.

4-007.03H1 Facilities must have a toilet and sink adjoining each bedroom or shared toilet rooms may be provided as follows:

One toilet fixture per six licensed beds in existing facilities;
One toilet fixture per four licensed beds in new facilities; and
One toilet room adjoining each resident’s bedroom in new construction.

4-007.03I Resident Bedrooms: The assisted-living facility must provide resident bedrooms which allow for sleeping, afford privacy, provide access to furniture and belongings, and accommodate the care and treatment provided to the resident.

4-007.03I1 Resident Bedrooms:

Must not be located in any garage, storage area, shed or similar detached buildings;
Must be a single room located within an apartment, dwelling, or dormitory-like structure;
Must not be accessed through a bathroom, food preparation area, laundry or another bedroom;
Must be located on an outside wall with an operable window and a minimum size of six square feet per resident. Such window must be provided an unobstructed view of at least ten feet;
Must contain at least 45 cubic feet of enclosed storage volume per resident in dressers, closet, or wardrobes; and

6.Which contain multiple beds must allow for an accessible arrangement of furniture, which provides a minimum of 3 feet between beds.

4-007.03I2 Existing or New Facility: Resident bedrooms in existing and new facilities must have at least the following floor areas:

Floor areas for single resident rooms must be 80 square feet;
Floor areas for multiple bed resident rooms must be 60 square feet per occupant with a maximum of four beds; or
Floor area for apartments or dwellings must have 120 square feet for one resident plus 100 square feet for each additional resident.

4-007.03I3 New Construction: Resident bedrooms in new construction must have at least the following floor areas:

Floor areas for single resident rooms must be 100 square feet;
Floor areas for multiple bed resident rooms must be 80 square feet per bed with a maximum of 2 beds; or
Floor area for apartments or dwellings must have 150 square feet for one resident plus 110 square feet for each additional resident.

4-007.03J Examination Rooms: If provided, each examination room must have a minimum floor area of 80 square feet and a minimum of 3 feet clear dimension around 3 sides of the examination table or chair. A handwashing sink equipped with towel and soap dispenser must be in the room.

4-007.03K Areas Used by All Residents: Existing licensed facilities, new facilities and new construction must comply with the following:

The facility corridors and doors must be wide enough to allow passage and be equipped as needed by the residents with safety and assistive devices to minimize resident injury;
All stairways and ramps must have handrails;
Doors to resident rooms must provide privacy yet not create seclusion or prohibit staff access for routine or emergency care;
The facility must provide space for administrative offices, and storage space for such things as records, supplies and equipment; and
The facility must provide an outdoor area for resident usage. It must be equipped and situated to allow for resident safety.

4-007.04 Building Systems: Assisted-living facilities must have building systems that are designed, installed and operated in such a manner as to provide for the safety, comfort, and well being of the resident.

4-007.04A Water and Sewer Systems: The assisted-living facility must have and maintain an accessible, adequate, safe and potable supply of water. Where an authorized public water supply of satisfactory quantity, quality, and pressure is available, the facility must be connected to it and its supply used exclusively.

4-007.04A1 The collection, treatment, storage, and distribution potable water system of a facility that regularly services 25 or more individuals must be constructed, maintained, and operated in accordance with all provisions of the Nebraska Safe Drinking Water Act and Title 179 Regulations Governing Public Water Systems.

4-007.04A2 The collection, treatment, storage and distribution potable water system of a facility that serves less than 25 individuals on a regular basis must be maintained and operated as if it were a public water system in accordance with the Regulations Governing Public Water Systems, 179 NAC 2-002, 3 and 4. The facilities must report to the Department the result of all tests that indicate the water is in violation of the standards set out in 179 NAC 2-002 or 3. The facilities must construct all water wells in accordance with 178 NAC 12, Water Well Construction, Pump Installation, and Water Well Decommissioning Standards.

4-007.04A3 The water distribution system must be protected with anti-siphon devices, and air-gaps to prevent potable water system and equipment contamination.

4-007.04A4 The facility must maintain a sanitary and functioning sewage system.

4-007.04B Hot Water System: The hot water system must have the capacity to provide continuous hot water temperatures as required by these regulations.

4-007.04C Heating and Cooling Systems: The assisted-living facility must provide a heating and air conditioning system for the comfort of the resident and capable of producing temperatures in resident care and treatment areas as follows:

4-007.04C1 In existing and new facilities the systems must be capable of producing a temperature of at least 70 degrees Fahrenheit during heating conditions and a temperature that does not exceed 85 degrees Fahrenheit during cooling conditions.

4-007.04C2 In new construction the systems must be capable of producing a temperature of at least 75 degrees Fahrenheit during heating conditions and a temperature that does not exceed 80 degrees Fahrenheit during cooling conditions.

4-007.04C3 In new construction the central air distribution and return systems must be equipped with filters.

4-007.04C4 Airflow must move from clean to soiled locations. In new construction, air movement must be designed to reduce the potential of contamination of clean areas.

4-007.04D Ventilation System: All assisted-living facilities must provide exhaust and clean air to prevent the concentrations of contaminants which impair health or cause discomfort to residents and employees.

4-007.04D1 Existing facilities must have adequate ventilation.

4-007.04D2 New construction and new facilities must provide mechanical exhaust ventilation for windowless toilets, baths, laundry rooms, housekeeping rooms, kitchens, and similar rooms at five air changes per hour.

4-007.04E Electrical System: The assisted-living facility must have an electrical system that has sufficient capacity to maintain the care and treatment services that are provided and that properly grounds care and treatment areas.

4-007.04E1 New construction and new facilities must have ground fault circuit interrupters protected outlets in wet areas and within 6 feet of sinks.

4-007.04E2 All facilities must provide minimum illumination levels as follows:

General purpose areas 5 foot candles;
General corridors and resident living areas 10 foot candles;
Personal care and dining areas 20 foot candles;
Reading and activity areas 30 foot candles;
Food preparation areas 40 foot candles;
Hazardous work surfaces 50 foot candles;
Examination task lighting and 100 foot candles;
Reduced night lighting in corridors, resident toilet and bathing rooms.

Light levels are measured at 30 inches above the floor in multiple areas in the room being evaluated and the readings are averaged.

4-007.04F Call Systems: Call system(s) must be operable from resident rooms, care and treatment locations, and all toilet and bathing areas used by residents. The system must transmit a receivable (visual, audible, tactile, or other) signal to on-duty staff which readily notifies and directs the staff to the location where the call was activated.

4-007.04F1 New facilities and new construction with a capacity of more than 16 residents must be equipped with a call system or other call devices which may be worn.

4-007.04F2 Wireless call systems must have dedicated devices in all resident occupied central toilet and bathing locations to promptly summon staff to the location where the call was activated.

4-007.04F3 Existing facilities without a call system are not required to provide a call system.

4-007.05 Waivers: The Department may waive any provision of 175 NAC 4 relating to construction or physical plant requirements of an assisted-living facility upon proof by the licensee satisfactory to the Department (1) that the waiver would not unduly jeopardize the health, safety, or welfare of the persons residing in the facility, (2) that the provision would create an unreasonable hardship for the facility, and (3) that the waiver would not cause the State of Nebraska to fail to comply with any applicable requirements of Medicare or Medicaid so as to make the state ineligible for the receipt of all funds to which it might otherwise be entitled.

4-007.05A Unreasonable Hardship: In evaluating the issue of unreasonable hardship, the Department will consider the following:

The estimated cost of the modification or installation;
The extent and duration of the disruption of the normal use of areas used by persons residing in the assisted-living facility resulting from construction work;
The estimated period over which the cost would be recovered through reduced insurance premiums and increase reimbursement related to costs;
The availability of financing; and
The remaining useful life of the building.

4-007.05B Waiver Terms and Conditions: Any waiver may be granted under the terms and conditions and for such period of time as are applicable and appropriate to the waiver. Terms and conditions and period of waiver include but are not limited to:

Waivers that are granted to meet the special needs of a resident remain in effect as long as required by the resident;
Waivers may be granted for a period of time that ends at the time the conditions of approval no longer exist;
Waivers may be granted to permit an assisted-living facility time to come into compliance with the physical plan standards for a period of one year. Upon submission of proof of ongoing progress, the waiver may be continued for an additional year; and
An applicant or licensee must submit a request for waiver of any construction or physical plant requirements set forth in 175 NAC 4. An applicant for a waiver may construct a request for waiver form or obtain a form from the Department.

4-007.05C Denial of Waiver: If the Department denies an assisted-living facility’s request for waiver, the facility may request an administrative hearing as provided in the Administrative Procedure Act (APA) and the Department’s rules and regulations adopted and promulgated under the APA.

4-008 DENIAL, REFUSAL TO RENEW, OR DISCIPLINARY ACTION

4-008.01 Grounds for Denial, Refusal to Renew, or Disciplinary Action

4-008.01A The Department may deny or refuse to renew an assisted-living facility license for failure to meet the requirements for licensure, including:

Failing an inspection specified in 175 NAC 4-005;
Having had a license revoked within the two-year period preceding an application; or
Any of the grounds specified in 175 NAC 4-008.01B.

4-008.01B The Department may take disciplinary action against an assisted-living facility license for any of the following grounds:

Violation of any of the provisions of the Assisted-Living Facility Act, the Health Care Facility Licensure Act or 175 NAC 4;
Committing, permitting, aiding, or abetting the commission of any unlawful act;
Conduct or practices detrimental to the health or safety of an assisted-living resident or employee;
A report from an accreditation body or public agency sanctioning, modifying, terminating, or withdrawing the accreditation or certification of the assisted-living facility;
Failure to allow an agent or employee of the Department of Health and Human Services, the Department of Health and Human Services Finance and Support, or the Department of Health and Human Services Regulation and Licensure access to the assisted-living facility for the purposes of inspection, investigation, or other information collection activities necessary to carry out the duties of the departments;
Discrimination or retaliation against an assisted-living facility resident or employee who has submitted a complaint or information to the Department of Health and Human Services, the Department of Health and Human Services Finance and Support, or the Department of Health and Human Services Regulation and Licensure;
Discrimination or retaliation against an assisted-living facility resident or employee who has presented a grievance or information to the office of the state long-term care ombudsman;
Failure to allow a state long-term care ombudsman or an ombudsman advocate access to the assisted-living facility for the purposes of investigation necessary to carry out the duties of the office of the state long-term care ombudsman as specified in 15 NAC 3;
Violation of the Emergency Box Drug Act;
Failure to file a report of payment or action taken due to a liability claim or an alleged violation, as required by Neb. Rev. Stat. § 71-168.02;
Violation of the Medication Aide Act; or
Failure to file a report of suspected abuse or neglect as required by Neb. Rev. Stat. §§ 28-372 and 28-711.

4-008.02 Procedures for Denial, Refusal to Renew, or Disciplinary Action

4-008.02A If the Department determines to deny, refuse renewal of, or take disciplinary action against a license, the Department will send a notice to the applicant or licensee, by certified mail to the last address shown on its records. The notice will state the determination, including a specific description of the nature of the violation and the statute or regulation violated, and the type of disciplinary action pending.

4-008.02B The denial, refusal to renew, or disciplinary action will become final 15 days after the mailing of the notice unless the applicant or licensee, within the 15-day period, makes a written request to the Director for an informal conference or an administrative hearing.

4-008.02C Informal Conference

4-008.02C1 At the request of the applicant or licensee, the Department will hold an informal conference within 30 days of the receipt of the request. The conference must be held in person or by other means, at the request of the applicant or licensee. If the pending action is based on an inspection, the Department’s representative at the conference will not be the individual who did the inspection.

4-008.02C2 Within 20 working days of the conference, the Department representative will state in writing the specific reasons for affirming, modifying, or dismissing the notice. The representative will send a copy of the statement to the applicant or licensee by certified mail to the last address shown in the Department’s records and a copy to the Director.

4-008.02C3 If the applicant or licensee successfully demonstrates at the informal conference that the deficiencies should not have been cited in the notice, the Department will remove the deficiencies from the notice and rescind any sanction imposed solely as a result of those cited deficiencies.

4-008.02C4 If the applicant or licensee contests the affirmed or modified notice, the applicant or licensee must submit a request for hearing in writing to the Director within five working days after receipt of the statement.

4-008.02D Administrative Hearing

4-008.02D1 When an applicant or a licensee contests the notice and request a hearing, the Department will hold a hearing in accordance with the Administrative Procedure Act (APA) and the Department’s rules and regulations adopted and promulgated under the APA. Either party may subpoena witnesses, who must be allowed fees at the rate prescribed by Neb. Rev. Stat. §§ 33-139 and 33-139.01.

4-008.02D2 On the basis of evidence presented at the hearing, the Director will affirm, modify, or set aside the determination. The Director’s decision will:

Be in writing;
Be sent by registered or certified mail to the applicant or licensee; and
Become final 30 days after mailing unless the applicant or licensee, within the 30-day period, appeals the decision.

4-008.02D3 An applicant or a licensee’s appeal of the Director’s decision must be in accordance with the APA .

4-008.03 Types of Disciplinary Action

4-008.03A The Department may impose any one or a combination of the following types of disciplinary action against the license:

A fine not to exceed $10,000 per violation;
A prohibition on admissions or re-admissions, a limitation on enrollment, or a prohibition or limitation on the provision of care or treatment;
A period of probation not to exceed two years during which the assisted-living facility may continue to operate under terms and conditions fixed by the order of probation;
A period of suspension not to exceed three years during which the assisted-living facility may not operate; and
Revocation, which is a permanent termination of the license. The licensee may not apply for a license for a minimum of two years after the effective date of the revocation.

4-008.03B In determining the type of disciplinary action to impose, the Department will consider:

The gravity of the violation, including the probability that death or serious physical or mental harm will result;
The severity of the actual or potential harm;
The extent to which the provisions of applicable statutes, rules, and regulations were violated;
The reasonableness of the diligence exercised by the assisted-living facility in identifying or correcting the violation;
Any previous violations committed by the assisted-living facility; and
The financial benefit to the assisted-living facility of committing or continuing the violation.

4-008.03C If the licensee fails to correct a violation or to comply with a particular type of disciplinary action, the Department may take additional disciplinary action as described in 175 NAC 4-008.03A.

4-008.03D Temporary Suspension or Temporary Limitation: If the Department determines that residents of the assisted-living facility are in imminent danger of death or serious physical harm, the Director may:

Temporarily suspend or temporarily limit the assisted-living facility license, effective when the order is served upon the assisted-living facility. If the licensee is not involved in the daily operation of the assisted-living facility, the Department will mail a copy of the order to the licensee, or if the licensee is a corporation, to the corporation’s registered agent;
Order the immediate removal of residents; or
Order the temporary closure of the assisted-living facility pending further action by the Department.

The Department will simultaneously institute proceedings for revocation, suspension, or limitation of the license, and will conduct an administrative hearing no later than ten days after the date of the temporary suspension or temporary limitation.

4-008.03D1 The Department will conduct the hearing in accordance with the Administrative Procedure Act (APA) and the Department’s rules and regulations adopted and promulgated under the APA. Either party may subpoena witnesses, who must be allowed fees at the rate prescribed by Neb. Rev. Stat. §§ 33-139 and 33-139.01.

4-008.03D2 If the licensee makes a written request for continuance of the hearing, the Department will grant a continuance, which may not exceed 30 days.

4-008.03D3 On the basis of evidence presented at the hearing, the Director will:

Order the revocation, suspension, or limitation of the license; or
Set aside the temporary suspension or temporary limitation.

If the Director does not reach a decision within 90 days of the date of the temporary suspension or temporary limitation, the temporary suspension or temporary limitation will expire.

4-008.03D4 Any appeal of the Department’s decision after hearing must be in accordance with the APA.

4-008.04 Reinstatement from Disciplinary Probation or Suspension, and Re-Licensure After Revocation

4-008.04A Reinstatement at the End of Probation or Suspension

4-008.04A1 Reinstatement at the End of Probation: A license may be reinstated at the end of probation after the successful completion of an inspection, if the Department determines an inspection is warranted.

4-008.04A2 Reinstatement at the End of Suspension: A license may be reinstated at the end of suspension following:

Submission of an application to the Department for renewal that conforms to the requirements of 175 NAC 4-003.02;
Payment of the renewal fee as specified in 175 NAC 4-004.09; and
Successful completion of an inspection.

The Department will reinstate the license when it finds, based on an inspection as provided for in 175 NAC 4-005, that the assisted-living facility is in compliance with the operation, care, treatment, and physical plant requirements of 175 NAC 4-006 and 4-007.

4-008.04B Reinstatement Prior to Completion of Probation or Suspension

4-008.04B1 Reinstatement Prior to the Completion of Probation: A licensee may request reinstatement prior to the completion of probation and must meet the following conditions:

Submit a petition to the Department stating:

a. The reasons why the license should be reinstated prior to the probation completion date; and

b. The corrective action taken to prevent recurrence of the violation(s) that served as the basis of the probation; and

Successfully complete any inspection that the Department determines necessary.

4-008.04B2 Reinstatement Prior to Completion of Suspension: A licensee may request reinstatement prior to the completion of suspension and must meet the following conditions:

Submit a petition to the Department stating:

a. The reasons why the license should be reinstated prior to the suspension completion date; and

b. The corrective action taken to prevent recurrence of the violation(s) that served as the basis of the suspension;

Submit a written renewal application to the Department as specified in 175 NAC 4-003.02;
Pay the renewal fee as specified in 175 NAC 4-004; and
Successfully complete an inspection.

4-008.04B3 The Director will consider the petition submitted and the results of any inspection or investigation conducted by the Department and:

Grant full reinstatement of the license;
Modify the probation or suspension; or
Deny the petition for reinstatement.

4-008.04B4 The Director’s decision is final 30 days after mailing the decision to the licensee unless the licensee requests a hearing within the 30-day period. The requested hearing will be held according to rules and regulations of the Department for administrative hearings in contested cases.

4-008.04C Re-Licensure After Revocation: An assisted-living facility license that has been revoked is not eligible for re-licensure until two years after the date of revocation.

4-008.04C1 An assisted-living facility seeking re-licensure must apply for an initial license and meet the requirements for initial licensure in 175 NAC 4-003.01.

4-008.04C2 The Department will process the application for re-licensure in the same manner as specified in 175 NAC 4-003.01.

History

Effective 2007-04-03

Chapter 5 Adult Day Service

Neb. Admin. Code tit. 175, ch. 5 Adult Day Service {#sec-175-nac-5 omnilex-key=us-ne-regs-official--title-175--175 NAC 5}

001. SCOPE AND AUTHORITY . These regulations govern licensing of adult day services under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479. These regulations do not apply to adult day services provided in a licensed health care facility to consumers of that licensed facility.

002. DEFINITIONS . The definitions in the Health Care Facility Licensure Act, in 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.

002.01 ABUSE. Any knowing, intentional, or negligent act or omission on the part of a person which results in physical, sexual, verbal, or mental abuse, unreasonable confinement, cruel punishment, exploitation, or denial of care, treatment, or services to a consumer.

002.02 AGREEMENT OF PARTICIPATION. A written agreement negotiated between the adult day service and the consumer served or designee.

002.03 CAREGIVER. For the purpose of this chapter, has the same meaning as caretaker found in Neb. Rev. Stat. § 71-6721.

002.04 COMMUNITY-BASED. Serving consumers at a defined location outside of the consumer’s home or a health care facility not licensed as an adult day service.

002.05 DEVICE. An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is prescribed by a medical practitioner and dispensed by a pharmacist or other person authorized by law to do so.

002.06 EVALUATION. A written action plan based on the identified needs of the consumer and the strategy for providing care to meet those needs.

002.07 EXPLOITATION. The taking of property of a consumer by means of undue influence, breach of a fiduciary relationship, deception, or extortion or by any unlawful means.

002.08 FOOD CODE. As defined in Neb. Rev. Stat. § 81-2,244.01 and as published by the Nebraska Department of Agriculture, except for compliance and enforcement provisions.

002.09 FUNCTIONAL IMPAIRMENT. A condition marked by physical disabilities such as sensory loss, loss of mobility, incontinence, loss of speech, and mental or emotional disabilities such as social isolation, depression, or behavioral disorders.

002.10 MENTAL ABUSE. Humiliation, harassment, threats of punishment or deprivation, or other actions causing mental anguish.

002.11 NEGLECT. A failure to provide care, treatment, or services necessary to avoid physical harm or mental anguish of a consumer.

002.12 PHYSICAL ABUSE. Hitting, slapping, pinching, kicking, or other actions causing injury to the body.

002.13 SERVICE PLAN. A written action plan based on evaluation and assessment data that identifies the consumer’s needs and the strategy for addressing care, treatment, and services to meet those needs within the scope of the adult day service.

002.14 SEXUAL ABUSE. Sexual harassment, sexual coercion, or sexual assault.

002.15 SOCIAL SERVICES. Those activities that assist the consumer in carrying out their therapeutic activities as outlined in their agreement of participation.

002.16 SUPERVISION. The daily observation and monitoring of the consumer by direct care staff and oversight of staff by the administrator or administrator’s designee.

002.17 SUPPORTIVE SERVICES. Services which support personal care, provision of medications, activities of daily living, and health maintenance activities.

002.18 THERAPEUTIC ACTIVITY. A professionally directed set of actions designed to improve, maintain, or lessen the decline of physical, cognitive, or social functioning.

002.19 VERBAL ABUSE. The use of oral, written, or gestured language including disparaging or derogatory terms to consumers or within hearing distance of the consumer or within the consumer’s sight.

002.20 5 RIGHTS. The meaning found in Neb. Rev. Stat. § 71-6721.

003. LICENSING REQUIREMENTS . For all applications for initial licensure, renewal and reinstatement, an applicant or licensee must meet all requirements at 175 NAC 1-003, must meet the setting requirements as shown below, and must include the licensure fees as shown below.

003.01 ADULT DAY SERVICE SETTINGS. Adult day services may be provided in the following settings:

003.01(A) FREE-STANDING ADULT DAY SERVICE. An adult day service license is required when 4 or more persons are receiving adult day services in a location that is not licensed as another type of health care facility.

003.01(B) ADULT DAY SERVICE IN A LICENSED HEALTH CARE FACILITY. A separate adult day service license is required when a licensed facility provides adult day services to 4 or more consumers who do not reside at the licensed health care facility. The adult day service must have separate identifiable space available for adult day service activities during the hours adult day services are provided.

003.02 INITIAL AND RENEWAL LICENSURE FEES. The following fees apply:

(A) Programs with license capacity of 4-16 $200 (B) Programs with license capacity of 17-50 $250 (C) Programs with license capacity of 51 and up $300

004. INSPECTIONS . The adult day service must meet all inspection requirements shown at 175 NAC 1-004. Reserved for future use.

005. GENERAL REQUIREMENTS . The following requirements are applicable to all licensees.

005.01 NOTIFICATIONS. The licensee must:

(A) Meet notification requirements at 175 NAC 1-005.01 (A), (D), (E), (F), (G)(i) through (G)(v); and (B) Notify the Department in writing at least 30 working days before the facility would like to increase their license capacity, would like a change in the building, would like a change in location, or would like a change in the usage of the building.

005.02 EFFECTIVE DATE AND TERM OF LICENSE. The adult day service license expires on July 31 of each year.

005.03 CHANGE OF OWNERSHIP. Change of ownership or premises terminates the license. If there is a change of ownership and the adult day service remains on the same premises, the inspection in 175 NAC 1-004 and 175 NAC 5-004 is not required. If the adult day service changes premises, it must pass the inspection specified in 175 NAC 1-004 and 175 NAC 5-004.

005.04 OCCUPANCY. The adult day service must not serve more consumers at 1 time than the maximum occupancy for which the adult day service is licensed.

006. CONSTRUCTION . In new construction, the licensee must:

(A) Provide a conveniently located sink for soaking and hand washing of laundry, when laundry services are provided on-site at the adult day service; and (B) Locate toilet rooms no more than 40 feet from program and activity areas.

007. PHYSICAL PLANT . When an adult day service is located in a licensed health care facility or shares space with another entity, the licensee must ensure the adult day service has a unique physical address to ensure mail is secured against unauthorized access and must ensure a separate entrance to the adult day service space to ensure verbal communications are protected against unauthorized access. A licensee must maintain the facility it operates in a manner that is safe, clean, and functional and meets the requirements in this chapter.

007.01 LINENS. The licensee must provide a supply of clean linens and maintain all linens in good repair. The licensee must implement procedures for the storage and handling of soiled and clean linens.

007.02 DIETARY. If food preparation is provided on site, there must be dedicated space and equipment for the preparation and serving of meals. Such food preparation, serving, physical environment, and equipment must comply with the Food Code.

007.03 DESIGNED AND EQUIPPED. A site must be designed to meet the needs of consumers served. The licensee service must consider factors such as appropriate and sufficient space, accessibility, equipment, furnishings, lighting, noise control, room temperatures, and ventilation. The licensee must implement a written process for routine and preventative maintenance of equipment, fixtures, and furnishings to assure each are safe for use by staff and consumers and function in accordance with manufacturer’s recommendations.

007.04 LAUNDRY. If laundry services are provided, these services may be provided by contract or on-site by the adult day service.

007.04(A) CONTRACT. If contractual laundry services are used, areas for soiled linen awaiting pickup and separate areas for storage and distribution of clean linen must be provided and used.

007.04(B) ON-SITE. If on-site laundry services are provided, areas dedicated to laundry that include a washer and dryer must be provided and used.

007.05 CONSUMER LIVING AREAS. Living areas must have chairs, sofas, tables, and storage items that are comfortable and reflective of individual needs. A garage, barn, shed, or similar structure cannot be used as a consumer living area.

007.06 DINING AREAS. Space for dining, socialization, and leisure activities must be provided. Dining areas must:

(A) Have tables and chairs that meet the consumers’ needs; (B) Not be used for sleeping, offices, or as a corridor; and (C) Be arranged so that all consumers are able to eat meals at an appropriate time by having:

(i) All consumers eat at the same time; (ii) Consumers eat in different shifts; or (iii) Open times for consumer meals.

007.07 ACTIVITY AREAS. The activity areas must:

(A) Have furnishings to accommodate group and individual activities; (B) Not be used for sleeping, offices, or as a corridor; and (C) Be available to all consumers.

007.08 TOILET ROOMS. 1 toilet fixture for every 10 consumers must be provided. Hand washing sinks must be located near the toilet fixtures.

007.09 SLEEPING AREAS. The licensee must provide adult day services for a period of less than 24 consecutive hours. If consumers are served overnight, the adult day service must provide a sleeping area which affords privacy, provides access to furniture, and accommodates the care, treatment and services provided to the consumers. Sleeping rooms must:

(A) Not be located in a garage, storage area, shed, or similar detached buildings; and (B) Not be accessed through a bathroom, food preparation area, laundry, or bedroom.

007.10 CONSUMER STORAGE. Storage for consumers’ belongings must be provided.

007.11 DOORS. Doors must be wide enough to allow passage and be equipped for privacy, safety, and with assistive devices to minimize consumer injury, including the following:

(A) Toilet and bathing room doors must provide privacy yet not create seclusion or prohibit staff access for routine or emergency care; and (B) The door of a toilet or bathing room with less than 50 square feet of clear floor area and dedicated to consumer use must not swing inward.

007.12 BATHING ROOMS. If the licensee provides bathing services, the bathing room must have a tub or shower. Tubs and showers used by consumers must be equipped with handgrips or other assistive devices as needed by the consumer. The bathing room must not open directly into a dining or kitchen area.

007.13 ADDITIONAL SERVICES. If the licensee provides additional medical or therapy services, there must be space provided to assure privacy and appropriate care.

007.14 OUTDOOR AREAS. When the licensee provides an outdoor area for consumer use, it must be equipped and situated to allow for consumer safety and abilities.

008. RECORDKEEPING . When an adult day service is located in a licensed health care facility or shares space with another entity, the licensee must ensure all adult day service records are maintained at the unique physical address shown on the active adult day service license and must prevent unauthorized access to such records by other entities sharing the space.

009. ENVIRONMENTAL SERVICES . The licensee must implement a written process for routine and preventative maintenance of equipment and furnishings to ensure the equipment and furnishings are safe and function to meet the intended use.

010. STANDARDS OF OPERATION AND CARE . All licensees must meet the following requirements.

010.01 LICENSEE. The licensee is responsible for implementing written policies and procedures to ensure compliance with statutes and regulations as per 175 NAC 1, the Health Care Facility Licensure Act, and this chapter and is responsible for making such available to staff and consumers. The licensee’s responsibilities include:

(A) Ensure all services are provided in accordance with accepted standards of practice and oversee the management and fiscal affairs of the adult day service; (B) Ensure the quality of all care, treatment, and services provided to consumers, whether furnished by the adult day service staff or through contract with the adult day service; (C) Ensuring consumers are provided with a stable and supportive environment, through respect for the rights of consumers and responsiveness to consumer needs; (D) Ensuring that staff levels are sufficient to meet the consumers’ needs; (E) Monitoring policies and procedures to assure the appropriate administration and management of the adult day service; (F) Designating an administrator who is responsible for the day-to-day management of the adult day service and defining the duties, qualifications, and responsibilities of the administrator in writing; (G) Establishing policies and procedures to implement its program description as described in 175 NAC 5; (H) Reviewing all elements of the program description as described in 175 NAC 5 at least annually and must include, in this review process, relevant findings from its quality assurance and improvement program for the purpose of improving consumer services and resolving problems in consumer care, treatment and services; and (I) Ensuring maintenance of documentation to demonstrate compliance with statutes and regulations as per 175 NAC 1, the Health Care Facility Licensure Act, and this chapter.

010.02 ADMINISTRATOR. In a free-standing adult day service site, the administrator or equally qualified back-up administrator must be onsite during the hours of operation. The administrator is responsible for planning, organizing, and directing the day-to-day operation of the adult day service. The administrator must report all matters related to the maintenance, operation, and management of the adult day service and be directly responsible to the licensee or to the person, or persons, delegated governing authority by the licensee. The administrator’s responsibilities include:

(A) Being responsible for the adult day service’s compliance with rules and regulations; (B) Being responsible for the adult day service’s promotion of consumer self-direction and participation in decisions which incorporate independence, individuality, privacy, and dignity; (C) Maintaining sufficient number of staff with appropriate training and skills to meet consumers’ needs and to implement each consumer’s agreement of participation and service plan; (D) Providing written personnel policies, job descriptions, and current service policies and procedures, all of which are consistent with prevailing professional and practice standards and that are made available to all personnel; (E) Maintaining personnel and administrative records; (F) Providing orientation for new staff, schedule in-service education programs and opportunities for continuing education for the staff; (G) Designating an equally qualified backup administrator to act in the administrator’s absence who must be responsible for and accountable for management of the adult day service; (H) Monitoring that agreements of participation and service plans are established, implemented, and revised, as necessary, to meet the consumers’ needs; (I) Monitoring staff, including contracted staff, identify and review incidents and accidents, consumer complaints and concerns, patterns, and trends in overall operation such as provisions of consumer care, treatment, and service, and take action to alleviate problems and prevent recurrence; (J) Developing procedures that require the reporting of any evidence of abuse, neglect or exploitation of any consumer served by the adult day service in accordance with Neb. Rev. Stat. § 28-372 of the Adult Protective Services Act or in the case of a person under the age of 18, in accordance with Neb. Rev. Stat. § 28-711; (K) Ensuring an investigation is completed on suspected abuse, neglect, exploitation, or misappropriation of money or property and take action to prevent recurrence until the investigation is completed; (L) Ensuring written policies, procedures and forms are individualized for the adult day service and contain effective dates and revisions dates; (M) Ensuring the adult day service maintains a copy of all active policies, procedures and forms which are available for staff use; and (N) Ensuring the adult day service maintains a copy of all inactive policies, procedures, and forms for a minimum of 7 years after the document becomes inactive.

010.03 STAFF REQUIREMENTS. The licensee must have staff with the required training and skills to provide care, treatment, and services in a safe and timely manner to meet each consumer’s needs and to implement each consumer’s agreement of participation and service plan.

010.03(A) EMPLOYMENT ELIGIBILITY. Each licensee must ensure and maintain evidence of the following:

010.03(A)(i) CRIMINAL BACKGROUND CHECKS. Complete pre-employment criminal background checks on each direct care staff member must be made through a governmental law enforcement agency or a private entity that maintains criminal background information.

010.03(A)(ii) REGISTRY CHECKS. Complete pre-employment checks on each direct care staff for adverse findings on the following Nebraska registries:

(1) Nurse Aide Registry; (2) Adult Protective Services Central Registry; (3) Central Registry of Child Protection Cases; and (4) Sex Offender Registry.

010.03(A)(iii) HIRING DECISIONS. The licensee must:

(1) Determine how to use the criminal background and registry information, except for the Sex Offender Registry and Nurse Aide Registry, in making hiring decisions; (2) Decide whether employment can begin prior to receiving the criminal background and registry information; and (3) Document any decision to hire a person with a criminal background or adverse registry findings, except for the Sex Offender Registry and the Nurse Aide Registry. The documentation must include the basis for the decision and how it will not pose a threat to consumer safety or consumer property.

010.03(A)(iv) ADVERSE FINDINGS. The licensee must not employ a person with adverse findings on the Sex Offender Registry or on the Nurse Aide Registry regarding consumer abuse, neglect, or misappropriation of property.

010.03(A)(v) HEALTH STATUS. The licensee:

(1) Must complete a health screening for each staff person prior to having contact with clients and prior to beginning his or her job responsibilities; and (2) May, in its discretion, based on the health screening, require a staff person to have a physical examination.

010.03(B) STAFF TRAINING. Staff must have sufficient training to meet consumer needs for care, treatment, and services.

010.03(B)(i) ORIENTATION. The licensee must provide staff with orientation prior to staff having direct responsibility for care, treatment, or services to consumers. The training must include:

(1) Job duties, qualifications, and responsibilities; (2) Consumer rights; (3) Consumers agreement of participation and service plan; (4) Infection control practices including hand washing techniques, personal hygiene, and disposal of infectious material; (5) Information on any physical and mental special care needs of the consumers; (6) Emergency procedures and information regarding advance directives; (7) Personnel policies and procedures; (8) Consumer policies and procedures; (9) Information on abuse, neglect, and misappropriation of money or property of a consumer and reporting procedures; and (10) Disaster preparedness plans.

010.03(B)(ii) ONGOING TRAINING. Ongoing and continuous in-services or continuing education must be provided for staff. The adult day service must maintain a record of such education, including the date of the training, the topic, and participants.

010.03(C) STAFFING RESOURCES. The licensee must ensure care, treatment, and services meet the needs of the consumer, be provided in a safe and timely manner, and in accordance with physician orders, and instructions and directions from the consumer and caregiver.

010.03(C)(i) SUPERVISION. The adult day service must establish and revise, as necessary, policies and procedures regarding appropriate consumer supervision.

010.03(D) EMPLOYMENT RECORD. A current employment record must be maintained for each staff person. The record must contain information on orientation, in-services, employment eligibility information, and health history screening.

010.04 CONSUMER RIGHTS. Each licensee must protect and promote each consumer’s rights. This includes the establishment and enforcement of written policies and procedures to ensure the operations of the adult day service afford consumers the opportunity to exercise their rights. Each consumer must have the right to:

(A) Respectful and safe care, treatment, and services by competent personnel; (B) Be free from abuse, neglect, exploitation, and to be treated with dignity; (C) Receive adult day services without discrimination based upon race, color, religion, sex, or national origin; (D) Confidentiality of all records, communications, and personal information, except as otherwise provided by law; (E) Be free of chemical and physical restraints; (F) Be informed of changes in agency policies, procedures, and charges for care, treatment, and services; and (G) Voice complaints or grievances and suggest changes without fear of reprisal.

010.05 DESIGNEE OR CAREGIVER RIGHTS. Each designee or caregiver must have the right to:

(A) Be informed of any changes in the adult day service description; (B) Voice complaints without discrimination or reprisal against themselves or the consumer and have those complaints addressed; (C) Be informed of consumer and designee or caregiver rights during admittance; and (D) Be informed of changes in agency policies, procedures, and charges for care, treatment, and services.

010.06 DESIGNEE RIGHTS. Each designee must have the right to formulate advance directives and have the adult day service comply with the directives unless the adult day service notifies the designee of their inability to do so.

010.07 PROGRAM DESCRIPTION. The licensee must have a written program description available to staff, consumers, caregivers, designees, and members of the public that explains the range of adult day services that can be provided. The licensee will revise the program description, as necessary, to accurately reflect care, treatment, and services the adult day service is providing for consumers. The program description must include the following:

(A) The goals and objectives of the licensee; (B) The hours and days when care, treatment or services are provided; (C) The description of the types of consumers to be served, including age, sex, care needs, and any other relevant characteristics; (D) The composition of staff and their qualifications; (E) The job responsibilities of staff; (F) The system used for the reporting, investigating, and resolving allegations of consumer abuse, neglect, and exploitation; (G) The description of planned activities provided for consumers by the adult day service. These planned activities must:

(i) Meet consumers’ interests; (ii) Promote consumers’ physical, mental, and psychosocial wellbeing; and (iii) Be ongoing;

(H) The plan for providing emergency care, treatment, and services, including use of facility approved interventions to be used by staff in an emergency situation; (I) The admission and discharge criteria and process; and (J) The process for consumer’s pre-admission, admission, and ongoing assessment to determine appropriateness for admission and to develop and update the consumer-specific agreement of participation and service plan.

010.08 ADMISSION, EVALUATION, ASSESSMENT, AND DISCHARGE OF CONSUMERS. The licensee must ensure a written, consumer-specific agreement of participation and service plan is prepared after a consumer assessment is performed by a qualified staff member and before providing care, treatment, or services for the consumer.

010.08(A) ADMISSION CRITERIA AND DECISIONS. The licensee must have written criteria for admission of consumers that includes each level and components of care, treatment and services provided. The licensee must make the decision on whether to admit a consumer based upon the admission criteria and the licensee’s capability to meet the identified needs of the consumer.

010.08(B) AGREEMENT OF PARTICIPATION. An agreement of participation must be negotiated with the consumer or designee. This agreement must be updated, as needed, to ensure it meets the consumers’ needs. This agreement must meet the following requirements:

(i) The service to be provided within the scope of the adult day service; and (ii) The responsibilities of the consumer or designee.

010.08(C) SERVICE PLAN. The licensee must evaluate each consumer, and when necessary, have the consumer assessed by a licensed professional of the appropriate discipline, and have a written service plan which identifies how care, treatment, and services are to be provided to the consumer by the licensee to meet the consumers’ needs. The service plan must be updated, as needed, to ensure it meets the consumers’ needs. The service plan must meet the requirements within the scope of the adult day service and address the following basic needs of the consumer:

(i) Health; (ii) Psychosocial; and (iii) Functional.

010.08(D) DISCHARGE CRITERIA AND DECISIONS. The licensee must have written criteria for the discharge of consumers. The licensee must ensure the decision to discharge a consumer is based upon the discharge criteria.

010.09 ADMINISTRATION OR PROVISION OF MEDICATIONS. Consumers must receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and with prevailing professional standards.

010.09(A) METHODS OF ADMINISTRATION OF MEDICATION. When the licensee is responsible for the administration of medication, it must be accomplished by the following methods:

010.09(A)(i) SELF-ADMINISTRATION OF MEDICATIONS. Consumers must be permitted to self-administer medications, with or without visual supervision, when the licensee determines that the consumer is competent and capable of doing so safely. Written policies and procedures must be implemented and revised, as necessary, regarding self-administration of medication and must include the following:

(1) Storage and handling of medications; (2) The licensee’s written determination that the consumer may self-administer medication in the consumer’s individualized service plan; and (3) Monitoring the consumer’s individualized service plan to assure continued safe administration of medications by the consumer.

010.09(A)(ii) LICENSED HEALTH CARE PROFESSIONAL. When the licensee uses a licensed health care professional for whom medication administration is included in the scope of practice, the licensee must ensure the medications are properly administered in accordance with prevailing professional standards and state and federal law.

010.09(A)(iii) PROVISION OF MEDICATION BY A PERSON OTHER THAN A LICENSED HEALTH CARE PROFESSIONAL. When the licensee uses a person other than a licensed health care professional in the provision of medications, the licensee must only use individuals who are registered medication aides and must comply with the Medication Aide Act at Neb. Rev. Stat. §§ 71-6718 to 71-6742, and 172 NAC 95 and 96.

010.09(B) MAINTAIN OVERALL SUPERVISION, SAFETY, AND WELFARE OF CONSUMERS. When the licensee is not responsible for medication administration or provision, the licensee still retains the responsibility for overall supervision, safety, and welfare of the consumer.

010.09(C) REPORTING OF MEDICATION ERRORS AND ADVERSE REACTIONS TO A MEDICATION BY THE CONSUMER. When the licensee provides for medication administration or provision, the licensee must implement a written process for reporting any adverse reactions to a medication by a consumer and any medication errors in administration or provision of any medications to the consumer, the consumer’s designee, and the consumer’s licensed practitioner immediately upon discovery. A written report of the adverse reaction and medication error must be completed immediately upon discovery and kept in the consumer’s record. Errors must include any variance from the five rights or the prescription and the administration or provision of the medication.

010.09(D) STORAGE OF MEDICATION. The licensee must ensure all medications are stored in locked areas and stored in accordance with the manufacturer’s instructions for temperature, light, humidity, or other storage instructions.

010.09(E) ACCESS TO MEDICATION. The licensee must ensure only authorized staff who are designated by the licensee to be responsible for administration or provision of medications have access to medications.

010.09(F) MEDICATION RECORD. The licensee must maintain records with sufficient detail to assure that:

(i) Consumers receive the medications authorized by a licensed health care professional; (ii) The licensee is alerted to theft or loss of medication; and (iii) An individual medication administration record must be kept for each consumer. This record must include:

(1) Identification of the consumer; (2) Name of the medication given; (3) Date, time, dosage, and method of administration for each medication administered or provided; (4) Identification of the person who administered or provided the medication; (5) Any refusal by the consumer; and (6) Consumer’s medication allergies and sensitivities, if any.

010.09(G) DISPOSAL OF MEDICATIONS. The licensee must destroy medications that are discontinued by the licensed health care professional and those medications which are beyond expiration date. The licensee must implement and revise, as necessary, policies and procedures to identify who will be responsible for disposal of medications and how disposal will occur.

010.09(H) MEDICATION PROVISION DURING TEMPORARY ABSENCES. The licensee must put medications scheduled to be taken by the consumer in a container identified for the consumer when a consumer is temporarily absent from the adult day service.

010.10 FOOD SERVICE. The licensee must provide food service as specified in the consumer service plan, agreement of participation, and may include special diets. When the licensee provides food service, meals and snacks must be appropriate to the consumer’s needs and preferences and must meet daily nutritional requirements.

010.10(A) MENUS. Menus must be planned and written based on the Food Guide Pyramid, or equivalent, and modified to accommodate special diets and texture adaptations as needed by the consumers and show food as served. Menus must be made accessible to consumers, caregivers, and designees.

010.10(B) FOOD SAFETY. The licensee must store, prepare, protect, serve, and dispose of food in a safe and sanitary manner and in accordance with the Food Code. If consumers are involved in food service, the licensee must train consumers on food safety.

010.11 CONSUMER INFORMATION. The licensee must obtain written, accurate consumer information from the caregiver. The licensee must have a permanent record for all consumers. The licensee must establish the record prior to and immediately following the provision of care, treatment, or services for each consumer.

010.11(A) CONTENT. Consumer records must contain information as required in 175 NAC 1 and the following information:

(i) Significant medical conditions; (ii) Medications and any special diet; (iii) Designated physician or registered nurse; (iv) Consumer’s agreement of participation; (v) Consumer’s service plan; (vi) Any unusual event or occurrence; (vii) Daily documentation of care, treatment, services, and supervision provided for the consumer; and (viii) Physician orders when the consumer’s level of care requires a physician order.

010.11(B) CONSUMER IDENTIFICATION. The licensee must implement and revise, as necessary, system for identifying a consumer when there are multiple consumers at a site.

History

Effective 2024-03-20

Chapter 6 Children’s Day Health Service

Neb. Admin. Code tit. 175, ch. 6 Children’s Day Health Service {#sec-175-nac-6 omnilex-key=us-ne-regs-official--title-175--175 NAC 6}

001. SCOPE AND AUTHORITY . These regulations govern licensing of children’s day health services under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479.

002. DEFINITIONS . The definitions set out in the Health Care Facility Licensure Act, in 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.

002.01 ABUSE. Any knowing, intentional, or negligent act or omission on the part of a person which results in physical abuse, sexual abuse, verbal abuse, or mental abuse, unreasonable confinement, cruel punishment, exploitation, or denial of care, treatment, or services to a consumer.

002.02 ADVANCE DIRECTIVES. Include living wills, durable powers of attorney, powers of attorney for health care, or other instructions recognized by state law that relate to the provision of medical care if the consumer becomes incapacitated.

002.03 BASIC THERAPEUTIC CARE. Basic health care procedures, including, but not limited to, measuring vital signs, applying hot and cold applications and non-sterile dressings, and assisting with, but not administering, internal and external medications which are normally self-administered. Basic therapeutic care does not include health care procedures which require the exercise of nursing or medical judgment.

002.04 CAREGIVER. A caregiver has the same meaning as caretaker found in Neb. Rev. Stat. § 71-6721.

002.05 CHEMICAL RESTRAINT. A psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms.

002.06 CHILDREN’S DAY HEALTH AIDE. An individual who is employed directly or through contract by a children’s day health service to provide one or more of the following services: personal care, assistance with the activities of daily living, or basic therapeutic care to children’s day health service consumers.

002.07 CHILDREN’S DAY HEALTH AIDE SERVICES. The use of a trained, supervised paraprofessional to provide one or more of the following services: personal care, assistance with activities of daily living or basic therapeutic care to consumers of a children’s day health service.

002.08 COMMUNITY-BASED. Serving consumers at a defined location outside of the consumer’s home or a health care facility not licensed as a children’s day health service.

002.09 DEVELOPMENTAL DISORDERS. A disorder that interrupts normal development in childhood.

002.10 DEVICE. An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is prescribed by a medical practitioner and dispensed by a pharmacist or other person authorized by law to do so.

002.11 DIRECT SUPERVISION. The responsible practitioner is physically present in the consumer care, treatment, and service area and with the children’s day health service consumer when the consumer is out of the children’s day health service for transport or offsite activities.

002.12 EXPLOITATION. The taking of property of a consumer by means of undue influence, breach of a fiduciary relationship, deception, or extortion or by any unlawful means.

002.13 FOOD CODE. The Nebraska Food Code as defined in Neb. Rev. Stat. § 81-2,244.01 and as published by the Nebraska Department of Agriculture, except for compliance and enforcement provisions is the food code.

002.14 FUNCTIONAL IMPAIRMENT. A serious limitation or limitations a consumer has which substantially interfere with or limit role functioning in major life activities, as determined through an assessment by a practitioner credentialed under the Uniform Credentialing Act whose scope of practice includes care and treatment applicable to the functional impairment.

002.15 INTRAVENOUS THERAPY. Initiating and monitoring therapy related to substances that are administered intravenously.

002.16 MEDICAL DEPENDENCE. A medically fragile individual who requires specialized care and treatment by a practitioner as prescribed by a physician.

002.17 MEDICAL SERVICES. Those services that address the health concerns and needs of consumers, including complex interventions, within the scope of practice of the licensed practitioner.

002.18 MENTAL ABUSE. Humiliation, harassment, threats of punishment or deprivation, or other actions causing mental anguish.

002.19 MENTAL HEALTH SERVICES. Mental health practice as defined in Neb. Rev. Stat. § 38-2115 and other activities, interventions, or directives designed to address behavioral needs outlined in the consumer-specific, written plan of care.

002.20 NEGLECT. Failure to provide care, treatment, or services necessary to avoid physical harm or mental anguish of a consumer.

002.21 OVERNIGHT CARE. Care, treatment, or services provided for consumers between the hours of 9:00 p.m. and 6:00 a.m.

002.22 PARENT. A natural parent, adoptive parent, stepparent, guardian, or other legally responsible individual for an individual under 19 years of age.

002.23 PERSONAL CARE AIDE. An individual who is employed directly or through contract by a children’s day health service to provide personal care, assistance with activities of daily living, or both to children’s day health service consumers.

002.24 PERSONAL CARE AIDE SERVICES. The use of trained, supervised paraprofessional to provide personal care, assistance with activities of daily living, or both to consumers of a children’s day health service. Personal care aide services do not include basic therapeutic care.

002.25 PHYSICAL ABUSE. Hitting, slapping, pinching, kicking, or other actions causing injury to the body.

002.26 PHYSICAL RESTRAINT. Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the consumer’s body that the consumer cannot remove easily and that restricts freedom of movement or normal access to the consumer’s own body.

002.27 PHYSICIAN. An individual with an active license as a physician under the Uniform Credentialing Act to practice medicine and surgery or osteopathic medicine and surgery.

002.28 PRESCRIBING PRACTITIONER. Any podiatrist, dentist, physician, osteopathic physician, advanced practice registered nurse, or physician assistant licensed to prescribe, diagnose, and treat as provided in the Uniform Credentialing Act.

002.29 SEXUAL ABUSE. Sexual harassment, sexual coercion, or sexual assault.

002.30 SKILLED NURSING CARE. Skilled nursing services that:

(A) Are ordered by a physician and included in the plan of care approved by the physician for the consumer; and (B) Can be provided in this state only by or under the direct supervision of a registered nurse to assure the safety of the consumer and to achieve the medically desired result.

002.31 SKILLED NURSING CARE SERVICES. See skilled nursing care.

002.32 SOCIAL SERVICES. Those activities that assist the consumer in carrying out their therapeutic activities as outlined in their service agreement.

002.33 SPECIALIZED CARE AND TREATMENT. Care and treatment provided at a level requiring a practitioner or under the direction of a practitioner for one or more of the following services: skilled nursing care, speech-language pathology, occupational therapy, physical therapy, or mental health.

002.34 STAFF. An individual who is a direct or contracted employee of the children’s day health service.

002.35 SUMMARY REPORT. A written compilation of the pertinent facts from the clinical notes and progress notes regarding a consumer’s care, treatment, and services provided by the children’s day health service.

002.36 SUPERVISING PRACTITIONER. A person who supervises a mental health service. Such person may be a psychiatrist, psychologist, or Licensed Independent Mental Health Practitioner (LIMHP) licensed under the Uniform Credentialing Act.

002.37 SUPERVISION. The daily observation and monitoring of the consumer by direct care staff and oversight of staff by the administrator or administrator’s designee.

002.38 SUPPORT SERVICES. Services which support personal care, provision of medications, activities of daily living, and health maintenance activities.

002.39 THERAPEUTIC ACTIVITIES. Professionally directed set of actions designed to improve, maintain, or lessen the decline of physical, cognitive, or social functioning.

002.40 VERBAL ABUSE. The use of oral, written, or gestured language including disparaging or derogatory terms to consumers or within hearing distance of the consumer or within the consumer’s sight.

002.41 VOLUNTEER. An individual who is not a direct or contracted employee of the children’s day health service.

003. LICENSING REQUIREMENTS . To receive a license, an applicant or licensee must submit a complete application and meet all requirements set out in statute, 175 NAC 1, and in this chapter. An applicant for license must have an active license as a childcare provider, and a current Occupancy Permit from the State Fire Marshal or their delegated authority. A licensee must only admit a consumer when the licensee can meet the needs of the consumer through the provision of 1 or more of the following services:

(A) Skilled nursing care; (B) Mental health; or (C) Rehabilitation.

003.01 INITIAL AND DUPLICATE LICENSE FEES. The following fees apply:

(A) Initial license $650

003.02 RENEWAL LICENSURE FEES. The following fees apply:

(A) 1 to 50 unduplicated consumer admissions in the past year $525 (B) 51 to 200 unduplicated consumer admissions in the past year $675 (C) 201 or more unduplicated consumer admissions in the past year $750

003.03 SEPARATE LICENSE. An applicant must obtain a separate license for each type of facility or service that the applicant seeks to operate. A single license document may be requested for a children’s day health service operating in separate buildings or structures on the same premises under one management.

003.04 SEPARATE AND DISTINCT PARTS OF PREMISES. If the applicant seeks to operate more than 1 type of service or facility licensed under the Health Care Facility Licensure Act on the same premises, the children’s day health service must hold a separate license, as required, for each type of service and provide the different types of service in separate and distinct parts of the premises.

004. INSPECTIONS . The children’s day health service must meet all inspection requirements shown at 175 NAC 1, this chapter, and as required for active licensure as a childcare provider.

005. GENERAL REQUIREMENTS . The licensee must meet all requirements shown at 175 NAC 1-005.02 through 1-005.07 and the requirements shown below.

005.01 NOTIFICATIONS. The children’s day health service must:

(A) Meet notification requirements at 175 NAC 1-005 (A), (C)(iii), (D), (E), (F), (G)(i) through (G)(v); and (B) Notify the Department, in writing, at least 30 working days before the licensee would like to increase license capacity, would like to serve consumers dependent on life support equipment, would like a change in the building, or would like a change in the usage of the building.

005.02 EFFECTIVE DATE AND TERM OF LICENSE. A children’s day health service license expires on December 31 of each year.

005.03 CHANGE OF OWNERSHIP. Change of ownership or premises terminates the license. If there is a change of ownership and the children’s day health service remains on the same premises, the inspection in 175 NAC 1-004 is not required. If the children’s day health service changes premises, it must pass the inspection specified in 175 NAC 1-004.

005.04 OCCUPANCY. The licensee must not serve more consumers at 1 time than the maximum occupancy for which the location is licensed.

006. CONSTRUCTION . In new construction, the licensee must:

(A) Provide a conveniently located sink for soaking and hand washing of laundry when laundry services are provided on-site at the children’s day health service; (B) Ensure the door of a toilet, changing, or bathing room with less than 50 square feet of clear floor area and dedicated to consumer use must not swing inward; (C) Ensure curtain layout must totally surround each care and treatment location which will not restrict access to the entrance to the room, lavatory, toilet, or enclosed storage facilities; (D) Ensure electrical systems have ground fault circuit interrupter protected outlets in all wet areas and within 6 feet of all hand washing sinks; (E) Ensure mechanical exhaust ventilation at a rate of 10 air exchanges per hour for windowless toilets, changing and bathing areas, laundry rooms, housekeeping rooms, and kitchens; and (F) Ensure mechanical exhaust ventilation at a rate of 5 air exchanges per hour for care, treatment, and service areas.

007. PHYSICAL PLANT . All buildings must be designed, constructed, and maintained in a manner that is safe, clean, and functional for the specialized care and treatment provided. All buildings must comply with the Health Care Facility Licensure Act, 175 NAC 1, this chapter, and the Nebraska State Fire Code and Life Safety Code requirements. Each building must comply with the following physical plant requirements.

007.01 DIETARY. If food preparation is provided on site, there must be dedicated space and equipment for the preparation and serving of meals. Such food preparation, serving, physical environment, and equipment must comply with the Food Code.

007.02 DINING AREAS. Adequate space for dining, socialization, and leisure activities must be provided. Dining areas must:

(A) Have tables and chairs that meet the consumers’ needs; (B) Not be used for offices or as a corridor; and (C) Be arranged so that all consumers are able to eat meals at an appropriate time by having:

(i) All consumers eat at the same time; (ii) Consumers eat in different shifts; or (iii) Open times for consumers meals.

007.03 LAUNDRY. When laundry services are provided, they may be provided by contract or on-site by the licensee.

007.03(A) CONTRACT. If contractual laundry services are used, areas for soiled linen awaiting pickup and separate areas for storage and distribution of clean linen must be utilized.

007.03(B) ONSITE. If onsite laundry services are provided there must be areas dedicated to laundry that include a washer and dryer.

007.04 LINENS AND CLOTHING. There must be an adequate supply of bed, bath, and other linens as necessary for each consumer. The linen must be clean and in good repair. Procedures must be implemented for the storage and handling of soiled and clean linens and consumer clothing. Covered or sealable, waterproof containers are provided for storing wet, soiled clothing.

007.05 WASTE PROCESSING. There must be areas to collect, contain, process, and dispose of medical and general waste produced in a manner that prevents the attraction of vermin, and to minimize the transmission of infectious diseases.

007.06 HOUSEKEEPING ROOM. There must be a room with a service sink and space for storage of supplies and housekeeping equipment.

007.07 PHARMACY. If pharmacy or pharmaceutical services are provided, they must be provided in conformance with the statutes and regulations governing such practice.

007.08 CARE AND TREATMENT AREAS. The following care and treatment areas cannot be shared among detached structures or with other licensed health care facilities or services. Care and treatment areas must safeguard consumer privacy and dignity and comply with the following standards.

007.08(A) STAFF AREAS. The following support areas must be provided for each distinct care and treatment area:

(i) An area for charting and consumer records; (ii) A medication station for storage and distribution of drugs and routine medications. Distribution may be done from a medicine preparation room or unit, from a self-contained medicine-dispensing unit, or by another system. If used, a medicine preparation room or unit must be under visual control of nursing staff and must contain a work counter, sink, refrigerator, and double-locked storage for controlled substances; (iii) Space for consumer care, treatment, services, and activities allowing for consumer privacy; and (iv) A work area where clean materials are assembled. The work area must contain a work counter, a hand washing fixture, and storage facilities for clean and sterile supplies. If the area is used only for storage and holding as part of a system for distribution of clean and sterile supply materials, the work counter and hand washing fixtures may be omitted. There must be separate work areas or holding rooms for soiled materials. A workroom for soiled materials must contain a fixture for disposing of wastes and a hand washing sink.

007.08(B) EQUIPMENT AND SUPPLY. The licensee must provide services and space to distribute, maintain, clean, and sanitize durable medical instruments, equipment, and supplies the license has agreed to provide for the consumer and which are required for the care, treatment, and services provided by the licensee. There must be space to store equipment, wheelchairs, supplies, and linen out of the path of normal traffic.

007.09 TOILET ROOMS. There must be toilet rooms with hand washing sinks located near the toilet fixtures.

007.10 SLEEPING AREAS. When overnight care is provided, there must be areas which allow for sleeping and accommodate the care, treatment and services provided to the consumer. Sleeping rooms must:

(A) Not be located in a garage, storage area, shed, or similar detached buildings; and (B) Not be accessed through a bathroom, food preparation area, laundry, or bedroom.

007.11 CONSUMER STORAGE. Storage for consumers’ belongings must be provided and must not be the same storage area where food or medication is kept. Consumer toothbrushes, if used, must be distinctly marked with each consumer’s name, and stored to prevent contamination.

007.12 DOORS. Doors must be wide enough to allow passage and be equipped for privacy, safety, and with assistive devices to minimize consumer injury. Toilet, changing, and bathing room doors must provide privacy yet not create seclusion or prohibit staff access to provide consumer supervision and routine or emergency care.

007.13 BATHING ROOMS. If bathing services are provided there must a bathing room with a tub or shower. Tubs and showers used by consumers must be equipped with handgrips or other assistive devices as needed by the consumer. The bathing room must not open directly into a dining or kitchen area.

007.14 ADDITIONAL SERVICES. If additional medical or therapy services are provided, there must be adequate space provided to assure privacy and provision of appropriate care, treatment, and services.

007.15 OUTDOOR AREAS. There must be an outdoor area for consumer usage. The area must be equipped and situated to allow for consumer safety, abilities, and special needs.

007.16 SINKS. There must be a hand washing facility equipped with sink, disposable towels, and soap dispenser in areas where hands are likely to become soiled or require frequent hand washing. Such areas include toileting, changing, and bathing areas, food preparation areas, and near rooms specifically designated for patient care, treatment, and services.

007.17 FINISHES. There must be washable room finishes in clean workrooms and food preparation areas that have smooth, non-absorptive surfaces which are not physically affected by routine housekeeping cleaning solutions and methods. Acoustic lay-in ceilings, if used, must not interfere with infection control. Perforated, tegular, serrated cure, or highly textured tiles must not be used.

007.18 CALL SYSTEMS. Call systems, when used, must be operable from consumer-used toileting, changing, and bathing areas. The system must transmit a receivable, visual, audible, tactile, or other type of signal to on-duty staff which readily notifies staff to the location where the call was activated. When wireless call systems are used, they must have dedicated devices in all consumer occupied central toilet and bathing locations to promptly summon staff to the call location.

007.19 ELECTRICAL SYSTEM. The electrical system must have the capacity to maintain the care, treatment, and services that are provided and that properly grounds care, treatment, and services areas.

007.20 ESSENTIAL POWER SYSTEM. All existing and new facilities must maintain an emergency power system for all essential care, treatment, and service areas, when electrical life support systems are used for consumers.

007.21 ELECTRICAL LIFE SUPPORT EQUIPMENT. Facilities with electrical life support equipment must maintain essential power systems and must have an on-site fuel source. The minimum fuel source capacity must allow for non-interrupted system operations.

007.22 HOT WATER SYSTEM. There must be hot and cold water to all hand washing and bathing locations.

007.23 HEATING AND COOLING SYSTEMS. A heating and air conditioning system must be provided, for the comfort of the consumer that is capable of producing a temperature of at least 70 degrees Fahrenheit during heating conditions and that does not exceed 85 degrees Fahrenheit during cooling conditions. Airflow must move from clean to soiled locations.

007.24 VENTILATION SYSTEM. All facilities must provide exhaust and clean air to prevent the concentrations of contaminants which could impair health or cause discomfort to consumers and employees.

007.25 WATER AND SEWER SYSTEMS. There must be an accessible and safe potable supply of water. Where a public water supply system is available, the facility must be connected to it and must use it exclusively. All water distribution systems must be protected with anti-siphon devices and airgaps to prevent contamination. All facilities must maintain a sanitary and functioning sewage system and the following:

(A) If the facility operates its own water supply system it must operate as if it is a public water supply system and in compliance with The Nebraska Safe Drinking Water Act and Title 179 Regulations Governing Public Water Systems; and (B) Continuously circulated filtered and treated water systems must be provided as required for the care and treatment equipment used in the facility.

008. RECORDKEEPING . The licensee must meet all recordkeeping requirements under the Health Care Licensure Act, 175 NAC 1 and this chapter. The licensee, when sharing space with another entity, must ensure the children’s day health service has a unique physical address to ensure mail is secured against unauthorized access and must ensure a separate entrance to the children’s day health service space to ensure verbal communications are protected against unauthorized access.

009. ENVIRONMENTAL SERVICES . The licensee must have a written process for performing routine and preventative maintenance on equipment and furnishings to ensure equipment and furnishings are safe and function to meet the intended use.

010. STANDARDS OF OPERATION, CARE, AND TREATMENT . Each licensee must assure protection to consumers and compliance with state statutes and regulations. All services provided by the licensee must be provided in accordance with the Health Care Facility Licensure Act, The Uniform Credentialing Act, the Medication Aide Act, the regulations adopted under those Acts, physician orders, supervising practitioner orders, and prevailing standards of practice.

(A) Ensuring the quality of care, treatment, and services provided to consumers, whether furnished by the children’s day health service employees, volunteers, or through contract staff; (B) Ensuring consumers are provided with a stable and supportive environment, through respect for the rights of consumers and responsiveness to consumer needs; (C) Ensuring staff levels are sufficient to meet the consumers’ needs; (D) Monitoring policies and procedures to assure the appropriate administration and management of the children’s day health service; (E) Defining in writing the duties and responsibilities of the administrator; (F) Designating in writing an administrator who meets the administrator requirements at 175 NAC 6 and who is responsible for the day to day management of the children’s day health service; (G) Implementing written procedures and criteria for the admission, discharge; and transfer of consumers. Such implementation shall ensure the needs of consumers that are admitted are met; (H) Implementing written procedures for obtaining and incorporating physician and supervising practitioner verbal and written orders into a plan of care for each consumer; (I) Establishing written policies and procedures to implement all service agreements and to create a written program description which must include the range of services provided by the children’s day health service; (J) Reviewing all elements of the written program description as described in 175 NAC 6 at least annually and must include, in this review process, relevant findings from its quality assurance and improvement program for the purpose of improving consumer services and resolving problems in consumer care, treatment and services; (K) Ensuring maintenance of documentation to demonstrate compliance with statutes and regulations as per 175 NAC 1, the Health Care Facility Licensure Act, and this chapter; (L) Ensuring written policies and procedures for staff and volunteers to report immediately to the administrator or, in the administrator’s absence, the administrator’s designee all suspected abuse, neglect, or exploitation of consumers; and (M) Making records available for inspection and copying by an authorized representative of the Department.

010.02 ADMINISTRATION. There must be an administrator to carry out the policies and directives of the licensee and to be responsible for the day-to-day management of the children’s day health service. Whether employed, elected, contracted, or appointed, the administrator must report and be directly responsible to the licensee in all matters related to the maintenance, operation, and management of the children’s day health service.

010.02(A) ADMINISTRATOR QUALIFICATIONS. The administrator must have training and experience with a health care program where specialized care and treatment, as defined at 175 NAC 6-002, was provided. The administrator must be a:

(i) Physician; (ii) Registered nurse who meets the Director of Nursing requirements at 175 NAC 6; or (iii) An individual with:

(1) A bachelor’s degree in health care administration, mental health practice, speech-language pathology, physical therapy, occupational therapy, or related field; and (2) 3 years or more of full-time work experience in health care or mental health administration or as a practitioner in 1 of these fields.

010.02(B) ADMINISTRATOR RESPONSIBILITIES. The administrator is responsible for the management of the children’s day health service to the extent authority is delegated by the licensee. An individual who meets the administrator qualification requirements at 175 NAC 6 must be designated in writing to act in the absence of the administrator. The administrator or the administrator’s written designee must be available to children’s day health service staff during all hours of operation. The administrator is responsible to:

(i) Ensure compliance with statutes and regulations by all children’s day health service staff, volunteers, and contracted staff; (ii) Organize and direct the ongoing functions of the children’s day health service; (iii) Oversee and be responsible for the provision and coordination of consumer services; (iv) Maintain communication between the licensee and staff; (v) Implement written personnel policies and procedures and written job descriptions for each staff position that include minimum job qualifications; (vi) Employ or contract with qualified personnel in accordance with job descriptions; (vii) Maintain sufficient number of staff with appropriate training and skills to meet consumers’ needs and to implement each consumer’s service agreement and plan of care; (viii) Maintain personnel and administrative records; (ix) Provide orientation for new staff, volunteers and contracted staff, schedule in-service education programs and opportunities for continuing education of the staff; (x) Ensure the completion, maintenance, and submission of reports and records as required by the Department; (xi) Establish planned hours of operation during which consumer care, treatment, and services will be provided, and ensure daily oversight of staff, volunteers, and contracted staff and consumer scheduling so that qualified staff are available to meet each consumer’s needs; (xii) Monitor that a service agreement and a plan of care are established, implemented, and revised, as necessary, to meet the consumer’s needs; (xiii) Monitor staff, volunteers, and contracted staff, identify and review incidents and accidents, consumer complaints and grievances, patterns, and trends in overall operation such as provisions of consumer care, treatment, and service, and take action to alleviate problems and prevent recurrence of problems identified; (xiv) Develop procedures that require reporting of any evidence of abuse, neglect or exploitation of any consumer served by the children’s day health service in accordance with Neb. Rev. Stat. § 28-372 or in the case of a person under the age of 18, in accordance with Neb. Rev. Stat. § 28-711; (xv) Ensure staff and volunteers are trained to report immediately to the administrator or, in the administrator’s absence, the administrator’s designee all suspected abuse, neglect, or exploitation of consumers; (xvi) Ensure an investigation is completed on suspected abuse, neglect, or exploitation, and take action to prevent recurrence until, and after, the investigation is completed; (xvii) Ensure written policies, procedures and forms are individualized for the children’s day health service and contain effective dates and revision dates; (xviii) Ensure the children’s day health service maintains a copy of all active policies, procedures and forms which are available for staff use; and (xix) Ensure the children’s day health service maintains a copy of all inactive policies, procedures, and forms for a minimum of 7 years after the document becomes inactive.

010.03 STAFF AND VOLUNTEER REQUIREMENTS. Sufficient number of staff with the required experience, orientation, training, and demonstrated competency to meet the needs of all consumers accepted for care, treatment, and services must be present on the premises to provide care. Before a staff member is scheduled to care for consumers, the qualification of the staff must be assessed through orientation, training, and demonstrated competency to provide consumer care, treatment, and services as ordered by the consumer’s physician and supervising practitioner in a safe and timely manner.

010.03(A) STAFF-TO-CONSUMER RATIOS. There must be a system to monitor and appropriately adjust staff-to-consumer ratios based on the number of consumers in attendance daily, the complexity of those consumers’ needs, and the number of qualified and trained staff available to provide care, treatment, and services. When volunteers are counted in the staff-to-consumer ratios, the volunteer must meet the staff requirements for the position he or she is assuming. All volunteers must receive direct supervision by staff who meet 175 NAC 6 requirements to provide and supervise such services.

010.03(B) UNCREDENTIALED DIRECT CARE STAFF AND VOLUNTEERS. When unlicensed direct care staff are used to provide care, the licensee must maintain documentation to demonstrate compliance with the following requirements for any unlicensed direct care staff member who provides any of the following regulated services:

(i) Children’s day health aide services and personal care aide services must be provided in accordance with 175 NAC 6; and (ii) Provision of medication must be performed by a registered medication aide and in compliance with the Medication Aide Act, this chapter and 172 NAC 95 and 96.

010.03(C) STAFFING RECORDS. A daily roster of available staff must be maintained and contain the first initial and last name of the staff member, job title, license or other credential, and hours available for duty. A daily schedule of staffing and consumer assignments must be maintained.

010.04 EMPLOYMENT AND VOLUNTEER ELIGIBILITY. Pre-employment criminal background and registry checks for each direct or contracted staff member and volunteer. must be completed and documented. Employment and training records for each direct or contracted staff member and volunteer must be maintained. Documentation of written contracts for consumer care, treatment, and services provided by contracted staff must be maintained. Any individual who meets the restrictions identified in 175 NAC 6-010.04(B) must not be on the premises during the hours of operation, except that a parent who meets such restrictions may be allowed on the premises when accompanied by staff and only to pick up and drop off his or her child.

010.04(A) PRE-EMPLOYMENT BACKGROUND CHECKS. Pre-employment background checks must be completed in accordance with 391 NAC 3. Pre-employment checks must include a check for adverse findings on the Nurse Aide Registry for each direct or contracted staff member and volunteer.

010.04(B) EMPLOYMENT AND VOLUNTEER RESTRICTIONS. A children’s day health service must not employ, use as a contracted staff member, or use as a volunteer, any individual who is disqualified under 391 NAC 3 and who is:

(i) Listed as a perpetrator on the Central Registry of Child Protection Cases, if the individual is age 13 or older; (ii) Listed as a perpetrator on the Adult Protective Services central registry if the individual is age 18 or older; (iii) Listed as a perpetrator on the State Patrol sex offender registry; or (iv) Listed with adverse findings on the Nurse Aide Registry.

010.04(C) EMPLOYMENT RECORD. An employment record for each direct or contracted staff member must be maintained and include:

(i) The title of that individual’s position, qualifications, and description of the duties and functions assigned to that position; (ii) Evidence of licensure, certification, registration, or approval, if required; (iii) Performance evaluations made within 6 months of employment and annually, thereafter; (iv) Post-hire and pre-employment health history screening. All staff must have a health history screening after accepting an offer of employment and prior to assuming job responsibilities. A physical examination is at the discretion of the employer based on results of the health history screening; and (v) Sufficient documentation to demonstrate that the requirements of this chapter are met.

010.04(D) TRAINING. All staff and contracted staff must receive training and demonstrate competency before independently performing job duties or assigned tasks. Records must be maintained of each orientation and in-service or other training program, including the signature of staff and volunteers attending, subject matter of the training, the names and qualifications of instructors, dates of training, length of training sessions, and any written materials provided. Volunteers must not be left alone with consumers.

010.04(D)(i) ORIENTATION. Orientation and training programs must be provided for all new staff, existing staff who are given new assignments, all contract staff, and volunteers. For existing staff with job duty, title, or role changes, the staff members must receive orientation and training and must demonstrate competency for all newly assigned job duties before independently performing a new duty. The orientation program must include:

(1) Job duties and responsibilities; (2) Organizational structure; (3) Consumer rights; (4) Consumer care policies and procedures; (5) Personnel policies and procedures, including confidentiality policies; and (6) Reporting requirements for abuse, neglect, or exploitation of any consumer in accordance with these regulations and with Neb. Rev. Stat. § 28-711 of the Child Protection Act or, in the case of a consumer who has reached the age of majority, in accordance with Neb. Rev. Stat. § 28-372 of the Adult Protective Services Act.

010.04(D)(ii) ONGOING TRAINING. Ongoing and continuous training, in-services or continuing education for staff and volunteers counted in the staff-to-consumer ratios must be provided. Records to confirm this requirement is met must be kept. Documentation for ongoing and continuous in-services or continuing education must include the date provided, the topic and content, and participants’ names and job titles.

010.04(D)(iii) SPECIALIZED TRAINING. Training, whether part of a program or as individualized instruction of staff and volunteers, to perform particular procedures or to provide specialized care and treatment, such as the use of ventilators, mechanical lifts, and other similar devices necessary to safely provide prescribed care and treatment must be provided.

010.04(E) CONTRACT STAFF. The licensee may contract for consumer care, treatment, and services. Documentation of all contracts between the licensee and outside resources must be maintained. Any contract with a provider must be in writing and must include:

(i) A statement that the contractor will accept consumers of the licensee only if approved by the licensee; (ii) A description of the services and the manner in which they are to be provided; (iii) A statement that the contractor must be in compliance with all 175 NAC 6 requirements and must conform to all applicable licensee policies and procedures, including those related to qualifications; (iv) A statement that the contractor is responsible for participating in the development of plans of care; (v) A statement that the care, treatment, and services are controlled, coordinated, and evaluated by the licensee; (vi) The policies and procedures for submitting clinical and progress notes, scheduling consumer care, treatment, and services, and continuing periodic consumer evaluations; and (vii) The policies and procedures for determining charges and reimbursement.

010.05 CONSUMER RIGHTS. The licensee must implement a written Bill of Rights that is equally applicable to all consumers. The licensee must protect and promote these rights. The consumer must be given a copy of the Bill of Rights before care, treatment, or services are provided to the consumer and this action must be documented.

010.05(A) CONSUMER RIGHTS. The consumer has the right to:

(i) Receive mental health services ordered by a supervising practitioner and to receive skilled nursing care services and rehabilitation services as ordered by a physician and to communicate with those physicians and practitioners; (ii) Participate in the planning of the consumer’s care and treatment, receive appropriate instruction and education regarding the plan; (iii) Request information about the consumer’s diagnosis, prognosis, and treatment, including alternatives to care and risks involved, in terms that they can readily understand so that they can give their informed consent; (iv) Refuse care and be informed of possible health consequences of this action; (v) Receive care without discrimination as to race, color, creed, sex, age, or national origin; (vi) Exercise religious beliefs; (vii) Be admitted for service only if the children’s day health service has sufficient, qualified, and trained staff to provide safe and timely care, treatment, and services; (viii) Receive the full range of services provided by the licensee; (ix) Personal privacy and confidentiality of all records, communications, and personal information; (x) Review and receive a copy of all health records pertaining to them; (xi) Receive from the licensee the policies and procedures for admission, discharge, transfer, and termination of services prior to admission; (xii) Voice complaints and grievances and suggest changes in service or staff without fear of reprisal or discrimination and be informed of the resolution; (xiii) Be fully informed of policies and charges for services, including eligibility for third-party reimbursement, prior to receiving care; (xiv) Be free from verbal, physical, and psychological abuse and to be treated with dignity; (xv) Expect all efforts will be made to ensure continuity and quality of care, treatment, and services in the children’s day health service setting; (xvi) Have his or her person and property treated with respect; (xvii) Be informed, in advance, about the care, treatment and services to be furnished, and any changes in the care, treatment and services to be furnished; (xviii) Formulate advance directives and have the licensee comply with the directives unless the licensee notifies the consumer of the inability to do so; and (xix) Be free from chemical and physical restraints, including locked seclusion, imposed for the purposes of discipline or convenience, and not required to treat the consumer’s medical symptoms.

010.05(B) ADVANCE DIRECTIVES. The licensee must comply with the requirements of Neb. Rev. Stat. §§ 30-3041 to 30-3432, the Health Care Power of Attorney Act, Neb. Rev. Stat. §§ 20-401 to 20-416, and the Rights of the Terminally Ill Act. The licensee must inform and distribute written information to the consumer in advance concerning its policies and procedures on advance directives, including a description of applicable State law.

010.05(C) COMPETENCE OF CONSUMERS. The following apply related to competence of consumers:

(i) When a consumer is under 19 years of age, the parent is responsible for decisions about consumer care and treatment to be provided by the children’s day health service. In the case of a consumer age 19 or older adjudged incompetent or incapacitated under the laws of the State by a court of competent jurisdiction, the rights of the consumer are exercised by the persons authorized under State law to act on the consumer’s behalf; and (ii) In the case of a consumer who has not been adjudged incompetent by the State court, any person designated in accordance with State law may exercise the consumer’s rights to the extent provided by the law.

010.06 ADMISSION AND RETENTION REQUIREMENTS. Written policies and procedures that encompass admission, transfer, discharge, and termination of services must be implemented and delineate the scope of services provided and describe the consumer population that will be served.

010.06(A) ADMISSION. The licensee must only admit individuals when the licensee reasonably expects the individual’s needs can be meet through the provision of one or more of the services listed in 175 NAC 6. A written service agreement must be signed and dated by the prospective consumer or the prospective consumer’s parent before he or she is admitted.

010.06(B) SERVICE AGREEMENT. The licensee must negotiate a written service agreement with each prospective consumer or the prospective consumer’s parent. The service agreement must be signed and dated by the prospective consumer or the prospective consumer’s parent and must not conflict with the physician-approved and/or or supervising practitioner-approved written plan of care. The service agreement must include:

(i) A consumer-specific written emergency plan identifying the consumer’s emergency contact information, methods of contact, and assuring continuity of the consumer’s external home back-up power source for life-sustaining and emergent-care equipment operation while the licensee is responsible for the consumer’s care, treatment, and services. For consumers that use a ventilator, this plan must include:

(1) The consumer’s ventilator type and instructions for proper implementation and use of the external back-up power source; (2) The method for staff to assure, during the daily communication report, that the consumer’s external back-up power source is operational and has sufficient power to operate for a minimum of 24 hours; and (3) Any additional information necessary to assure the consumer’s safety in an emergency;

(ii) Written authorization from the consumer or the consumer’s parent allowing the licensee to:

(1) Transfer the consumer for emergent care when needed; and (2) Release and receive consumer information necessary to provide consumer care, treatment, and services as ordered by the consumer’s physician;

(iii) A list of supplies, medications, and equipment necessary to provide care, treatment, and services in accordance with the consumer’s physician-approved written plan of care identifying which items will be provided by the licensee and which items will be provided by the consumer; (iv) A written description of the procedures for communication between the consumer or consumer’s parent and a licensee’s practitioner in accordance with the daily communication report requirements of this chapter; (v) Acknowledgment signed and dated by the consumer or the consumer’s parent that the licensee must:

(1) Receive consumer, consumer’s parent, or physician notification of all changes to the consumer’s current physician orders and practitioner care plans prior to accepting the consumer for daily care, treatment, or services by the children’s day health service; (2) Only accept the consumer for care, treatment, or services when the consumer’s, or their parent’s, instructions for his or her care, treatment, and services are not in conflict with the physician-approved and supervising practitioner written plan of care, or could compromise the consumer’s health or safety; and (3) Not accept the consumer for care, treatment, or services when the consumer does not bring the supplies, medications, and equipment necessary to provide care, treatment, or services as ordered by the consumer’s physician and supervising practitioner, as shown on the consumer’s care plan, and in accordance with the signed service agreement; and

(vi) A list of care, treatment and service providers authorized by the consumer to exchange consumer information necessary for the licensee to:

(1) Coordinate the licensee’s consumer care plans with care, treatment or services provided by the consumer’s non-licensee practitioners; and (2) Send written summary reports when requested by the consumer or the consumer’s parent.

010.06(C) DAILY COMMUNICATION REPORT. The licensee must have an established procedure for communication between the consumer and the licensee to ensure that services are appropriately provided. Such communication must occur each time the consumer is accepted for care, treatment, or services and include:

(i) Any changes in the consumer’s medication, care, and treatment regimen, or both; (ii) Any changes to the consumer’s health condition; and (iii) The condition and availability of life-sustaining and emergent-care equipment needs for consumers who require such equipment.

010.06(D) ACCEPTANCE FOR DAILY CARE AND TREATMENT. The licensee must exclude the consumer from attendance when symptoms of illness are present as identified in 173 NAC 3. Written policies and procedures to prevent exposure to others when consumers develop symptoms of illness while at the premises must be implemented and revised as necessary and be consistent with prevailing professional standards to protect the health and safety of consumers.

010.06(E) TRANSFER. When the consumer is transferred to another health care facility, the licensee must provide appropriate information for continuity of the consumer’s care and treatment to the receiving facility with written consumer consent or as permitted by law.

010.06(F) DISCHARGE. Oral and written notification must be provided to the consumer within 2 working days after receipt of the physician’s discharge order.

010.06(G) TERMINATION OF SERVICES. If a licensee terminates services for any reason other than a physician-ordered discharge or a transfer, the consumer or the consumer’s parent must receive both an oral and written explanation. Information regarding community resources must be given to the consumer or the consumer’s parent.

010.06(G)(i) 2-WEEK NOTICE. Consumers must receive at least a 2 week notice prior to termination of services. No notice prior to termination of services is required when a patient consumer is discharged by the physician’s order, or when consumer services are being terminated based on non-compliance with the consumer’s physician-approved or supervising practitioner-approved written plan of care, failure to pay for services, or disruptive, abusive, or uncooperative behavior to the extent that delivery of care, treatment or services to the consumer or the ability of the licensee to operate safely and effectively is impaired.

010.06(G)(ii) TERMINATION OF SERVICES. The licensee must make a serious effort to address presenting problems or issues that adversely affect care, treatment, or services prior to termination of services and document such efforts to address problems and issues in the consumer’s medical record.

010.07 CONSUMER CARE, TREATMENT, AND ACTIVITIES. Written policies and procedures that address all care, treatment, services, and activities provided to, consumers must be implemented and delineate the scope of services provided, address how physician and supervising practitioner orders will be obtained, updated, and incorporated into the physician-approved or supervising practitioner-approved written plan of care initially and on an ongoing basis, and to protect the health and safety of consumers.

010.07(A) PLAN OF CARE. The consumer must have a physician-approved, and when mental health services are provided, a supervising practitioner-approved, written plan of care which includes all care, treatment, and services to be provided for each consumer by the licensee. The consumer’s care, treatment and services must follow a written plan of care which must:

(i) Include physician’s order when the following services are provided:

(1) Skilled nursing care services; (2) Rehabilitation services; or (3) Respiratory care services;

(ii) Include a supervising practitioner’s order when mental health services are provided; (iii) Be developed by a:

(1) Registered nurse for skilled nursing care services after an initial consumer assessment by the registered nurse; or (2) Practitioner of the appropriate discipline for mental health practice services or rehabilitation services, after an initial consumer assessment by the practitioner of the appropriate discipline;

(iv) Specify the scope and frequency of services to be provided; (v) Include a physician-approved medication list with complete medication orders and known medication allergies for the consumer including those medications to be administered by the licensee; (vi) Provide for the coordination of all services to ensure the services complement one another and support the objectives in the plan of care; (vii) Provide for coordination with any other existing plan of care for the consumer from a non licensee practitioner identified in the consumer’s service agreement; (viii) Recognize the parent and family as members of the care team; (ix) Be reviewed by a registered nurse, or a practitioner of the appropriate discipline for mental health or rehabilitation services, as often as the consumer’s condition requires, but at least every 62 days; (x) Be reviewed, approved, and signed by the consumer’s physician, and when mental health services are provided signed by a supervising practitioner, every 6 months or when the physician-approved or supervising practitioner-approved written plan of care requires a change either through a recommendation by a practitioner of the appropriate discipline or when a change in the severity of the consumer’s condition requires; and (xi) Include a written summary report of the consumer’s care, treatment and services provided by the licensee which must be submitted to the consumer’s ordering physician and when mental health services are provided to the supervising practitioner, every 6 months or when there has been a significant change in the consumer’s condition.

010.07(B) THERAPEUTIC ACTIVITIES. The licensee must:

(i) Provide age and developmentally appropriate daily activities designed to promote the consumer’s social well-being in accordance with each consumer’s plan of care. Activity areas are not required, but developmentally appropriate equipment and materials must be available for consumer daily use; (ii) Allow flexibility with eating, toileting, sleeping, resting, and play times as needed in coordination with the consumer’s plan of care; and (iii) When activities for consumers are routinely conducted outdoors or off the premises, the children’s day health service must:

(1) Develop a schedule of activities which is posted in a conspicuous place in the children’s day health service or given to the parents; (2) Obtain written permission from parents before transporting consumers on field trips or leaving the children’s day health service; and (3) While consumers are in the care of the licensee, but off the licensee’s premises, the licensee must maintain staff requirements as provided in 175 NAC 6 to ensure consumer care, treatment, and services are provided as ordered in a safe and timely manner.

010.08 NURSING SERVICES. The licensee must provide skilled nursing care services to consumers in a manner that protects the health and safety of the consumers.

010.08(A) REGISTERED NURSE ON DUTY. A registered nurse must be on duty and available to the direct care staff during all hours of operation.

010.08(B) DIRECTOR OF NURSING. The licensee must have a Director of Nursing when skilled nursing care services, children’s day health aide services or intravenous therapy services are provided. The Director of Nursing must:

(i) Be designated in writing; (ii) Be a registered nurse with at least 3 years of full-time registered nursing experience. Such experience must include providing direct consumer care or supervising registered nurses providing direct consumer care; (iii) Be available to staff during all hours of operation; and (iv) The Director of Nursing must name and designate, in writing, a registered nurse to assume the Director of Nursing responsibilities during times when the Director of Nursing is unavailable to staff. This designated registered nurse must have 2 years of full-time experience in providing direct consumer care as a registered nurse.

010.08(C) SKILLED NURSING CARE SERVICES. Skilled nursing care services must be provided by a registered nurse or licensed practical nurse in accordance with these regulations and the physician-approved written plan of care. Skilled nursing care services are:

(i) Services of such complexity that they can be safely and effectively performed only by or under the direct supervision of a registered nurse; (ii) Services not normally requiring skilled nursing care, but which, because of special medical complications, become skilled nursing services because they must be performed or supervised by a registered nurse; and (iii) The above services when needed to prevent a consumer’s further deterioration or preserve a consumer’s current capabilities even if recovery or medical improvement is not possible.

010.08(D) REGISTERED NURSE SERVICES. When skilled nursing care is ordered by a physician, the following specific services must be provided by a registered nurse:

(i) Initial consumer assessment visit; (ii) Reevaluation of the consumer’s nursing needs; (iii) Provision of services requiring specialized nursing skill; (iv) Initiation of appropriate preventive and rehabilitative nursing procedures; (v) Coordination of services; (vi) Direct supervision of other nursing staff; and (vii) Assignment of nursing care and treatment to meet the consumer’s needs.

010.08(E) LICENSED PRACTICAL NURSE SERVICES. When skilled nursing care is ordered by a physician, the following specific services may be performed by a registered nurse or by a licensed practical nurse if the licensed practical nurse is under the direct supervision of a registered nurse:

(i) Implementing the physician-approved written plan of care and necessary revisions to the plan. A registered nurse must review the plan of care as often as the severity of the consumer’s condition requires, but at least every 62 days; (ii) Preparation of clinical and progress notes; (iii) Informing the physician and other staff of changes in the consumer’s conditions and needs; (iv) Teaching other nursing staff; and (v) Teaching the consumer and caregiver for the purpose of meeting nursing and other related needs.

010.09 CHILDREN’S DAY HEALTH AIDE AND PERSONAL CARE AIDE SERVICES. A licensee that employs children’s day health aides or personal care aides must meet the following requirements for training and testing prior to the children’s day health aides or personal care aides providing care and services to consumers. The children’s day health service must ensure the following requirements are met:

010.09(A) EMPLOY QUALIFIED AIDES. Only children’s day health aides and personal care aides who meet the qualifications as required in 175 NAC 6 may provide services.

010.09(B) IN-SERVICE PROGRAM. The licensee must provide or make available to children’s day health aides and personal care aides 4 hours of in-service programs per year on multiple subjects relevant to the consumer population. Sufficient records to confirm this requirement is met must be kept. Documentation for in-service or continuing education must include the date provided, the topic and content, trainer qualifications, length of the in-service program, and participants printed name, signature, job title and attendance date.

010.09(C) PERMITTED ACTS. Children’s day health aides may perform only personal care, assistance with the activities of daily living, and basic therapeutic care. A personal care aide may perform only personal care and assist with activities of daily living. Children’s day health aides and personal care aides must not perform acts which require the exercise of nursing or medical judgment.

010.09(D) REQUIREMENTS. A children’s day health aide and a personal care aide must be listed on the Medication Aide Registry operated by the Department before being allowed to perform the provision of medication. A children’s day health aide and personal care aide must only perform the provision of medication in accordance with the Medication Aide Act, 172 NAC 95 and 96, and 175 NAC 6.

010.09(E) CHILDREN’S DAY HEALTH AIDE AND PERSONAL CARE AIDE TRAINING. The training requirements are set out below:

(i) Children’s day health aide and personal care aide training must meet the following standards with regard to training content, qualifications for instructors, and documentation of training. The training must, at a minimum, address each of the subject areas identified below. Personal care aide training must include Items 1 through 10 below. Children’s day health aide training must include Items 1 through 13 below:

(1) Communication skills; (2) Observation, reporting, and documentation of consumer status and the care or service furnished; (3) Adequate nutrition and fluid intake; (4) Basic infection control procedures; (5) Basic elements of body functioning and changes in body functioning that must be reported to an aide’s supervisor; (6) Maintenance of a clean, safe, and healthy environment; (7) Recognizing emergencies and knowledge of emergency procedures; (8) The physical, emotional, and developmental needs of and ways to work with the populations served by the children’s day health service, including the need for respect of the consumer, his or her privacy, and his or her property; (9) Appropriate and safe techniques in personal hygiene and grooming that include:

(a) Nail and skin care; (b) Oral hygiene; and (c) Toileting and elimination;

(10) Safe transfer techniques and ambulation; (11) Normal range of motion and positioning; (12) Reading and recording temperature, pulse, and respiration; and (13) Any other task which the licensee may choose to have the children’s day health aide perform except children’s day health aides must not perform other tasks which require the exercise of nursing or medical judgment;

(ii) Except as identified in 175 NAC 010.09(F)(ii), the training above will be waived for a children’s day health aide or a personal care aide who successfully completes a nurse aide or nurse assistant training course approved by the Department in accordance with 172 NAC 108 and meets the requirements at 175 NAC 6-010.09(F). (iii) Children’s day health aide and personal care aide training must be provided under the direct supervision of registered nurse or licensed practical nurse who has 2 years or more of direct consumer care experience as registered nurse or licensed practical nurse, preferably in a pediatric setting; and (iv) Sufficient documentation to demonstrate the requirements above are met must be kept.

010.09(F) VERIFY COMPETENCY. The competency requirements are set out below:

(i) Competency of all children’s day health aides and personal care aides must be verified prior to the aides providing services and documentation of the verification must be kept; (ii) Any children’s day health aide not acting as a children’s day health aide for a period of 3 years must meet the children’s day health aide training requirements identified in this chapter. Any personal care aide not acting as a personal care aide for a period of 3 years must meet the personal care aide training requirements identified in this chapter. The licensee must determine and verify competency of all children’s day health aides and personal care aides as indicated below; (iii) Children’s day health aide and personal care aide competency evaluations must:

(1) Address each of the subjects specific to the type of aide being trained or evaluated or both as identified and listed in 175 NAC 6010.09(E)(i); (2) Be performed by registered nurse who has 2 years or more of direct consumer care experience as registered nurse; and (3) Include the subject areas in 175 NAC 6010.09(E)(i) and must be evaluated by observation and a written or oral examination:

(a) Children’s day health aides must demonstrate competency for Items 1-7 below. Personal care aides must demonstrate competency for Items 1-4 below. Observations must be made with a consumer or other individual, and must include but are not limited to:

(i) Safe transfer techniques and ambulation; (ii) Nail and skin care; (iii) Oral hygiene; (iv) Toileting and elimination; (v) Reading and recording temperatures, pulse, and respiration; (vi) Normal range of motion and positioning; and (vii) Any other task which the licensee may choose to have the children’s day health aide perform except children’s day health aides must not perform other tasks which require the exercise of nursing or medical judgment; and

(b) The written or oral examination must include:

(i) Communication skills; (ii) Observation, reporting, and documentation; (iii) Basic infection control procedures; (iv) Basic elements of body functioning and changes in body functioning that must be reported to the children’s day health aide’s supervisor; (v) Maintenance of a clean, safe, and healthy environment; (vi) Recognizing emergencies and knowledge of emergency procedures; (vii) The physical, emotional, and developmental needs of and ways to work with the population served by the children’s day health service, including respect for the consumer, his or her privacy and property; (viii) Adequate nutrition and fluid intake; and (iv) A children’s day health aide or personal care aide that receives an unsatisfactory on any task performed must not perform that task without direct supervision by a nurse until after he or she receives additional training in that task, is evaluated, and subsequently is evaluated as satisfactory.

010.09(G) AIDE CARE PLAN AND SUPERVISION. The aide care plan and supervision requirements are set out below:

010.09(G)(i) CHILDREN’S DAY HEALTH AIDE CARE PLAN. A registered nurse must make the initial evaluation of each consumer for whom the physician orders children’s day health aide services, devise a written aide care plan, and prepare a written plan of care for the physician’s approval. The registered nurse must review this aide care plan as often as the consumer’s condition requires, but at least every 62 days.

010.09(G)(ii) PERSONAL CARE AIDE CARE PLAN. A registered nurse or practitioner of the appropriate discipline must make the initial evaluation of each consumer for whom the physician orders personal care aide services, devise a written aide care plan, and prepare a written plan of care for the physician’s approval. The registered nurse or practitioner must review this aide care plan as often as the consumer’s condition requires, but at least every 62 days.

010.09(G)(iii) SUPERVISION. The children’s day health aide must provide services in accordance with the physician-approved written plan of care and the aide care plan under the direct supervision of the registered nurse. The personal care aide must provide services in accordance with the physician-approved written plan of care and the aide care plan under the direct supervision of the registered nurse or practitioner of the appropriate discipline. The aide care plans must include consumer-specific written instructions for each consumer’s care, prepared by the supervising registered nurse for children’s day health aides and prepared by the supervising registered nurse or practitioner of the appropriate discipline for personal care aides.

010.09(G)(iv) DOCUMENTATION. Children’s day health aide and personal care aide services must be provided and documented in accordance with the written aide care plan and the plan of care prepared by the registered nurse or practitioner of the appropriate discipline as required in 175 NAC 6.

010.10 ADMINISTRATION OR PROVISION OF MEDICATIONS. Consumers must receive medications only as legally prescribed by a prescribing practitioner, in accordance with the children’s day health service physician-approved written plan of care, the 5 rights and prevailing professional standards.

010.10(A) ACCEPTANCE OF CONSUMER INSTRUCTIONS AND MEDICATIONS. Written policies and procedures must be implemented and revised, as necessary, for staff acceptance of consumer medications, supplies, equipment, and consumer instructions necessary to provide consumer care, treatment, services, and medications in accordance with the physician-approved written plan of care.

010.10(A)(i) ACCEPTANCE OF CONSUMER INSTRUCTIONS. If a conflict exists between the physician-approved written plan of care and the consumer’s instructions for providing care, treatment, or medications, staff must contact the physician for clarification before providing the care, treatment, services, or medications.

010.10(A)(ii) ACCEPTANCE OF CONSUMER MEDICATIONS. When accepting consumer medications and related supplies the licensee must:

(1) Only accept medications that are clearly labeled for the consumer; and (2) Only accept medications in the original manufacturers or pharmacy’s container.

010.10(B) METHODS OF ADMINISTRATION. When the licensee is responsible for the administration of medications, it must be accomplished by the following methods:

010.10(B)(i) SELF-ADMINISTRATION OF MEDICATIONS. Consumers must be allowed to self-administer medications, with or without supervision, when the licensee determines that the consumer is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner. The licensee must establish, implement, and revise as necessary, written policies and procedures to address consumer self-administration of medication, including:

(1) Inclusion of the determination that the consumer may safely and independently self-administer medication in the consumer’s physician-approved written plan of care; and (2) Monitoring the plan to assure continued safe and independent administration of medications by the consumer.

010.10(B)(ii) LICENSED PRACTITIONER. When the licensee uses a licensed practitioner for whom medication administration is included in the scope of practice, the licensee must ensure the medications are properly administered and documented in accordance with prevailing professional standards and state and federal law.

010.10(B)(iii) PROVISION OF MEDICATION BY OTHER THAN A LICENSED PRACTITIONER. When the children’s day health service uses someone other than a licensed practitioner for whom medication administration is included in the scope of practice in the provision of medications, the children’s day health service must only use individuals who are registered medication aides and must comply with the Medication Aide Act, 172 NAC 95 and 96 and this chapter.

010.10(B)(iv) MAINTAIN OVERALL SUPERVISION, SAFETY AND WELFARE OF CONSUMERS. When the licensee is not responsible for medication administration or provision, the licensee still retains responsibility for overall supervision, safety, and welfare of the consumer.

010.10(C) REPORTING OF MEDICATION ERRORS AND ADVERSE REACTIONS TO A MEDICATION. When the licensee provides for medication administration or provision, the licensee must implement a written process for reporting any adverse reactions to a medication by a consumer and any medication errors in administration or provision of any medications to the consumer, the consumer’s parent, and the consumer’s licensed practitioner immediately upon discovery. A written report of the adverse reaction and medication error must be completed immediately upon discovery and kept in the consumer’s record. Errors must include any variance from the 5 rights or the prescription and the administration or provision of the medication.

010.10(D) STORAGE OF MEDICATION. All medications must be stored in locked areas and stored in accordance with the manufacturer’s instructions for temperature, light, humidity, or other storage instructions. If children under age 13 are being served, all medications must be locked. Unused medications, when no longer needed or are expired, must be given to the consumer’s parent, or given to the consumer when the licensee has included a determination that the consumer may safely and independently self-administer medication in the consumer’s physician-approved written plan of care.

010.10(E) ACCESS TO MEDICATION. Only staff who are designated by the licensee to be responsible for administration or provision of medications may have access to medications.

010.10(F) MEDICATION RECORD. The licensee must maintain medication records with sufficient detail to assure that:

(i) Consumers receive the medications authorized by a licensed health care professional; (ii) The staff are alerted to theft or loss of medication; and (iii) An individual medication administration record is maintained for each consumer. This record must include:

(1) Identification of the consumer; (2) Name of the medication given; (3) Date, time, dosage, and method of administration for each medication administered or provided; (4) Identification of the person who administered or provided the medication; and (5) Consumer’s medication allergies and sensitivities, if any.

010.11 INTRAVENOUS THERAPY SERVICES. All intravenous therapy services, when provided, must be provided by a registered nurse in accordance with the physician-approved written plan of care, the 5 rights, and prevailing standards of practice. Intravenous therapy includes, but is not limited to:

(A) Total parenteral nutrition (TPN); (B) Hydration therapy; (C) Chemotherapy; (D) Antibiotic therapy; and (E) Blood and blood products.

010.12 MEDICAL SUPPLIES AND EQUIPMENT. When medical supplies, equipment, and appliances are provided, the licensee must have a process designed for routine and preventative maintenance of equipment to ensure that it is safe and works as intended. The service agreement, prior to admitting a consumer, must set out all supplies, equipment, and appliances the consumer is expected to provide while at the children’s day health service. The medical supplies and equipment in this section include such items as pulse oximetry and blood pressure machines, alcohol pads, syringes, and other similar supplies and equipment.

010.12(A) DURABLE MEDICAL EQUIPMENT. When the licensee provides durable medical equipment for use in the provision of consumer care, treatment, or services, the licensee must ensure such equipment is tested and calibrated in accordance with the manufacturer’s recommendations.

010.12(B) REQUIRED EQUIPMENT. The children’s day health service must provide equipment adequate for meeting each consumer’s needs as specified in the service agreement and the consumer’s physician-approved written plan of care.

010.13 MENTAL HEALTH SERVICES. Mental health services, when provided must be provided as follows:

(A) Mental health practice must be provided by an appropriately credentialed practitioner under the Uniform Credentialing Act; and (B) When other activities, interventions, or directives designed to address behavioral needs outlined in the consumer-specific, written plan of care are provided by un-credentialed staff, such services must be:

(i) Supervised by a licensed mental health practitioner who must:

(1) Have a minimum of 2 years of experience in providing mental health practice services; (2) Assume overall responsibility and direction for all mental health services provided by the un-credentialed staff; and (3) Be immediately available, during operating hours, to the children’s day health service staff by phone, and when required, available onsite; and

(ii) Provided in accordance with the plan of care.

010.14 REHABILITATION SERVICES. Rehabilitation services, when provided must be provided by an appropriately credentialed practitioner as provided in (A)-(C) below. A consumer-specific rehabilitation plan of care must be incorporated into the physician-approved written plan of care and be devised by the rehabilitation practitioner, as appropriate for the rehabilitation services provided, after performing an initial consumer assessment. If the consumer chooses not to use the rehabilitation services furnished by the licensee, the consumer is responsible to arrange for continuation of rehabilitation services by a non-licensee provider that meets the following requirements:

(A) Speech-language pathology services must be provided by persons who are credentialed under the Uniform Credentialing Act and whose scope of practice permits them to provide speech-language pathology services; (B) Occupational therapy services must be provided by persons who are credentialed under the Uniform Credentialing Act and whose scope of practice permits them to provide occupational therapy services; and (C) Physical therapy services must be provided by persons who are credentialed under the Uniform Credentialing Act and whose scope of practice permits them to provide physical therapy services.

010.15 RESPIRATORY CARE SERVICES. Respiratory care services, when provided, for consumers must be provided by persons who are credentialed under the Uniform Credentialing Act and whose scope of practice permits them to provide respiratory care services. When a children’s day health service provides a Respiratory Care Service or Department, it must designate a medical director who must be a licensed physician who has special interest and knowledge in the diagnosis and treatment of respiratory problems. Such physician must:

(A) Be an active medical staff member of a licensed health care facility; and (B) Be qualified by special training or experience in the management of acute and chronic respiratory disorders.

010.16 SOCIAL SERVICES. The licensee must provide activities to promote the development and utilization of consumers’ social skills, including such things as appropriate interaction, sharing, and cooperation. All social services provided must be based on consumer assessments, development of consumer-specific activities, and include referral to outside social services when necessary to promote the consumer’s social well-being. A social service needs assessment must be part of the initial consumer assessment for use in developing a written, consumer-specific plan of activities designed to promote the consumer’s social well-being and, if needed, referring the consumer to outside resources when the consumer’s social service needs exceed the social services provided by the licensee. The licensee must reassess the consumer’s social service needs and update the consumer-specific plan of activities as often as the severity of the consumer’s condition requires reassessment. The licensee must maintain sufficient documentation in the consumer’s clinical record to demonstrate these requirements are met.

010.17 FOOD SERVICES. The daily nutritional needs of all consumers must be met, including any diet ordered by the consumer’s physician. Food service must include:

(A) Providing food service directly or through a written agreement; (B) Ensuring a staff member is trained or experienced in food management or nutrition with the responsibility of:

(i) Planning menus which meet the nutritional needs of each consumer, following the orders of the consumer’s physician; and (ii) Supervising the meal preparation and service to ensure that the menu plan is followed;

(C) Being able to meet the needs of the consumer’s physician-approved written plan of care; nutritional needs, and therapeutic diet; and (D) Procuring, storing, preparing, distributing, and serving all food under sanitary conditions and in accordance with the Food Code.

010.18 TRANSPORTATION SERVICES. When transportation services are provided the licensee must meet, all applicable statutes and regulations, 175 NAC 1, 175 NAC 6, and the following additional requirements:

(A) Staff in each vehicle must have a functioning cellular telephone or other functioning 2-way voice communication device with them for use in an emergency; (B) When a consumer who requires registered nursing observation or assessment is transported, there must be at least 2 staff members on the transporting vehicle at all times, one of whom must be a registered nurse; and (C) When a consumer who requires a ventilator power source is transported the back-up power source must be checked before transport to confirm the power source is operational and has sufficient charge to ensure uninterrupted ventilator service during transport.

010.19 CONSUMER ROSTER AND CLINICAL RECORD REQUIREMENTS. Consumer rosters and clinical records must be maintained and safeguarded in accordance with accepted professional standards and practice. The licensee must meet all applicable statutes and regulations, 175 NAC 1, 175 NAC 6, and the following additional requirements:

010.19(A) CONSUMER ROSTER. The consumer roster must identify consumers scheduled and accepted for care, treatment, and services on a daily basis. Consumer roster must distinguish between childcare clients and children’s day health service consumers and document the hours of care the consumer is receiving children’s day health service services as specified in 175 NAC 6.

010.19(B) CONTENT OF CLINICAL RECORDS. The clinical record must contain sufficient information to identify the consumer clearly, to justify the diagnosis, care, treatment, and services and to accurately document the results of care, treatment, and services. There must be a separate clinical record for each consumer. All clinical records must contain at least the following categories of data:

(i) Identification data and consent forms; (ii) The consumer’s service agreement; (iii) The name and address of the consumer’s physicians; (iv) The physician’s signed order and physician-approved plan of care for skilled nursing care services and rehabilitation services. The supervising practitioner’s signed order and supervising practitioner’s-approved plan of care for mental health services. The documents must include, when appropriate:

(1) Medical diagnosis; (2) Medication orders; (3) Dietary orders; (4) Activity orders; and (5) Safety orders;

(v) Initial and periodic assessments and care plan by disciplines providing services. The children’s day health service must provide pertinent current and past medical history to the credentialed staff providing services on its behalf; (vi) Signed and dated admission, observation, progress, and supervisory notes; (vii) Copies of summary reports sent to the consumer’s physician and supervising practitioners, the consumer, and care and service coordinators as authorized by the consumer to receive medical information; (viii) Diagnostic and therapeutic orders signed by the physician and supervising practitioner; (ix) Reports of treatment and clinical findings; and (x) Discharge summary report.

010.19(C) CENTRALIZED CLINICAL INFORMATION. All clinical information pertaining to the consumer’s care and treatment must be centralized in the consumer’s clinical record maintained by the licensee.

010.19(D) TIMELY ENTRIES. Entries into the clinical record for care, treatment, and services rendered must be written within 24 hours and incorporated into the clinical record within 7 working days.

010.19(E) PROVIDER IDENTIFICATION. Entries must be made by the individual providing services, must contain a statement of facts personally observed, and must be signed with full name and title. Initials may be used if identified in the clinical record.

010.19(F) VERBAL ORDERS. The licensee must, implement a written process that identifies staff by job title who can receive verbal orders from the physician and the supervising practitioner for mental health services and that ensures all such verbal orders for care, treatment, services, and medications are signed and dated by the physician or supervising practitioner for mental health services who gave the order and incorporated in the consumer’s clinical record within 30 days.

010.19(G) REVISED PLAN OF CARE. The licensee must implement a written process that ensures a consumer’s plan of care is revised immediately following receipt of a physician or supervising practitioner written or verbal order. The revised consumer plan of care must be approved and incorporated into the consumer’s clinical record within 30 days following receipt of the written order.

010.19(H) SECURED. Clinical records must be secured in locked storage. The licensee must have a written process regarding use and removal of records and the conditions for release of information.

010.20 EMERGENCY CARE OF CONSUMERS. The licensee must have the necessary drugs, devices, biologicals, equipment, and supplies immediately available for provision of care and treatment should an emergency arise and must meet the following requirements:

(A) At least 2 staff members with a current cardiopulmonary resuscitation (CPR) certification are on duty at all times; and (B) Staff members are trained to use an Automated External Defibrillator (AED) and there must be an operable Automated External Defibrillator on the premises.

History

Effective 2024-02-20

Chapter 7 Health Clinics

Neb. Admin. Code tit. 175, ch. 7 Health Clinics {#sec-175-nac-7 omnilex-key=us-ne-regs-official--title-175--175 NAC 7}

7-001 SCOPE AND AUTHORITY : These regulations govern licensure of Health Clinics. The regulations are authorized by and implement the Health Care Facility Licensure Act, Neb. Rev. Stat. §§ 71-401 to 71-462.

7-001.01 These regulations apply to any health care facility where advice, counseling, diagnosis, treatment, surgery, care, or services relating to the preservation or maintenance of health are provided on an outpatient basis for a period of less than 24 consecutive hours to persons not residing or confined at such facility. Health clinic includes, but is not limited to:

An ambulatory surgical center;
A public health clinic;
A facility where 10 or more abortions as defined in Neb. Rev. Stat. § 28-326 are performed during any one calendar week;
A facility providing hemodialysis and not licensed as another type of health care facility; or
A facility providing labor and delivery services and not licensed as another type of health care facility.

7-001.02 Health clinic does not include:

A health care practitioner facility which is a residence, office or clinic of a practitioner or group of practitioners credentialed under the Uniform Licensing Law or any distinct part of such residence, office or clinic unless such facility:

a. Is an ambulatory surgical center;

b. Performs 10 or more abortions during any one calendar week;

c. Provides hemodialysis services; or

d. Provides labor and delivery services.

A facility which provides only routine health screenings, health education or immunizations.

7-002 DEFINITIONS

Abuse means any knowing, intentional or negligent act or omission on the part of a person which results in physical, sexual, verbal or mental abuse, unreasonable confinement, cruel punishment, exploitation, or denial of essential care, treatment and services to a patient.

Activities of daily living (See definition of “Care.”)

Adjoining means located to allow access without having to enter a general corridor area used or observed by other facility occupants.

Administrator means the operating officer for a health clinic and may include such titles as administrator, chief executive officer, manager, superintendent, director or similar designation.

Ambulatory surgical center means a facility:

Where surgical services are provide to persons not requiring hospitalization who are admitted to and discharged from such facility within the same working day and are not permitted to stay overnight at such facility;
Which meets all applicable requirements for licensure as a health clinic under the Health Care Facility Licensure Act; and
Which has qualified for a written agreement with the Health Care Financing Administration of the United States Department of Health and Human Services or its successor to participate in Medicare as an ambulatory surgical center as defined in 42 CFR 416.1 to 416.200 or which receives other third-party reimbursement for such services.

Ambulatory surgical center does not include an office or clinic used solely by a practitioner or group of practitioners in the practice of medicine, dentistry, or podiatry.

Applicant means the individual, government, corporation, partnership, limited liability company or other form of business organization who applies for a license.

Biological means any virus, therapeutic serum, toxin, antitoxin or analogous product applicable to the prevention, treatment or cure of disease or injuries of humans.

Activities of daily living means transfer, ambulation, exercise, toileting, eating, self-administered medication, and similar activities;
Health maintenance activities means noncomplex interventions which can safely be performed according to exact direction, which do not require alteration of the standard procedure, and for which the results and patient responses are predictable; and
Personal care means bathing, hair care, nail care, shaving, dressing, oral care, and similar activities.

Complaint means an expression of a concern or dissatisfaction.

Completed application means the application that contains all the information specified in 175 NAC 7-003 and includes all required attachments and documentation and the licensure fee.

Department means the Department of Health and Human Services Regulation and Licensure.

Designee means a person who is authorized by law or the patient to act on his or her behalf, for example a parent of a minor child, a legal guardian, a conservator, and an attorney in fact named in a durable power of attorney for health care.

Direction and monitoring means, for the purpose of medication administration, the acceptance of responsibility for observing and taking appropriate action regarding any desired effects, side effects, interactions and contraindications associated with the medication. Direction and monitoring can be done by a:

Competent individual for himself or herself;

2 Caretaker; or

Licensed health care professional.

Director means the Director of Regulation and Licensure.

Drug means substances as defined in Neb. Rev. Stat. § 71-1,142.

Existing facility means a licensed health care facility or a facility whose construction or remodeling plans were approved by the Department prior to the effective date of 175 NAC 7.

Exploitation means the taking of property of a patient by means of undue influence, breach of a fiduciary relationship, deception, or extortion or by any unlawful means.

Facility means a health clinic as defined.

Five rights means getting the right drug to the right recipient in the right dosage by the right route at the right time.

Food code means the Nebraska Food Code as defined in Neb. Rev. Stat. § 81-2,244.01 and as published by the Nebraska Department of Agriculture, except for compliance and enforcement provisions.

Food service means the storage, preparation, serving, and disposition of food intended for consumption in a health clinic. Food service does not include provision of prepackaged snacks or nutritional supplements.

Foreign when applied to corporations means all those created by authority other than that of the State of Nebraska.

Grievance means a written expression of dissatisfaction which may or may not be the result of an unresolved complaint.

Health care practitioner means any individual credentialed under the Uniform Licensing Law or other laws of the State of Nebraska.

Health care practitioner facility means the residence, office, or clinic of a practitioner or group of practitioners credentialed under the Uniform Licensing law or any distinct part of the residence, office, or clinic.

Health care service means an adult day service, a home health agency, a hospice or hospice service, or a respite care service.

Health maintenance activities (See definition of “Care.”)

Health clinic means a facility where advice, counseling, diagnosis, treatment, surgery, care, or services relating to the preservation or maintenance of health are provided on an outpatient basis for a period of less than 24 consecutive hours to persons not residing or confined at such facility. Health clinic includes, but is not limited to, an ambulatory surgical center or a public health clinic.

Health clinic does not include:

A health care practitioner facility

a. Unless such facility is an ambulatory surgical center;

b. Unless ten or more abortions, as defined in subdivision (1) of Neb. Rev. Stat. § 28-326, are performed during any one calendar week at such facility; or

c. Unless hemodialysis or labor and delivery services are provided at such facility; or

A facility which provides only routine health screenings, health education, or immunizations.

Hemodialysis means the mechanical process of removing unwanted wastes and fluid from the blood to prevent toxic buildup in patients whose kidneys no longer perform this function. This is done by circulating a patient’s blood through a semipermeable membrane, or dialyzer. Circulation occurs outside the patient’s body.

Licensed health care professional means an individual for whom administration of medication is included in the scope of practice.

Licensee means the individual, government, corporation, partnership, limited liability company, or other form of business organization legally responsible for the operation of the facility and to whom the Department has issued a license.

Medication means any prescription or nonprescription drug intended for treatment or prevention of disease or to affect body function in humans.

Medication administration includes, but is not limited to:

Providing medications for another person according to the five rights;
Recording medication provision; and
Observing, monitoring, reporting and otherwise taking appropriate actions regarding desired effects, side effects, interactions, and contraindications associated with the medication.

Medication aide means an individual who is listed on the medication aide registry operated by the Department as provided in 172 NAC 95 and 96.

Mental abuse means humiliation, harassment, threats of punishment, deprivation or other actions causing mental anguish.

NAC means Nebraska Administrative Code.

Neglect means a failure to provide care, treatment or services necessary to avoid physical harm or mental anguish of a patient.

New facility means a facility or a distinct part of a facility in which care and treatment is to be provided and which is not currently licensed as a health care facility. New facility also includes those facilities, which were previously licensed for care and treatment in another licensure category which now intend to seek licensure in a different category.

Patient means a person who receives care and treatment as recommended by a medical practitioner at a health clinic.

Personal care (See definition of “Care.”)

Physical abuse means hitting, slapping, pinching, kicking, or other actions causing injury to the body.

Physician means any person authorized to practice medicine in this state as provided in Neb. Rev. Stat. §§ 71-102 to 71-110.

Premises means a facility, the facility’s grounds and each building or grounds on contiguous property used for administering and operating a facility.

PRN means an administration scheme in which a medication is not routine, is taken as needed and requires assessment for need and effectiveness.

Public health clinic means the department, and county, city-county, or multicounty health department, or any private not-for-profit family planning clinic licensed as a health clinic.

Qualified inspector means a professional architect or engineer licensed to practice in Nebraska, an official or employee of a local jurisdiction authorized by that jurisdiction to make inspections or particular building equipment or systems, or an individual certified by a nationally recognized organization to make such inspections.

Routine health screenings means the collection of health data through the administration of a screening tool designed for a specific health problem, evaluation, and comparison of results to referral criteria, and referral to appropriate sources of care, if indicated.

Screening tool means a simple interview or testing procedure to collect basic information on health status.

Sexual abuse means sexual harassment, sexual coercion, or sexual assault.

Unlicensed direct care staff includes nursing assistants, medication aides, and other personnel with this responsibility and with job titles designated by the facility.

Verbal abuse means the use of oral, written, or gestured language including disparaging and derogatory terms to patients or within their hearing distance.

7-003 LICENSING REQUIREMENTS AND PROCEDURES : Any person intending to establish, operate, or maintain a health clinic must first obtain a license from the Department. A facility must not hold itself out as a health clinic or as providing health care services unless licensed under the Health Care Facility Licensure Act. An applicant for an initial or renewal license must demonstrate that the health clinic meets the care, treatment, operational and physical plant standards contained in 175 NAC 7.

7-003.01 Initial License: The initial license process occurs in two stages. The first stage consists of the applicant’s submission of affirmative evidence of the ability to comply with the operational and physical plant standards contained in 175 NAC 7-006 and 7-007. The application is not complete until the Department receives documents specified in 175 NAC 7-003.01.

The second stage consists of the Department’s review of the completed application together with an inspection of the health clinic. The Department determines whether or not the applicant for an initial license meets the standards contained in 175 NAC 7 and the Health Care Facility Licensure Act.

7-003.01A Applicant Responsibilities: An applicant for an initial health clinic license must:

Intend to provide health clinic services as defined;
Comply with the applicable codes, guidelines, and standards specified in 175 NAC 7-007;
Submit a written application to the Department as provided in 175 NAC 7-003.01B;
Receive approval in writing, from the Department, of schematic plan and, if new construction, of construction plans; and
Notify the Department at least 30 working days prior to planned patient occupancy.

7-003.01B Application Requirements: The applicant may construct an application or obtain an application form from the Department. The application must include:

Full name of the health clinic to be licensed, street and mailing address, telephone number and facsimile number, if any;
Type of health clinic to be licensed;
Name of the administrator;
Name and address(es) of the health clinic owner(s);
Ownership type;
Mailing address(es) for the owner(s);
Preferred mailing address for receipt of official notices from the Department;
List of names and addresses of all persons in control of the health clinic. The list must include all individual owners, partners, limited liability company members, parent companies, if any, and members of boards of directors owning or managing the operations and any other persons with financial interests or investments in the health clinic. In the case of publicly held corporations, the individual owners listed must include any stockholders who own 5% or more of the company’s stock;
Legal name of the individual or business organization (government, corporation, partnership, limited liability company, or other type) to whom the license should be issued and a statement that the individual or organization accepts the legal responsibility for compliance with 175 NAC 7;
Applicant’s federal employer identification number, if not an individual;
Applicant’s social security number, if the applicant is an individual (To ensure social security numbers are not part of public records and are used only for administrative purposes, applicants may submit social security numbers in a separate document);
Signature(s) of:

a. The owner, if the applicant is an individual or partnership;

b. Two of its members, if the applicant is a limited liability company;

c. Two of its officers, if the applicant is a corporation; or

d. The head of the governmental unit having jurisdiction over the health clinic to be licensed, if the applicant is a governmental unit;

Copy of the registration as a foreign corporation filed with the Nebraska Secretary of State, if applicant is a foreign corporation;
Schematic plans;
For new construction, construction plans completed in accordance with the Engineers and Architects Regulation Act, Neb. Rev. Stat. §§ 81-3401 to 81-3455. An applicant may construct a project description and/or certification document, or obtain a form from the Department. Construction plans must include the following:

a. Project name, description of the project with quantity and floor area information on bed, care, treatment, and toileting locations, building systems, medical equipment, street address, and contact person;

b. Site plan, floor plans, elevations, wall and building sections, construction details, plumbing and electrical diagrams, construction component schedules;

c. Complete list of names, titles, and telephone numbers of other authorities reviewing or inspecting the construction;

d. Upon Department request, any additional information that may be required for review, such as structural and mechanical calculations, electrical system calculations, and product and equipment information; and

e. Certification, if any, from a licensed architect or engineer that the schematic plans, construction plans, and any revisions thereof meet the requirements of 175 NAC 7-007;

Planned occupancy date;
Copies of zoning approval from the relevant jurisdiction;
Occupancy certificates issued by the State Fire Marshal or delegated authority; and
Required licensure fee specified in 175 NAC 7-004.09.

7-003.01C Department Responsibilities: The Department will:

Review the application for completeness;
Provide notification to the applicant of any information needed to complete the application;
Confirm, either by Department review or by accepting certification from an architect or engineer, that the schematic plans and, if new construction, the construction plans meet the standards of 175 NAC 7-007;
Upon receipt of the requested information, conduct an on-site inspection in accordance with 175 NAC 7-005 prior to the issuance of a health clinic license; and
Issue or deny a license based on the results of the initial inspection.

7-003.01D Denial of License: See 175 NAC 7-008.01 and 7-008.02 for grounds and procedures for the Department’s denial of an initial license.

7-003.02 Renewal Licenses

7-003.02A Licensee Responsibilities: The licensee must submit a written application to the Department. The licensee may construct an application, or obtain an application form from the Department. The application must include:

Full name of the health clinic to be licensed, street and mailing address, telephone number, and facsimile number, if any;
Type of health clinic to be licensed;
Name of the administrator;
Name and address(es) of the health clinic or service owner(s);
Ownership type;
Mailing address(es) for the owner(s);
Preferred mailing address for receipt of official notices from the Department;
List of names and addresses of all persons in control of the health clinic. The list must include all individual owners, partners, limited liability company members, parent companies, if any, and members of boards of directors owning or managing the operations and any other persons with financial interests or investments in the health clinic. In the case of publicly held corporations, the individual owners listed must include any stockholders who own 5% or more of the company’s stock;
Legal name of the individual or business organization (government, corporation, partnership, limited liability company or other type) to whom the license should be issued and a statement that the individual or organization accepts the legal responsibility for compliance with 175 NAC 7;
Applicant’s federal employer identification number, if an individual;
Applicant’s social security number if the applicant is an individual. To ensure social security numbers are not part of public records and are used only for administrative purposes, applicants may submit social security numbers in a separate document;
Number of patient admissions in the past year;
Signature(s) of:

a. The owner, if the applicant is an individual or partnership;

b. Two of its members, if the applicant is a limited liability company;

c. Two of its officers, if the applicant is a corporation; or

d. The head of the governmental unit having jurisdiction over the health clinic to be licensed, if the applicant is a governmental unit;

Occupancy certificates issued by the State Fire Marshal or delegated authority dated within the 18 months prior to the license expiration date; and
Required licensure fee as specified in 175 NAC 7-004.09.

7-003.02B Department Responsibilities: The Department will:

Send a notice of expiration and an application for renewal to the licensee’s preferred mailing address not later than 30 days prior to the expiration date. The licensure renewal notice specifies:

a. Date of expiration;

b. Fee for renewal;

c. License number; and

d. Name and address of the health clinic.

Issue a renewal when it determines that the licensee has submitted a completed application;
Send to each licensee that fails to renew its license a second notice, which is the final notice and specifies that:

a. The licensee failed to pay the renewal fee or submit an application or both;

b. The license has expired;

c. The Department will suspend action for 30 days following the date of expiration;

d. Upon receipt of the renewal fee and completed renewal application, the Department will issue the renewal license; and

e. That upon failure to receive the renewal fee and completed renewal application, the license will be lapsed.

Place the health clinic license on lapsed status for nonpayment of fees if the licensee fails to renew the license. During this time, the health clinic may not operate. The license remains in lapsed status until it is reinstated.

7-003.02C Refusal to Renew: See 175 NAC 7-008.01 and 7-008.02 for grounds and procedures for the Department’s refusal to renew a license.

7-003.03 Reinstatement from Lapsed Status: A health clinic requesting reinstatement of its lapsed license must submit to the Department an application for reinstatement and pay the required licensure fee specified in 175 NAC 7-004.09. The application must conform to the requirements specified in 175 NAC 7-003.02.

7-003.03A The Department will review the application for completeness and will decide if an onsite inspection is needed to determine compliance with the operation, care, treatment, and physical plant requirements of 175 NAC 7-006 and 7-007. The decision is based on the following factors:

The length of time that has transpired from the date the license was placed on lapsed status to the date of the reinstatement application; and
Whether the health clinic has provided care or treatment from the site under a license that is different from the lapsed license.

7-003.03B When the Department decides that a reinstatement inspection is warranted, it will conduct the inspection in accordance with 175 NAC 7-005.

7-003.03C When the Department decides that a reinstatement inspection is not warranted, it will reinstate the license.

7-003.03D Refusal to Reinstate: See 175 NAC 7-008.01 and 7-008.02 for grounds and procedures for the Department’s refusal to reinstate a lapsed license.

7-004 GENERAL REQUIREMENTS

7-004.01 Separate License: An applicant must obtain a separate license for each type of health care facility or health care service that the applicant seeks to operate. All buildings in which care and treatment is provided must comply with 175 NAC 7-006 and 7-007. A single license may be issued for:

A health clinic operating in separate buildings or structures on the same premises under one management;
An inpatient facility that provides services on an outpatient basis at multiple locations; or
A health clinic operating satellite clinics on an intermittent basis within a portion of the total geographic area served by the health clinic and sharing administration with the clinics.

7-004.02 Single License Document: The Department may issue one license document that indicates the various types of health care facilities or health care services for which the entity is licensed.

7-004.03 Effective Date and Term of License: A health clinic license expires on the last day of February each year.

7-004.04 License Not Transferable: A license is issued only for the premises and persons named in the application and is not transferable or assignable. Change of ownership (sale, whether of stock, title, or assets, lease, discontinuance of operations) or change of premises terminates the license. If there is a change of ownership and the health clinic remains on the same premises, the inspection in 175 NAC 7-005 is not required. If there is a change of premises, the health clinic must pass the inspection specified in 175 NAC 7-005.

7-004.05 Change of Ownership or Premises: The licensee must notify the Department in writing ten days before a health clinic is sold, leased, discontinued, or moved to new premises.

7-004.06 Notification: An applicant or licensee must notify the Department in writing by electronic mail, facsimile, or postal service:

To request a single license document;
To request simultaneous facility or service licensure inspections for all types of licensure held or sought;
If new construction is planned, and submit construction plans for Department approval prior to any new construction affecting patient care and treatment areas of the health clinic. The Department may accept certification from an architect or engineer in lieu of Department review;
Within 24 hours if a facility has reason to believe that a patient death was due to abuse or neglect by staff;
Within 24 hours of any clinic fire requiring fire department response; or
Within 24 hours of an accident or natural disaster resulting in damage to the physical plant and having a direct or immediate adverse effect on the health, safety, and security of patients. This must include a description of the well- being of the clinic’s patients and the steps being taken to assure patient safety, well-being, and continuity of care and treatment. The notification may be made by telephone if the accident or natural disaster has affected the clinic’s capacity to communicate.

7-004.07 Information Available to Public: The licensee must make available for public inspection upon request licenses, license record information, and inspection reports. This information may be displayed on the licensed premises.

7-004.08 Deemed Compliance

7-004.08A Accreditation or Certification: The Department may deem an applicant or licensee in compliance with 175 NAC 7-006 based on its accreditation or certification as a health clinic, ambulatory surgical center, provider of hemodialysis services, or provider of labor and delivery services by the:

Joint Commission on Accreditation of Healthcare Organizations;
Accreditation Association of Ambulatory Health Care; or
Medicare or Medicaid certification program.

7-004.08A1 An applicant or licensee must request the Department to deem its facility in compliance with 175 NAC 7-006 based on accreditation or certification. The request must be:

Made in writing;
Submitted within 30 days of receipt of a report granting accreditation or certification; and
Accompanied by a copy of the accreditation or certification report.

7-004.08A2 Upon receipt of the request, the Department will deem the facility in compliance with 175 NAC 7-006 and will provide written notification of the decision to the facility within ten working days of receipt of the request.

7-004.08A3 The Department will exclude a facility that has been deemed in compliance with 175 NAC 7-006 from the random selection of up to 25% of facilities for compliance inspections under 175 NAC 7-005.04A. The facility may be selected for a compliance inspection under 175 NAC 7-005.04B.

7-004.08A4 To maintain deemed compliance, the licensee must maintain the accreditation or certification on which the license was issued. If the accreditation or certification has been sanctioned, modified, terminated, or withdrawn, the licensee must notify the Department within 15 days of receipt of notification of the action. After notifying the Department, the health clinic may continue to operate unless the Department determines that the health clinic no longer meets the requirements for licensure under the Health Care Facilities Licensure Act. If the Department determines the facility no longer qualifies for deemed compliance, the facility is subject to inspections under 175 NAC 7-005.

7-004.09 Fees: The Department will charge fees for licensure as set forth below:

7-004.09A Initial Licensure Fee:

All types of health clinics except public health clinics and ambulatory surgical centers: $600
Public health clinics: $400
Ambulatory surgical centers:

a. 1 operating/procedure room $1,250

b. 2 to 3 operating/procedure rooms $1,350

c. 4 or more operating/procedure rooms $1,450

7-004.09B Renewal Licensure Fees:

All types of health clinics except public health clinics and ambulatory surgical centers:

a. 1 to 50 patient admissions in the past year $600

b. 51 to 100 patient admissions in the past year $800

c. 101 or more patient admissions in the past year $1,000

Public health clinics:

a. 1 to 50 patient admissions in the past year $400

b. 51 to 100 patient admissions in the past year $450

c. 101 or more patient admissions in the past year $500

Ambulatory surgical centers:

a. 1 operating/procedure room $1,250

b. 2 to 3 operating/procedure rooms $1,350

c. 4 or more operating/procedure rooms $1,450

d. All ambulatory surgical centers must also pay an additional fee under the Outpatient Surgical Procedures Data Act, Neb. Rev. Stat. §§ 81-6,111 to 81-6,119, as follows:

(1) 500 or fewer outpatient surgeries per year $275

(2) 501 to 2,000 outpatient surgeries per year $350

(3) More than 2,000 outpatient surgeries per year $425

7-004.09C Duplicate original license: $ 10

7-004.09D Refunds for denied applications:

If the Department did not perform an inspection, the license fee is refunded except for an administrative fee of $25; or
If the Department performed an inspection, the fee is not refunded.

7-005 INSPECTIONS : To determine compliance with operational, care, treatment, and physical plant standards, the Department inspects the health clinic prior to and following licensure. The Department determines compliance through on-site inspections, review of schematic and construction plans, and reports of qualified inspectors.

7-005.01 Initial Inspection: The Department will conduct an announced initial on-site inspection to detemine compliance with 175 NAC 7-006 and 7-007. The inspection will occur within 30 working days, or later if requested by the applicant, of receipt of a completed application for an initial license. The Department will provide a copy of the inspection report to the health clinic within ten working days after completion of an inspection.

7-005.02 Results of Initial Inspection

7-005.02A When the Department finds that the applicant fully complies with the requirements of 175 NAC 7-006 and 7-007, the Department will issue a license.

7-005.02B When the Department finds that the applicant had complied substantially but has failed to comply fully with the requirements of 175 NAC 7-006 and 7-007 and the failure(s) would not pose an imminent danger of death or physical harm to persons served by the health clinic, the Department may issue a provisional license. The provisional license:

Is valid for up to one year; and
Is not renewable.

7-005.02C When the Department finds the applicant has one or more violations that create no imminent danger of death or serious physical harm and no direct or immediate adverse relationship to the health, safety, or security of the persons served by the health clinic, the Department may send a letter to the health clinic requesting a statement of compliance. The letter will include:

A description of each violation;
A request that the health clinic submit a statement of compliance within ten working days; and
A notice that the Department may take further steps if the statement of compliance is not submitted.

7-005.02D The statement of compliance must indicate any steps that have been or will be taken to correct each violation and the estimated time to correct each violation. Based on the statement of compliance, the Department will take one of the following actions:

If the health clinic submits and implements a statement of compliance that indicates a good faith effort to correct the violations, the Department will issue either a regular license or a provisional license; or
If the health clinic fails to submit and implement a statement of compliance that indicates a good faith effort to correct the violations, the Department may deny the license.

7-005.02E When the Department finds the applicant fails to meet the requirements of 175 NAC 7-006 and 7-007 and the failure(s) would create an imminent danger of death or serious physical harm, the Department will deny the license.

7-005.03 Physical Plant Inspections: The Department will conduct inspections for conformity with construction plans and compliance with 175 NAC 7-007 at new facilities or new construction prior to use or occupancy.

7-005.03A On-site progress inspections of the physical plant by qualified inspectors for conformity to construction documents and compliance with code requirements may occur at any time after construction has begun and prior to the concealment of essential components.

7-005.03B The Department will conduct an on-site final inspection of the physical plant prior to use or occupancy. In lieu of an on-site final inspection by the Department, the Department may accept a certification from a licensed architect or engineer that the physical plant meets the requirements of the Health Care Facility Licensure Act and 175 NAC 7, and that the health clinic is complete and ready for occupancy in accordance with Department-approved plans. The architect or engineer may construct a certification form or obtain a certification form from the Department.

7-005.03B1 The certification must state:

Name of the architect or engineer;
Name of the professional entity with which he or she is affiliated, if any;
Address and telephone number;
Type of license held, the state in which it is held, and the license number;
Name and location of the health clinic;
Name(s) of the owner(s) of the health clinic;

7 New construction had the building structure and plumbing rough-in inspected by a qualified inspector prior to the time these would be concealed and preclude observation;

All new construction, care and treatment room sizes, handrails, grab bars, hardware, building systems, protective shielding, privacy curtains, appropriate room finishes, and other safety equipment are completed in accordance with approved construction plans; and
The facility is furnished, cleaned, and equipped for the care and treatment to be performed in compliance with 175 NAC 7-007, and approved for use and occupancy.

7-005.03B2 The certification must have attached to it:

Copies of documents from other authorities having jurisdiction verifying that the facility meets the codes specified in 175 NAC 7-007.03A, and approved for use and occupancy;
Copies of certifications and documentation from equipment and building system installers verifying that all equipment and systems installed are operating and approved for use and occupancy; and
Schematic floor plans documenting actual room numbers and titles, bed locations, and life safety information.

7-005.04 Compliance Inspections: The Department may, following the initial licensure of a health clinic, conduct an unannounced onsite inspection at any time as it deems necessary to determine compliance with 175 NAC 7-006 and 7-007. The inspection may occur based on random selection or focused selection.

7-005.04A Random Selection: Each year the Department may inspect up to 25% of the health clinics based on a random selection of licensed health clinics.

7-005.04B Focused Selection: The Department may inspect a health clinic when the Department is informed of one or more of the following:

An occurrence resulting in patient death or serious physical harm;
An occurrence resulting in imminent danger to or the possibility of death or serious physical harm to patients;
An accident or natural disaster resulting in damage to the physical plant and having a direct or immediate adverse effect on the health, safety, and security of patients;
The passage of five years without an inspection;
A complaint alleging violation of the Health Care Facility Licensure Act or 175 NAC 7;
Complaints that, because of their number, frequency, or type, raise concerns about the maintenance, operation, or management of the health clinic;
Financial instability of the licensee or of the licensee’s parent company;
Outbreaks or recurrent incidents of physical health problems such as dehydration, pressure sores, or other illnesses;
Change of services, management, or ownership;
Change of status of accreditation or certification on which licensure is based as provided in 175 NAC 7-004.08; or
Any other event that raises concerns about the maintenance, operation, or management of the health clinic.

7-005.05 Results of Compliance Inspections

7-005.05A When the inspection reveals violations that create imminent danger of death or serious physical harm or have a direct or immediate adverse effect on the health, safety, or security of persons served by the health clinic, the Department will review the inspection findings within 20 working days after the inspection. If the evidence from the inspection supports the findings, the Department will impose discipline in accordance with 175 NAC 7-008.03.

7-005.05B When the inspection reveals one or more violations that create no imminent danger of death or serious physical harm and no direct or immediate adverse effect on the health, safety, or security of persons served by the health clinic, the Department may request a statement of compliance from the health clinic. The statement of compliance must indicate any steps that have been or will be taken to correct each violation and the estimated time to correct each violation. Based on the statement of compliance, the Department will take one of the following actions:

If the health clinic submits and implements a statement of compliance that indicates a good faith effort to correct the violations, the Department will not take any disciplinary action against the license; or
If the health clinic fails to submit and implement a statement of compliance, the Department will initiate disciplinary action against the health clinic license, in accordance with 175 NAC 7-008.

7-005.06 Re-inspections

7-005.06A The Department may conduct re-inspections to determine if a health clinic fully complies with the requirements of 175 NAC 7-006 and 7-007. Re-inspection occurs:

After the Department has issued a provisional license;
Before a provisional license is converted to a regular license;
Before a disciplinary action is modified or terminated; or
After the Department receives a statement of compliance for cited violations.

7-005.06B Following a re-inspection, the Department may:

Convert a provisional license to a regular license;
Affirm that the provisional license is to remain effective;
Modify a disciplinary action in accordance with 175 NAC 7-008.02; or
Grant full reinstatement of the license.

7-006 STANDARDS OF OPERATION, CARE AND TREATMENT : 175 NAC 7-006 applies to the following types of health clinics unless specified otherwise: public health clinics, ambulatory surgical centers, facilities at which ten or more abortions are performed during any one calendar week, facilities providing hemodialysis, and facilities providing labor and delivery services. Each health clinic must organize, manage, and administer in a manner consistent with the size, resources, and type of services to assure each patient receives the necessary care and treatment.

7-006.01 Licensee Responsibilities: The licensee of each health clinic must assume the responsibility for the total operation of the facility. The licensee responsibilities include:

Monitoring policies to assure the appropriate administration and management of the health clinic;
Maintaining the health clinic’s compliance with all applicable state statutes and relevant rules and regulations;
Providing quality care and treatment to patients whether care and treatment are furnished by health clinic staff or through a contract with the health clinic;
Periodically reviewing reports and recommendations regarding the Quality Assurance/Performance Improvement program and implementing programs and policies to maintain and improve the quality of patient care and treatment;
Maintaining written minutes of meetings and actions;
Designating an administrator who is responsible for the day to day management of the health clinic and defining the duties and responsibilities of the administrator in writing;
Notifying the Department in writing within five working days when a vacancy in the administrator position occurs including who will be responsible for the position until another administrator is appointed;
Notifying the Department in writing within five working days when the vacancy is filled including effective date and name of person appointed administrator; and
Determining if emergency medical technician-intermediates or emergency medical technician-paramedics may perform activities within their scope of practice as either an employee or volunteer within the health clinic.

7-006.02 Administration: The administrator is responsible for planning, organizing, and directing the day to day operation of the health clinic. The administrator must report in all matters related to the maintenance, operation and management of the health clinic and be directly responsible to the licensee or to the person or persons delegated governing authority by the licensee. The administrator’s responsibilities include:

Being on the premises a sufficient number of hours to permit adequate attention to the management of the health clinic;
Providing for the protection and promotion of patients’ health, safety, and well-being;
Maintaining staff appropriate to meet patient needs;
Designating a substitute, who is responsible and accountable for management of the health clinic, to act in the absence of the administrator; and
Developing procedures which require the reporting of any evidence of abuse, neglect or exploitation of any patient served by the health clinic in accordance with Neb. Rev. Stat. § 28-372 of the Adult Protective Services Act or in the case of a child, in accordance with Neb. Rev. Stat. § 28-711.
Determining the supervision of and training for emergency medical technician-intermediates or emergency medical technician-paramedics.

7-006.03 Staff Requirements: Each health clinic must maintain a sufficient number of staff with the qualifications, training, and skills to meet operational and patient needs. Each health clinic must have job descriptions for each staff position, which include minimum qualifications required for the position.

7-006.03A Employment Eligibility: Each health clinic must ensure and maintain evidence of the following:

7-006.03A1 Staff Credentials: Each health clinic must verify:

The current active licensure, registration, certification or other credentials in accordance with applicable state law, prior to staff assuming job responsibilities and must have procedures for verifying that the current status is maintained; and
That an emergency medical technician-intermediate or an emergency medical technician-paramedic providing service in the health clinic is employed by or serving as a volunteer member of an emergency medical service licensed by the Department.

7-006.03A1a If unlicensed staff assist in provision of care or treatment, such staff must be supervised by the appropriate licensed health care professional.

7-006.03A2 Health Status: Each health clinic must establish and implement policies and procedures related to the health status of staff to prevent the transmission of disease to patients.

7-006.03A2a Each health clinic must complete a health history screening for all staff prior to assuming job responsibilities and must require staff to have a physical examination when the results of the health history screening indicate the examination is necessary.

7-006.03A3 Criminal Background and Registry Checks: Each health clinic must complete and maintain documentation of pre-employment criminal background and registry checks on each unlicensed direct care staff member.

7-006.03A3a Criminal Background Checks: The health clinic must complete a criminal background check through a governmental law enforcement agency or a private entity that maintains criminal background information.

7-006.03A3b Registry Checks: The health clinic must check for adverse findings on each of the following registries:

Nurse Aide Registry;
Adult Protective Services Central Registry;
Central Register of Child Protection Cases; and
Nebraska State Patrol Sex Offender Registry.

7-006.03A3c The health clinic must:

Determine how to use the criminal background and registry information, except for the Nurse Aide Registry, in making hiring decisions;
Decide whether employment can begin prior to receiving the criminal background and registry information; and
Document any decision to hire a person with a criminal background or adverse registry findings, except for the Nurse Aide Registry. The documentation must include the basis for the decision and how it will not pose a threat to patient safety or patient property.

7-006.03A3d The health clinic must not employ a person with adverse findings on the Nurse Aide Registry regarding patient abuse, neglect, or misappropriation of patient property.

7-006.03B Training: Each health clinic must ensure staff receive training in order to perform job responsibilities.

7-006.03B1 Orientation: Each health clinic must provide and maintain evidence of an orientation program for all new staff and, as needed, for existing staff who are given new assignments. The orientation program must include an explanation of the:

Job duties and responsibilities;
The health clinic’s sanitation and infection control program;
Organizational structure;
Patient Rights;
Patient care policies and procedures;
Personnel policies and procedures;
Emergency procedures;
Disaster preparedness plan; and
Reporting requirements for abuse, neglect and exploitation in accordance with the Adult Protective Services Act, Neb. Rev. Stat. § 28-372 or in the case of a child in accordance with Neb. Rev. Stat. § 28-711 and with health clinic policies and procedures.

7-006.03B1a Each health clinic that approves emergency medical technician-intermediates and emergency medical technician-paramedics to provide service as either an employee or a volunteer must provide orientation to registered nurses, physicians, and physician assistants involved in the supervision of emergency medical technician-intermediates and emergency medical technician-paramedics. The orientation must include:

Information regarding the scope of practice of an emergency medical technician-intermediate or emergency medical technician-paramedic; and
Supervision requirements, as determined by the governing authority of the health clinic, for emergency medical technician-intermediates and emergency medical technician-paramedics, to perform activities within their scope of practice as defined in 172 NAC 11, Regulations Governing Out-of-Hospital Emergency Care Providers, Section 11-006.

7-006.03B2 Ongoing Training: Each health clinic must maintain evidence of ongoing/continuous inservices or continuing education provided for staff. A record must be maintained including date, topic and participants. Specialized training of staff to permit performance of particular procedures or to provide specialized care, whether as part of a training program or as individualized instruction, must be documented in personnel records.

7-006.03C Employment Record: Each health clinic must maintain a current employment record for each staff person. The record must include information on orientation, inservice, credentialing and health history screening.

7-006.04 Patient Rights: Each health clinic must protect and promote each patient's rights. This includes the establishment of written policies and procedures and enforcement of such to ensure the operations of the clinic afford patients the opportunity to exercise their rights. At a minimum, each patient must have the right to:

Respectful and safe care by competent personnel;
Be informed of patient rights during the admission process;
Be informed in advance about care and treatment and related risks;
Make informed decisions regarding care and treatment and to receive information necessary to make those decisions;
Refuse care and treatment and to be informed of the medical consequences of refusing such;
Formulate advance directives and to have the health clinic comply with the directives unless the clinic notifies the patient of the inability to do so;
Personal privacy and confidentiality of medical records;
Be free from abuse, neglect and exploitation;
Access information contained in his/her medical record within a reasonable time when requested;
Receive health clinic services without discrimination based upon race, color, religion, gender, national origin, or payer. Health clinics are not required to provide uncompensated or free care and treatment unless otherwise required by law; and
Voice complaints and grievances without discrimination or reprisal and have those complaints and grievances addressed.

7-006.04A Grievances: Each health clinic must establish and implement a process that promptly addresses grievances filed by patients or their designee. The process, includes, but is not limited to:

A procedure for submission of grievances that is made available to patients or representatives;
Time frames and procedures for review of grievances and provision of a response; and
How information from grievances and responses are utilized to improve the quality of patient care and treatment.

7-006.05 Quality Assurance/Performance Improvement: Each health clinic must have an effective quality assurance/performance improvement program to evaluate care and treatment provided to patients. The program includes, but is not limited to:

A written plan of implementation;
Evaluation of care and treatment provided both by staff and through contract;
For ambulatory surgical centers, the tracking of surgical procedures that result in unplanned patient admissions to a hospital within 72 hours of a procedure, due to post surgical complications;
Appropriate action to address problems found through the program;
Evaluation of the outcome of any action taken; and
Reporting to the governing authority.

7-006.06 Patient Care and Treatment: Each health clinic must establish and implement written policies and procedures that encompass all care and treatment provided to patients. The policies and procedures are consistent with prevailing professional standards, delineate the scope of services provided in the health clinic and encompass aspects to protect the health and safety of patients.

7-006.06A Administration of Medications: Each health clinic must establish and implement policies and procedures to ensure patients receive medications only as legally prescribed by a medical practitioner in accordance with the Five Rights and prevailing professional standards.

7-006.06A1 Methods of Administration of Medications: When the health clinic is responsible for the administration of medications, it must be accomplished by the following methods:

7-006.06A1a Self Administration: The health clinic must allow patients of the health clinic to self-administer medications, with or without supervision, when assessment determines the patient is capable of doing so.

7-006.06A1b Licensed Health Care Professional: When the health clinic utilizes licensed health care professionals for whom medication administration is included in the scope of practice, the health clinic must ensure the medications are properly administered in accordance with prevailing professional standards.

7-006.06A1c Provision of Medication by a Person Other Than a Licensed Health Care Professional: When the health clinic utilizes persons other than a licensed health care professional in the provision of medications, the health clinic must follow 172 NAC 95 Regulations Governing the Provision of Medications by Medication Aides and Other Unlicensed Persons and 172 NAC 96 Regulations Governing the Medication Aide Registry. Each health clinic must establish and implement policies and procedures:

To ensure that medication aides who provide medications are trained and have demonstrated the minimum competency standards specified in 172 NAC 95-004.
To ensure that competency assessments and/or courses for medication aides have been completed in accordance with the provisions of 172 NAC 96-005.
That specify how direction and monitoring will occur when the health clinic allows medication aides to perform the routine/acceptable activities authorized by 172 NAC 95-005 and as follows:

a. Provide routine medication; and

b. Provision of medications by the following routes:

(1) Oral, which includes any medication given by mouth including sublingual (placing under the tongue) and buccal (placing between the cheek and gum) routes and oral sprays;

(2) Inhalation which includes inhalers and nebulizers, including oxygen given by inhalation;

(3) Topical application of sprays, creams, ointments, and lotions, and transdermal patches; and

(4) Instillation by drops, ointments, and sprays into the eyes, ears, and nose.

That specify how direction and monitoring will occur when the health clinic allows medication aides to perform the additional activities authorized by 172 NAC 95-009, which include but are not limited to:

a. Provision of PRN medications;

b. Provision of medications by additional routes including but not limited to gastrostomy tube, rectal, and vaginal; and/or

c. Participation in monitoring.

That specify how competency determinations will be made for medication aides to perform routine and additional activities pertaining to medication provision.
That specify how written direction will be provided for medication aides to perform the additional activities authorized by 172 NAC 95-009.
That specify how records of medication provision by medication aides will be recorded and maintained.
That specify how medication errors made by medication aides and adverse reactions to medications will be reported. The reporting must be:

a. Made to the identified person responsible for direction and monitoring;

b. Made immediately upon discovery; and

c. Documented in patient medical records.

7-006.06A2 Each health clinic must establish and implement policies and procedures for reporting any errors in administration or provision of prescribed medications to the prescriber in a timely manner upon discovery and a written report of the error must be prepared and maintained.

7-006.06A3 Each health clinic must establish and implement policies and procedures for reporting any adverse reaction to a medication, in a timely manner upon discovery, to the prescriber and for documenting such event in the patient’s medical record.

7-006.06A4 Each health clinic must establish and implement procedures to ensure patients receive medications as prescribed by a medical practitioner. At a minimum, the following must be evident:

A current policy and procedure manual regarding the handling of medications in the health clinic;
A count of all controlled substances in the health clinic every 24 hours; and
Only authorized personnel designated by health clinic policy are allowed access to medications.

7-006.06B Verbal Orders: Each health clinic must establish and implement appropriate policies and procedures for those staff authorized to receive telephone and verbal diagnostic and therapeutic orders.

7-006.06C Patient Education: Each health clinic must establish and implement a process to ensure patients and/or their designee receive appropriate education and instruction to assist in understanding the identified condition and the necessary care and treatment. Any instructions at the time of discharge must be given in writing.

7-006.06D Patient Transfers: Each health clinic must transfer to a health care facility and have procedures for continued care of any patient whose condition does not allow dismissal within 24 hours.

7-006.07 Record Keeping Requirements: Each health clinic must maintain records and reports in such a manner to ensure accuracy and easy retrieval.

7-006.07A Medical Records: Every patient who receives care or treatment in a health clinic must have a medical record established. Medical records must contain sufficient information to clearly identify the patient and document the diagnosis, care, treatment, and results accurately.

7-006.07A1 Content: Medical records must contain, when applicable, the following information:

Identification data;
Chief complaint;
Medical history;
Physical examination;
All pathology/laboratory and radiology reports;
Properly executed informed consent forms;
Consultation reports;
Medical practitioner orders;
Care and treatment provided;
Progress notes;
Pertinent observations and events; and
Instructions to patients, including discharge/dismissal.

7-006.07A2 Medical records must contain entries which are dated, legible, and indelible. The author of each entry must be identified and authenticated. Authentication must include signature, written initials, or computer entry.

7-006.07A3 Retention: Each health clinic must maintain and preserve all medical records in original, microfilm, electronic, or other similar form, for a period of at least five years. In the case of a minor, the medical records must be kept until three years after the age of majority has been attained. When a health clinic ceases operation, all medical records must be transferred as directed by the patient or authorized representative to the licensed health care facility or health care service to which the patient is transferred. All other medical records that have not reached the required time for destruction must be stored to assure confidentiality and the Department must be notified of the address where stored.

7-006.07A4 Confidentiality: Medical records must be kept confidential, available only for use by authorized persons or as otherwise permitted by law. Records must be available for examination by authorized representatives of the Department.

7-006.07A5 Access: Patient information and/or records will be released only with consent of the patient or designee or as required by law.

7-006.07A6 Destruction: Medical records may be destroyed only when they are in excess of five years of age. In order to ensure confidentiality, each health clinic must destroy or dispose of medical records by shredding, incineration, electronic deletion, or another equally effective protective measure.

7-006.07B Other Records/Reports: In addition to patient medical records, each health clinic must maintain accurate and complete administrative records of the clinic operation for not less than three years unless longer is required by law.

7-006.07B1 A report that summarizes the scope and volume of services provided at the health clinic each year must be maintained.

7-006.08 Infection Control: Each health clinic must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.

7-006.08A The infection control program must include, but is not limited to:

The responsible person(s) for the program;
A system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and staff;
A definition of nosocomial infection;
A system for reporting known or suspected cases of infection acquired at the health clinic among patients and for maintaining records of such infection;
Maintenance of a record of infection, communicable disease and nosocomial infections;
Implementation of corrective action plans; and
Mechanism for evaluation of the program.

7-006.08A Equipment and Supplies: Each health clinic must establish and implement written policies and procedures for cleaning, sterilization and storage of supplies and equipment. Equipment and supplies must be maintained in accordance with prevailing professional standards to protect patients from infection.

7-006.08B Handwashing: Facilities for handwashing must be easily accessible and good handwashing techniques must be practiced by staff before and after patient contact.

7-006.08C Food Service: Each health clinic that provides food service must store, prepare, protect, and dispose of food in a safe and sanitary manner and in accordance with the Food Code.

7-006.09 Pharmacotherapy Services: Each health clinic that provides pharmacotherapy services to meet patient needs must maintain drugs, devices, and biologicals under the supervision of a licensed Nebraska pharmacist or licensed Nebraska physician. The storage, control, handling, compounding, administration, provision, and dispensing of drugs, devices, and biologicals must be in accordance with state and federal law.

Any health clinic that conducts a pharmacy or engages in the practice of pharmacy must do so in accordance with Neb. Rev. Stat. §§ 71-1,142 to 71-1,147.61.

Each health clinic must ensure that information relating to interactions, contraindications, side effects, toxicology, dosage, indications for use, and routes of administration for drugs, devices, and biologicals is available to staff at all times.

7-006.09A Emergency Drugs, Devices, and Biologicals: Emergency drugs, devices, and biologicals, as determined by the need of patients served by each health clinic, must be readily available for use when an emergency occurs.

7-006.09B Prescribing Drugs, Devices, and Biologicals: Each health clinic must establish appropriate policies and procedures for those personnel authorized to receive telephone and verbal orders for drugs, devices, and biologicals. A separate policy and procedure must be required in health clinics where drugs, devices, and biologicals are dispensed to patients. All written orders and prescriptions must be legible as required by 175 NAC 7-006.07A1.

7-006.09C Preparation and Compounding of Drugs, Devices, and Biologicals: A current policy and procedure manual regarding the handling of drugs, devices and biologicals in the health clinic must be available at all times to personnel authorized to administer or provide such. The manual must include information on preparation and must comply with all state and federal law regarding the practice of pharmacy.

7-006.09D Dispensing of Drugs, Devices, and Biologicals: All drugs, devices, and biologicals dispensed from a health clinic must be dispensed by a pharmacist, a physician with a dispensing permit, or in accordance with Neb. Rev. Stat. §§ 71-1,147.39 to 71-1,147.61.

7-006.09E Storage of Drugs, Devices, and Biologicals: All drugs, devices, and biologicals must be stored in secured areas and stored in accordance with the manufacturer’s, distributor’s, packager’s, or dispensing pharmacist’s instructions for temperature, light, humidity, and other storage instructions. Only authorized personnel, designated by policy and procedure of the health clinic as responsible for administration, provision, or dispensing, must have access to drugs, devices, and biologicals. The supply of drugs, devices, and biologicals must be protected and restricted to use for legally authorized purposes and must be checked on a regular basis to ensure expired, mislabeled, unlabeled, or unusable products are not available for patient use.

7-006.09F Record Keeping: All drugs, devices, and biologicals administered, provided, or dispensed for a patient must be recorded in the patient’s medical record. The record must specify the name, dosage, date, time, and route of administration or provision and identification of the person who administered or provided such.

7-006.09F1 A complete and accurate record of all drugs, devices, and biologicals received, stored, administered, provided, dispensed, or disposed of by the health clinic must be kept and maintained for not less than five years.

7-006.09F2 Each health clinic must have a policy and procedure for the reporting and recording of any abuse or loss of drugs, devices, and biologicals. Such policy must be in accordance with state and federal law concerning abuse and loss of drugs, devices, and biologicals.

7-006.09G Sample Drugs, Devices, and Biologicals: Personnel of a health clinic must not receive manufacturer, distributor, or packager samples in violation of any state or federal law.

7-006.09G1 A complete and accurate record of all drugs, devices, and biologicals samples received, stored, administered, provided, dispensed, or disposed of by the health clinic must be kept and maintained for not less than five years.

7-006.09G2 All samples administered, provided, or dispensed to a patient must be recorded in the patient’s medical record.

7-006.09H Investigational Drugs, Devices, and Biologicals: All drugs, devices, and biologicals being used as a part of a clinical investigation must be maintained in a locked and separate area from all other drugs, devices, and biologicals. All investigational drugs, devices, and biologicals should be administered only in accordance with the clinical study protocol.

7-006.09I Disposal of Drugs, Devices, and Biologicals: Each health clinic must ensure that expired, mislabeled, unlabeled, or unusable drugs, devices, and biologicals are not available for patient use and are disposed of in accordance with clinic policies and state and federal law. The disposal must be conducted on a routine basis to prevent storage of large quantities of expired, mislabeled, unlabeled, or unusable drugs, devices, and biologicals.

7-006.10 Laboratory Services: All laboratory testing, whether provided directly by the health clinic or through agreement, must comply with the Clinical Laboratory Improvement Amendments of 1988 as amended (CLIA).

7-006.10A Complete laboratory test result reports must be kept in patient medical records.

7-006.11 Radiology Services: Each health clinic that provides radiology services must be under the direction of a physician and must comply with the provisions of Neb. Rev. Stat. §§ 71-3501 to 71-3520 of the Radiation Control Act and the regulations promulgated thereunder.

7-006.11A Personnel performing medical radiography procedures must be licensed in accordance with Neb. Rev. Stat. §§ 71-3515.01 to 71-3515.02 of the Radiation Control Act and the regulations promulgated thereunder.

7-006.12 Ambulatory Surgical Center: Each ambulatory surgical center must meet the regulations specified in 175 NAC 7-006.01 to 7-006.09 and 7-006.15. In addition, each ambulatory surgical center must meet all requirements to qualify for a written agreement with the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services or its successor to participate in Medicare as an ambulatory surgical center as defined in 42 CFR 416.1 to 416.200 attached to these regulations and incorporated by this reference.

7-006.12A Each ambulatory surgical center is limited to performing surgical and other medical procedures that can be safely performed in a dedicated operating room or suite and which may require a postoperative recovery room for convalescent stay. An ambulatory surgical center can only provide surgical services to persons who are admitted to and discharged from the ambulatory surgery center within the same working day and must not retain patients past midnight of the day of admission.

7-006.12B Each ambulatory surgical center must maintain a chronological permanent admission and discharge record that, at a minimum, includes:

Full name of each patient;
Identification number assigned by the ambulatory surgical center;
Date and time of admission and discharge;
Surgical procedure(s) performed;
Inclusive time of surgical procedure(s);
Name of surgeon and any assistants(s);
Name of nursing personnel (scrubbing and circulating);
Type of anesthesia; and
Name and title of person administering anesthesia.

7-006.12C Each ambulatory surgical center must provide discharge planning to patients or their designee.

7-006.12C1 If a patient is discharged to a health care facility or health care service, necessary medical information must be transferred to the receiving facility or service.

7-006.12D Before discharge from the ambulatory surgical center, the patient must be evaluated for proper recovery. Qualified personnel must remain with the patient until the patient’s status is stable and protective reflexes have returned to normal. A patient may be discharged only when a medical practitioner and facility policies determine it is safe and appropriate to discharge. The ambulatory surgical center must establish medical criteria for discharge which is consistent with prevailing professional standards.

7-006.12E Each ambulatory surgical center must, at least annually, provide surgeons performing surgery at the facility a report as to the number and rates of surgical infections in patients of the surgeons.

7-006.13 Hemodialysis Services: Each health clinic providing hemodialysis services must be licensed as a health clinic and must meet the regulations specified in 175 NAC 7-006.01 to 7-006.11 and 7-006.15. In addition, each health clinic must meet all requirements to qualify for a written agreement with the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services or its successor to participate in Medicare for hemodialysis services as defined in 42 CFR 405.2100 to 405.2163, attached to these regulations and incorporated by this reference.

7-006.14 Labor and Delivery Services: Each facility, not licensed as a hospital, that provides labor and delivery services must be licensed as a health clinic and must meet the regulations specified in 175 NAC 7-006.01 to 7-006.11; 7-006.15 and the following requirements:

7-006.14A Care and Treatment: Each facility must establish and implement written policies and procedures to ensure the safe delivery of care and treatment to patients. The policies and procedures must include, but are not limited to, the following:

Care and treatment during antepartum, intrapartum, postpartum, and newborn care;
Appropriate attire to be worn during labor and delivery;
The use of oxytocic drugs and administration of anesthetics, sedatives, analgesics, and other drugs, devices, and biologicals;
Visitation and attendance during the birth process; and
Method for identification of every newborn immediately after birth.

7-006.14B Staff: Each facility must have a sufficient number of qualified staff to meet the needs of patients. The staff must function in accordance with their scope of practice.

7-006.14B1 Appropriate licensed health care professional staff must be on call at all times and available on-site at the facility within 30 minutes.

7-006.14B2 Nursing care during labor and delivery including care of the newborn must be supervised by a qualified registered nurse.

7-006.14B3 The direction and coordination of all medical aspects of the facility’s policies must be by a physician designated by the governing authority.

7-006.14B4 At least one physician, certified nurse midwife, or registered nurse must be present at all times when a mother or newborn is in the facility.

7-006.14C Emergency Equipment and Supplies: Each facility must have the necessary, drugs, devices, biologicals, equipment, and supplies immediately available for provision of care and treatment should an equipment emergency arise.

7-006.14C1 The following emergency equipment must be available in the facility to provide care to both adults and newborns:

Emergency call system;
Oxygen;
Mechanical ventilation assistance equipment including airways and manual breathing bags;
Cardiac defibrillator;
Cardiac monitoring equipment;
Tracheotomy sets;
Laryngoscopes and endotracheal tubes; and
Suction equipment.

7-006.14D Emergency Transfer: Each facility must have a written agreement for emergency care with a hospital that provides obstetrical services or each medical practitioner practicing at the facility must have admitting privileges at a transferring hospital.

7-006.14D1 Each facility must have the capability to transfer and transport the mother and/or newborn to the contract hospital(s) timely or have a written contract with an ambulance service that will assure timely response.

7-006.14E Admission and Discharge: Each facility must establish and implement criteria for rejection, admission, discharge, and continuing care of patients which is clearly defined and made available for review to persons requesting such.

7-006.14E1 Admissions to the facility must be restricted to low-risk patients who have received antepartum care in accordance with the facility’s policies.

7-006.14E2 Planned Caesarean Section procedures are prohibited.

7-006.14E3 Each mother and newborn must be discharged within 24 hours after admission, in a condition which will not endanger the well-being of either. If the condition of mother or newborn does not allow discharge within 24 hours, then transfer to a hospital must occur.

7-006.14E4 Verbal and written instructions must be provided for observation and care of both the mother and newborn after discharge. The mother and newborn must be discharged in the care of the father or a responsible adult who will assist in their transport from the facility.

7-006.14F Records: Each facility must maintain a permanent admission and discharge patient index that includes, but is not limited to:

Full name of patient and identification number assigned by the facility;
Date and time of admission and discharge;
Name of admitting physician or certified nurse midwife;
Type of anesthesia;
Time of birth;
Gender of newborn; and
Disposition or place to which mother and newborn were discharged/ transferred.

7-006.14G All births must be reported in accordance with Neb. Rev. Stat. § 71-604.

7-006.15 Environmental Services: Each health clinic must provide a safe, clean, and comfortable environment for patients. Every detached building on the same premises used for care and treatment must comply with 175 NAC 7.

7-006.15A Housekeeping and Maintenance: The facility must provide the necessary housekeeping and maintenance to protect the health and safety of patients.

7-006.15A1 The facility’s buildings and grounds must be kept clean, safe and in good repair.

7-006.15A2 All garbage and rubbish must be disposed of in such a manner as to prevent the attraction of rodents, flies, and all other insects and vermin. Garbage must be disposed in such a manner as to minimize the transmission of infectious diseases and minimize odor.

7-006.15A3 The facility must maintain adequate lighting, environmental temperatures, and sound levels in all areas that are conducive to the care and treatment provided.

7-006.15A4 The facility must maintain and equip the premises to prevent the entrance, harborage, or breeding of rodents, flies, and all other insects and vermin.

7-006.15B Equipment, Fixtures, and Furnishings: The facility must provide and maintain all equipment, fixtures, and furnishings clean, safe and in good repair.

7-006.15B1 The facility must establish and implement a process designed for routine and preventative maintenance of equipment and furnishings to ensure that such equipment and furnishings are safe and function to meet the intended use.

7-006.15C Linens: The facility must maintain an adequate supply of linen necessary for the care and treatment of patients. Linen must be clean and in good repair.

7-006.15C1 The facility must establish and implement procedures for the storage and handling of soiled and clean linens.

7-006.15C2 When the facility provides laundry services, water temperatures to laundry equipment must exceed 160 degrees Fahrenheit or the laundry may be appropriately sanitized or disinfected by another acceptable method in accordance with manufacturer’s instructions.

7-006.15D Pets: The health clinic must assure any facility owned pet does not negatively affect patients. The health clinic must have policies and procedures regarding pets that include:

An annual examination by a licensed veterinarian;
Vaccinations as recommended by the licensed veterinarian that include, at a minimum, current vaccination for rabies for dogs, cats, and ferrets;
Provision of pet care necessary to prevent the acquisition and spread of fleas, ticks and other parasites; and
Responsibility for care and supervision of the pet by health clinic staff.

7-006.15E Environmental Safety: The health clinic must be responsible for maintaining the environment in a manner that minimizes accidents.

7-006.15E1 The facility must maintain the environment to protect the health and safety of patients by keeping surfaces smooth and free of sharp edges, mold, or dirt; keeping floors free of objects and slippery or uneven surfaces and keeping the environment free of other conditions which may pose a potential risk.

7-006.15E2 The facility must maintain all doors, stairways, passageways, aisles, or other means of exit in a manner that provides safe and adequate access for care and treatment.

7-006.15E3 The facility must provide water for bathing and handwashing at safe and comfortable temperatures to protect patients from potential for burns or scalds.

7-006.15E3a The facility must monitor and maintain water temperatures that accommodate comfort and preferences but not to exceed the following temperatures:

Water temperature at patient handwashing fixtures must not exceed 120 degrees Fahrenheit.
Water temperatures at bathing and therapy fixtures must not exceed 110 degrees Fahrenheit.

7-006.15E4 The facility must establish and implement policies and procedures to ensure hazardous/poisonous materials are properly handled and stored to prevent accidental ingestion, inhalation, or consumption of the hazardous/poisonous materials by patients.

7-006.15E5 The facility must restrict access to mechanical equipment which may pose a danger to patients.

7-006.15F Disaster Preparedness and Management: The health clinic must establish and implement disaster preparedness plans and procedures to ensure that patient care and treatment, safety, and well-being are provided and maintained during and following instances of natural (tornado, flood, etc.) and other disasters, disease outbreaks, or other similar situations causing patients to remain at the clinic. Such plans and procedures must address and delineate:

How the clinic will maintain the proper identification of each patient to ensure that care and treatment coincide with the patient’s needs;
How the clinic will move patients to points of safety or provide other means of protection when all or part of the building is damaged or uninhabitable due to natural or other disaster;
How the clinic will protect patients during the threat of exposure to the ingestion, absorption, or inhalation of hazardous substances or materials;
How the clinic will provide food, water, medicine, medical supplies, and other necessary items for care and treatment in the event of a natural or other disaster; and
How the clinic will provide for the comfort, safety, and well-being of patients in the event of 24 or more consecutive hours of:

a. Electrical or gas outage;

b. Heating, cooling, or sewer system failure, or

c. Loss or contamination of water supply.

7-007 PHYSICAL PLANT STANDARDS : All health clinics must be designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided. The physical plant standards for health clinics, which include support services, care and treatment areas, construction standards, building systems and waivers, are set forth below.

7-007.01 Support Areas: The health clinic may share the following support areas among detached structures, care and treatment areas, or with other licensed facilities.

7-007.01A Dietary: If food preparation is provided on site, the facility must dedicate space and equipment for the preparation of meals. Food service physical environment and equipment must comply with the Food Code.

7-007.01B Laundry: If the facility provides laundry services, the service may be provided by contract or on-site by the facility.

7-007.01B1 Contract: If contractual services are used, the facility must have areas for soiled linen awaiting pickup and separate areas for storage and distribution of clean linen.

7-007.01B2 On-site: If on-site services are provided, the facility must have areas dedicated to laundry.

7-007.01B2a In new construction, if the facility processes bulk laundry, the laundry must be divided into separate soiled (sort and washer areas) and clean (drying, folding, and mending areas) rooms with a separate soaking and hand washing sink in the laundry area.

7-007.01B2b Separate clean linen supply storage facilities must be conveniently located to care and treatment locations.

7-007.01C Diagnostic: If the facility provides radiology or laboratory services, the services must comply with the following:

7-007.01C1 Imaging rooms must accommodate the operational and shielding requirements of the equipment installed, condition of the patient, and provide clear floor area adequate for the safety of staff and patients.

7-007.01C2 Laboratory areas must provide for sample collection and protection, analyzing, testing, and storage. The facility must handle all potentially contagious and hazardous samples in a manner as to minimize transmission of infectious diseases.

7-007.01D Waste Processing: The health clinic must provide areas to collect, contain, process, and dispose of medical and general waste produced within the health clinic in such a manner as to prevent the attraction of rodents, flies, and all other insects and vermin, and to minimize the transmission of infectious diseases.

7-007.01E Housekeeping Room: The facility must have a room with a service sink and space for storage of supplies and housekeeping equipment.

7-007.02 Care and Treatment Areas: The health clinic must not share the following care and treatment areas among detached structures or with other facilities operated by another licensee. Care and treatment areas must comply with the following:

7-007.02A Staff Areas: Health clinics that provide nursing services must provide the following support areas for each distinct patient care and treatment areas.

7-007.02A1 Control Point: The facility must have an area or areas for charting and patient records, and call and alarm annunciation systems.

7-007.02A2 Medication Station: The facility must have a medication station for storage and distribution of drugs and routine medications. Distribution may be done from a medicine preparation room or unit, from a self-contained medicine-dispensing unit, or by another system. If used, a medicine preparation room or unit must be under visual control of nursing staff and must contain a work counter, sink, refrigerator, and double-locked storage for controlled substances.

7-007.02A3 Patient Facilities: The facility must have space for patient care, treatment, consultation, and waiting area.

7-007.02A4 Utility Area: The facility must have a work area where clean materials are assembled. The work area must contain a work counter, a handwashing fixture, and storage facilities for clean and sterile supplies. If the area is used only for storage and holding as part of a system for distribution of clean and sterile supply materials, the work counter and handwashing fixtures may be omitted. A facility must have separate work rooms or holding rooms for soiled materials. A work room for soiled materials must contain a fixture for disposing wastes and a handwashing sink.

7-007.02B Equipment and Supplies: The health clinic must have services and space to distribute, maintain, clean, and sanitize durable medical instruments, equipment, and supplies required for the care and treatment performed in the facility.

7-007.02B1 Durable Medical: The facility must ensure that the durable medical equipment is tested and calibrated in accordance with the manufacturer’s recommendations.

7-007.02B2 Sterile Processing: If sterile processing is completed onsite, the facility must have areas for decontamination and sterilizing of durable medical instruments and equipment.

7-007.02B2a The facility must provide separate sterile processing and waste processing areas.

7-007.02B2b In new construction and where provided, central sterile processing service area(s), must have separate soiled (sorting and decontamination) and clean (sterilizing and processing) rooms. The facility must have handwashing sinks in both clean and soiled rooms.

7-007.02B3 Required Equipment: The facility must provide equipment adequate for meeting the care and treatment needs of patients.

7-007.02B4 Equipment Storage: The facility must have space to store equipment, stretchers, wheelchairs, supplies, and linen out of the path of normal traffic.

7-007.02C Surgery: A health clinic providing surgical services must have at least one operating or procedure room and the following support areas. In new construction and facilities with more than two surgery rooms, the following support areas and central processing areas must be located in restricted access areas:

Preoperative Patient Area: Preoperative patient area(s) must have sufficient space and equipment to accommodate both ambulatory and non-ambulatory patients. These areas must be under the direct visual control of the nursing staff.
Recovery Area: Recovery area(s) must contain a medication station, handwashing sink, charting area, provisions for bedpan cleaning, and equipment and supply storage space.
Dressing Area: The facility must have patient dressing and toilet rooms separate from staff gowning areas.
Housekeeping Room: The facility must have soiled utility and housekeeping areas exclusively for the surgical suite.

7-007.02D Emergency Care: A health clinic providing emergency services must have at least one procedure or treatment room. To support the provision of emergency care, the facility must have the following:

Entrance: A well marked, illuminated covered entrance at grade level for emergency vehicle and pedestrian access;
Waiting Area: Patient and visitor waiting area(s) that are in direct observation of the reception, triage, or control station, and have access to a public phone and drinking fountain;
Storage: Storage areas for general medical/surgical emergency supplies, medications, and equipment under staff control and out of the
Toilet Room: A patient toilet room with handwashing sink which is convenient to the procedure or treatment room(s).

7-007.02E Rehabilitation: A facility providing rehabilitation services must have at least one treatment room or cubicle, an area for specialized treatment and care, handwashing sink(s), storage for equipment and supplies, call system, medication storage, and distribution, and areas to allow for patient toileting, dressing, and consultation.

7-007.02F Obstetrics: A facility providing obstetric services must have at least one patient room, space, and equipment to allow for care and treatment of both mother and infant, handwashing sink, storage for equipment and supplies, call and alarm annunciation systems, medication storage, and distribution, and convenient accommodations for patient toileting, dressing, and consultation.

7-007.03 Construction Standards: All health clinics must be designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided. The standards for such facilities are set forth below.

7-007.03A Codes and Guidelines

7-007.03A1 New Construction: New construction must comply with the following codes and guidelines to provide a safe and accessible environment that is conducive to the care and treatment to be provided:

Building: Building Construction Act, Neb. Rev. Stat. §§ 71-6401 to 71-6407;
Plumbing: Plumbing Ordinance or Code, Neb. Rev. Stat. § 18-1915;
Electrical: State Electrical Act, Neb. Rev. Stat. §§ 81-2101 to 81-2143;
Elevators: Nebraska Elevator Code, Neb. Rev. Stat. § 48-418.12 and Department of Labor Regulations, 230 NAC 1;
Boiler: Boiler Inspection Act, Neb. Rev. Stat. §§ 48-719 to 48-743;
Accessibility: Nebraska Accessibility Requirements, State Fire Marshal Regulations, 156 NAC 1 to 12;
Design: Guidelines for Design and Construction of Hospitals and Health Care Facilities, Chapter 9, 2001 edition, published by the American Institute of Architects; and
Energy: Nebraska Energy Code, Neb. Rev. Stat. §§ 81-1608 to 81-1626, for construction initiated on or after July 1, 2005.

7-007.03A2 All Facilities: All facilities must comply with the following applicable codes and standards to provide a safe environment:

Fire Codes: Nebraska State Fire Code Regulations, State Fire Marshal, 153 NAC 1; and
The Food Code, Neb. Rev. Stat. § 81-2,244.01, as published by the Nebraska Department of Agriculture, except for compliance and enforcement provisions.

7-007.03A3 Existing and New Facilities: Existing and new facilities must comply with the physical plant standards contained in 175 NAC 7-007. The facility must maintain all building materials and structural components so that total loads imposed do not stress materials and components more than one and one half times the working stresses allowed in the building code for new buildings of similar structure, purpose, or location.

7-007.03B Conflicts in Standards: In situations where the referenced codes and guidelines conflict with 175 NAC 7, the adopted rules and regulations of the Department and the Nebraska State Fire Marshal will prevail.

7-007.03C Interpretations: All dimension, sizes, and quantities; noted herein will be determined by rounding fractions to the nearest whole number.

7-007.03D Floor Area: Floor area is the space with ceilings at least seven feet in height and does not include areas such as enclosed storage, toilets, and bathing rooms, corridors, and halls. The space beyond the first two feet of vestibules and alcoves less than five feet in width will not be included in the required floor area. In rooms with sloped ceilings, at least half of the ceiling must be at least seven feet in height with areas less than five feet in height, not included in the required floor area.

7-007.03E Bathing Rooms: If the facility provides a tub or shower for patient bathing, they must be equipped with hand grips or other assistive devices.

7-007.03F Toilet Rooms: The facility must provide at least one room with a toilet and sink for patient use.

7-007.03G Patient Rooms: The facility may provide rooms of the following types which allow for sleeping, afford privacy, provide access to furniture and belongings, and accommodate the care and treatment provided to the patient.

7-007.03H Isolation Rooms: The number and type of isolation rooms in a health clinic must be determined by the facility and must ensure a safe environment for patients.

7-007.03I Observation Areas: If the facility provides medical observation or behavior intervention methods, the facility must provide one or more appropriately equipped rooms for patients needing close supervision. Each room must:

Have appropriate temperature control, ventilation, and lighting;
Be void of unsafe wall or ceiling fixtures and sharp edges;
Have a way to observe the patient, such as an observation window or if necessary, flat wall mirrors so that all areas of the room are observable by staff from outside of the room;
Have a way to assure that the door cannot be held closed by the patient in the room which could deny staff immediate access to the room; and
Be equipped to minimize the potential of the patient’s escape, injury, suicide, or hiding of restricted substances.

7-007.03J Bassinets: Each bassinet must have a minimum floor area of 40 square feet with at least 3 feet between bassinets.

7-007.03K Cubicles: Patient care and treatment cubicles must have a minimum floor area of 60 square feet with at least 3 feet between bedsides and adjacent side walls.

7-007.03L Examination Rooms: Each examination room must have a minimum floor area of 80 square feet and a minimum of 3 feet clear dimension around 3 sides of the examination table or chair.

7-007.03M Treatment Rooms: Treatment room for procedures performed under topical, local, or regional anesthesia without pre-operative sedation must have a minimum floor area of 120 square feet and a minimum of 10 feet clear dimension.

7-007.03N Procedure Rooms: Procedure rooms for invasive and minor surgical procedures performed in conjunction with oral, parenteral, or intravenous sedation or under analgesic or dissociative drugs must have a minimum floor area of 200 square feet and a minimum of 14 feet clear dimension.

7-007.03O Operating Rooms: Operating rooms for major surgical procedures that require general or regional block anesthesia and support of vital bodily functions must have a minimum floor area of 300 square feet and a minimum of 16 feet clear dimension.

7-007.03P Corridors: The facility corridors must be wide enough to allow passage and be equipped as needed by the patients with safety and assistive devices to minimize injury. All stairways and ramps must have handrails.

7-007.03Q Doors: The health clinic doors must be wide enough to allow passage and be equipped for privacy, safety, and with assistive devices to minimize patient injury.

7-007.03Q1 All toilet and bathing room doors must provide privacy yet not create seclusion or prohibit staff access for routine or emergency care.

7-007.03Q2 In new construction all toilet and bathing rooms used by patients with less than 50 square feet of clear floor area must not have doors that solely swing inward.

7-007.03Q3 Doors may prevent escape and create seclusion where therapeutically required, such as emergency protective custody, detoxification and psychiatric locations.

7-007.03R Outdoor Areas: Any outdoor area for patient usage provided by the facility must be equipped and situated to allow for patient safety and abilities.

7-007.03S Handwashing Sinks: The facility must provide a handwashing sink equipped with towels and soap dispenser in all examination, treatment, isolation, and procedure rooms; available to every four care and treatment cubicle locations; and one scrub sink near the entrance of each operating room.

7-007.03T Privacy: In multiple bed patient care and treatment rooms, visual privacy, and window curtains must be provided for each patient. In new construction and new facilities, the curtain layout must totally surround each care and treatment location which will not restrict access to the entrance to the room, lavatory, toilet, or enclosed storage facilities.

7-007.03U Finishes: Room finishes in care and treatment areas must comply with the following:

Washable room finishes provided in procedure rooms, existing isolation rooms, sterile processing rooms, workroom, laundry, and food-preparation areas must have smooth, non-absorptive surfaces which are not physically affected by routine housekeeping cleaning solutions and methods. Acoustic and lay-in ceilings, if used, must not interfere with infection control. Perforated, tegular, serrated cut, or highly textured tiles are not acceptable.
Scrubbable room finishes provided in operating rooms and new isolation rooms must have smooth, non-absorptive, non-perforated surfaces that are not physically affected by harsh germicidal cleaning solutions and methods.

7-007.04 Building Systems: Health clinics must have building systems that are designed, installed and operated in such a manner as to provide for the safety, comfort, and well being of the patient.

7-007.04A Water and Sewer Systems: The facility must have and maintain an accessible, adequate, safe, and potable supply of water. Where an authorized public water supply of satisfactory quantity, quality, and pressure is available, the facility must be connected to it and its supply used exclusively.

7-007.04A1 The collection, treatment, storage, and distribution potable water system of a facility that regularly serves 25 or more individuals must be constructed, maintained, and operated in accordance with all provisions of the Nebraska Safe Drinking Water Act and Title 179 Regulations Governing Public Water Systems.

7-007.04A2 The collection, treatment, storage and distribution potable water system of a facility that serves less than 25 individuals on a regular basis must be maintained and operated as if it were a public water system in accordance with the Regulations Governing Public Water Systems, 179 NAC 2-002, 3 and 4. The facilities must report to the Department the result of all tests that indicate the water is in violation of the standards set out in 179 NAC 2-002 or 3. The facilities must construct all water wells in accordance with 178 NAC 12, Water Well Construction, Pump Installation, and Water Well Decommissioning Standards.

7-007.04A3 The water distribution system must be protected with anti-siphon devices, and air-gaps to prevent potable water system and equipment contamination.

7-007.04A4 Continuously circulated filtered and treated water systems must be provided as required for the care and treatment equipment used in the health clinic.

7-007.04A5 The facility must maintain a sanitary and functioning sewage system.

7-007.04B Hot Water System: The facility must maintain hot and cold water to all hand washing and bathing locations. The hot water system must have the capacity to provide continuous hot water at temperatures as required by 175 NAC 7.

7-007.04C Heating and Cooling Systems: The facility must provide a heating and air conditioning system for the comfort of the patient and capable of maintaining the temperature in patient care and treatment areas as follows:

7-007.04C1 In existing and new facilities, the systems must be capable of producing a temperature of at least 70 degrees Fahrenheit during heating conditions and a temperature that does not exceed 85 degrees Fahrenheit during cooling conditions.

7-007.04C2 In new construction the systems must be capable of producing a temperature of at least 75 degrees Fahrenheit during heating conditions and a temperature that does not exceed 80 degrees Fahrenheit during cooling conditions.

7-007.04C3 In new construction, central air distribution, and return systems must have the following percent dust rated filters :

General areas: 30 +% ; and
Procedure and operating rooms: 90 +% .

7-007.04C4 Surgical areas must have heating and cooling systems that are capable of producing room temperatures at a range between 68 and 73 degrees Fahrenheit and humidity at a range between 30 and 60% relative humidity.

7-007.04C5 Airflow must move from clean to soiled locations. In new construction, air movement must be designed to reduce the potential of contamination of clean areas.

7-007.04C6 Floors in operating, procedure, and other locations subject to wet cleaning methods or body fluids must not have openings to the heating and cooling system.

7-007.04D Ventilation System: All facilities must provide exhaust and clean air to prevent the concentrations of contaminants which impair health or cause discomfort to patients and employees.

7-007.04D1 Existing and new facilities must have adequate ventilation.

7-007.04D2 New construction must provide mechanical exhaust ventilation system for windowless toilets, baths, laundry rooms, housekeeping rooms, kitchens, and similar rooms at ten air changes per hour.

7-007.04D3 New construction must provide mechanical ventilation system(s) capable of providing air changes per hour (hereafter ACH) as follows:

Care and treatment areas: 5 ACH;
Procedure and respiratory isolation areas: 15 ACH; and
Operating rooms: 20 ACH.

7-007.04E Electrical System: The facility must have an electrical system that has sufficient capacity to maintain the care and treatment services that are provided and that properly grounds care and treatment areas.

7-007.04E1 New construction and new facilities must have ground fault circuit interrupters protected outlets in wet areas and within 6 feet of sinks.

7-007.04E2 All facilities must provide minimum illumination levels as follows:

General purpose areas: 5 foot candles;
General corridors: 10 foot candles;
Personal care and dining areas: 20 foot candles;
Reading and activity areas: 30 foot candles;
Food preparation areas: 40 foot candles;
Hazardous work surfaces: 50 foot candles;
Care and treatment locations: 70 foot candles;
Examination task lighting: 100 foot candles;
Procedure task lighting: 200 foot candles; and
Surgery task lighting: 1000 foot candles.

Light levels are measured at 30 inches above the floor in multiple areas in the room being evaluated and the readings are averaged.

7-007.04F Essential Power System: Facilities must have an emergency power generator for all care and treatment locations which involve general anesthetics or electrical life support equipment, and in emergency procedure and treatment rooms.

7-007.04F1 Existing and new facilities must maintain emergency power for essential care and treatment equipment and lighting, medical gas systems, and nurse call systems.

7-007.04F2 New construction must maintain emergency power for essential care and treatment equipment and lighting, medical gas systems, ventilation and heating systems, and nurse call systems.

7-007.04F3 Facilities with electrical life support equipment must maintain essential power systems and must have on-site fuel source. The minimum fuel source capacity must allow for non-interrupted system operation.

7-007.04G Call Systems: Call system(s) must be operable from patient procedure and operating rooms, recovery bed, and toilet areas. The system must transmit a receivable (visual, audible, tactile, or other) signal to on-duty staff which readily notifies and directs the staff to the location where the call was activated.

7-007.04G1 In new construction, the call system must have a dedicated emergency call device which allows activation by a patient from treatment rooms and cubicles, and toilet and bathing fixtures.

7-007.04G2 In new construction, in locations where patients are unable to activate the call, a dedicated staff assist call device must promptly summon other staff for assistance.

7-007.04G3 Existing health clinics, except ambulatory surgical centers, that do not have a nurse call system are not required to provide a nurse call system.

7-007.04H Medical Gas System: The facility must safely provide medical gas and vacuum by means of portable equipment or building systems as required by patients receiving care and treatment.

7-007.04H1 The installation, testing, and certification of nonflammable medical gas, clinical vacuum, and air systems must comply with the requirements of 153 NAC 1, Nebraska State Fire Code Regulations.

7-007.04H2 The facility must identify portable and system components, and periodically test and approve all medical gas piping, alarms, valves, and equipment for patient care and treatment. The facility must document such approvals for review and reference.

7-007.05 Waivers: The Department may waive any provision of 175 NAC 7 relating to construction or physical plant requirements of a health clinic upon proof by the licensee satisfactory to the Department (a) that such waiver would not unduly jeopardize the health, safety, or welfare of the persons served by the facility, (b) that such provision would create an unreasonable hardship for the facility, and (c) that such waiver would not cause the State of Nebraska to fail to comply with any applicable requirements of Medicare or Medicaid so as to make the state ineligible for the receipt of all funds to which it might otherwise be entitled.

7-007.05A Unreasonable Hardship: In evaluating the issue of unreasonable hardship, the Department will consider the following:

The estimated cost of the modification or installation;
The extent and duration of the disruption of the normal use of areas used by persons residing in or served by the facility resulting from construction work;
The estimated period over which the cost would be recovered through reduced insurance premiums and increase reimbursement related to costs;
The availability of financing; and
The remaining useful life of the building.

7-007.05B Waiver Terms and Conditions: Any such waiver may be granted under the terms and conditions and for such period of time as are applicable and appropriate to the waiver. Terms and conditions and period of waiver include but are not limited to:

Waivers that are granted to meet the special needs of a patient remain in effect as long as required by the patient;
Waivers may be granted for a period of time that ends at the time the conditions of approval no longer exist;
Waivers may be granted to permit a facility time to come into compliance with the physical plant standards for a period of one year. Upon submission of proof of ongoing progress, the waiver may be continued for an additional year; and
An applicant or licensee must submit a request for waiver of any construction or physical plant requirements set forth in 175 NAC 7. An applicant for a waiver may construct a request for a waiver form or obtain a form from the Department.

7-007.05C Denial of Waiver: If the Department denies a health clinic’s request for waiver, the facility may request an administrative hearing as provided in the Administrative Procedure Act (APA) and the Department’s rules and regulations adopted and promulgated under the APA.

7-008 DENIAL, REFUSAL TO RENEW, OR DISCIPLINARY ACTION

7-008.01 Grounds for Denial, Refusal to Renew or Disciplinary Action:

7-008.01A The Department may deny or refuse to renew a health clinic license for failure to meet the requirements for licensure, including:

Failing an inspection specified in 175 NAC 7-005;
Having had a license revoked within the two-year period preceding an application; or
Any of the grounds specified in 175 NAC 7-008.01B.

7-008.01B The Department may take disciplinary action against a health clinic license for any of the following grounds:

Violation of any of the provisions of the Health Care Facility Licensure Act, or 175 NAC 7;
Committing or permitting, aiding, or abetting the commission of any unlawful act;
Conduct or practices detrimental to the health or safety of a health clinic patient or employee;
A report from an accreditation body or public agency sanctioning, modifying, terminating, or withdrawing the accreditation or certification of the health clinic;
Failure to allow an agent or employee of the Department of Health and Human Services, the Department of Health and Human Services Finance and Support, or the Department of Health and Human Services Regulation and Licensure access to the health clinic for the purposes of inspection, investigation, or other information collection activities necessary to carry out the duties of such departments;
Discrimination or retaliation against a health clinic patient or employee who has submitted a complaint or information to the Department of Health and Human Services, the Department of Health and Human Services Finance and Support, or the Department of Health and Human Services Regulation and Licensure;
Discrimination or retaliation against a health clinic patient or employee who has presented a grievance or information to the office of the state long-term care ombudsman;
Failure to allow a state long-term care ombudsman or an ombudsman advocate access to the health clinic for the purposes of investigation necessary to carry out the duties of the office of the state long-term care ombudsman as specified in 15 NAC 3;
Violation of the Emergency Box Drug Act;
Failure to file a report of payment or action taken due to a liability claim or an alleged violation, as required by Neb. Rev. Stat. § 71-168.02;
Violation of the Medication Aide Act; or
Failure to file a report of suspected abuse or neglect as required by Neb. Rev. Stat. §§ 28-372 and 28-711.

7-008.02 Procedures for Denial, Refusal to Renew, or Disciplinary Action:

7-008.02A If the Department determines to deny, refuse renewal of, or take disciplinary action against a license, the Department will send a notice to the applicant or licensee, by certified mail to the last address shown on its records The notice will state the determination, including a specific description of the nature of the violation and the statute or regulation violated, and the type of disciplinary action pending.

7-008.02B The denial, refusal to renew, or disciplinary action will become final 15 days after the mailing of the notice unless the applicant or licensee, within such 15-day period, makes a written request to the Director for an informal conference or an administrative hearing.

7-008.02C Informal Conference

7-008.02C1 At the request of the applicant or licensee, the Department will hold an informal conference within 30 days of the receipt of the request. The conference will be held in person or by other means, at the request of the applicant or licensee.

If the pending action is based on an inspection, the Department’s representative at the conference will not be the individual who did the inspection.

7-008.02C2 Within 20 working days of the conference, the Department representative will state in writing the specific reasons for affirming, modifying, or dismissing the notice. The representative will send a copy of the statement to the applicant or licensee by certified mail to the last address shown in the Department’s records and a copy to the Director.

7-008.02C3 If the applicant or licensee successfully demonstrates at the informal conference that the deficiencies should not have been cited in the notice, the Department will remove the deficiencies from the notice and rescind any sanction imposed solely as a result of those cited deficiencies.

7-008.02C4 If the applicant or licensee contests the affirmed or modified notice, the applicant or licensee must submit a request for hearing in writing within five working days after receipt of the statement.

7-008.02D Administrative Hearing

7-008.02D1 When an applicant or a licensee contests the notice and request a hearing, the Department will hold a hearing in accordance with the Administrative Procedure Act (APA) and the Department’s rules and regulations adopted and promulgated under the APA. Either party may subpoena witnesses, who must be allowed fees at the rate prescribed by Neb.Rev. Stat. §§ 33-139 and 33-139.01.

7-008.02D2 On the basis of evidence presented at the hearing, the Director will affirm, modify, or set aside the determination. The Director’s decision will:

Be in writing;
Be sent by registered or certified mail to the applicant or licensee; and
Become final 30 days after mailing unless the applicant or licensee, within such 30-day period, appeals the decision.

7-008.02D3 An applicant or a licensee’s appeal of the Director’s decision must be in accordance with the APA.

7-008.03 Types of Disciplinary Action

7-008.03A The Department may impose any one or a combination of the following types of disciplinary action against the license of a health clinic:

A fine not to exceed $10,000 per violation;
A prohibition on admissions or re-admissions, a limitation on enrollment, or a prohibition or limitation on the provision of care or treatment;
A period of probation not to exceed two years during which the facility or service may continue to operate under terms and conditions fixed by the order of probation;
A period of suspension not to exceed three years during which the facility or service may not operate; and
Revocation which is a permanent termination of the license. The licensee may not apply for a license for a minimum of two years after the effective date of the revocation.

7-008.03B In determining the type of disciplinary action to impose, the Department will consider:

The gravity of the violation, including the probability that death or serious physical or mental harm will result;
The severity of the actual or potential harm;
The extent to which the provisions of applicable statutes, rules, and regulations were violated;
The reasonableness of the diligence exercised by the health clinic in identifying or correcting the violation;
Any previous violations committed by the health clinic; and
The financial benefit to the facility of committing or continuing the violation.

7-008.03C If the licensee fails to correct a violation or to comply with a particular type of disciplinary action, the Department may take additional disciplinary action as described in 175 NAC 7-008.03A.

7-008.03D Temporary Suspension or Temporary Limitation: If the Department determines that patients of the health clinic are in imminent danger of death or serious physical harm, the Director may:

Temporarily suspend or temporarily limit the health clinic license, effective when the order is served upon the health clinic. If the licensee is not involved in the daily operation of the health clinic, the Department will mail a copy of the order to the licensee, or if the licensee is a corporation, to the corporation’s registered agent;
Order the immediate removal of patients; or
Order the temporary closure of the health clinic pending further action by the Department.

7-008.03D1 The Department will conduct the hearing in accordance with the Administrative Procedure Act (APA) and the Department’s rules and regulations adopted and promulgated under the APA. Either party may subpoena witnesses, who must be allowed fees at the rate prescribed by Neb. Rev. Stat. §§ 33-139 and 33-139.01.

7-008.03D2 If a written request for continuance of the hearing is made by the licensee, the Department will grant a continuance, which may not exceed 30 days.

7-008.03D3 On the basis of evidence presented at the hearing, the Director will:

Order the revocation, suspension, or limitation of the license; or
Set aside the temporary suspension or temporary limitation.

If the Director does not reach a decision within 90 days of the date of the temporary suspension or temporary limitation, the temporary suspension or temporary limitation will expire.

7-008.03D4 Any appeal of the Department’s decision after hearing must be in accordance with the APA.

7-008.04 Reinstatement from Disciplinary Probation, Suspension, and Re-licensure Following Revocation

7-008.04A Reinstatement at the End of Probation or Suspension

7-008.04A1 Reinstatement at the End of Probation: A license may be reinstated at the end of probation after the successful completion of an inspection, if the Department determines an inspection is warranted.

7-008.04A2 Reinstatement at the End of Suspension: A license may be reinstated at the end of suspension following:

Submission of an application to the Department for renewal that conforms to the requirements of 175 NAC 7-003.02;
Payment of the renewal fee as specified in 175 NAC 7-004.09; and
Successful completion of an inspection.

The Department will reinstate the license when it finds, based on an inspection as provided for in 175 NAC 7-005, that the health clinic is in compliance with the operation, care, treatment, and physical plant requirements of 175 NAC 7-006 and 7-007.

7-008.04B Reinstatement Prior to Completion of Probation or Suspension

7-008.04B1 Reinstatement Prior to the Completion of Probation: A licensee may request reinstatement prior to the completion of probation and must meet the following conditions:

Submit a petition to the Department stating:

a. The reasons why the license should be reinstated prior to the probation completion date; and

b. The corrective action taken to prevent recurrence of the violation(s) that served as the basis of the probation; and

Successfully complete any inspection that the Department determines necessary.

7-008.04B2 Reinstatement Prior to Completion of Suspension: A licensee may request reinstatement prior to the completion of suspension and must meet the following conditions:

Submit a petition to the Department stating:

a. The reasons why the license should be reinstated prior to the suspension completion date; and

b. The corrective action taken to prevent recurrence of the violation(s) that served as the basis of the suspension.

Submit a written renewal application to the Department as specified in 175 NAC 7-003.02;
Pay the renewal fee as specified in 175 NAC 7-004.09; and
Successfully complete an inspection.

7-008.04B3 The Director will consider the petition submitted and the results of any inspection or investigation conducted by the Department and:

Grant full reinstatement of the license;
Modify the probation or suspension; or
Deny the petition for reinstatement.

7-008.04B4 The Director’s decision is final 30 days after mailing the decision to the licensee unless the licensee requests a hearing within the 30-day period. The requested hearing will be held according to rules and regulations of the Department for administrative hearings in contested cases.

7-008.04C Re-Licensure After Revocation: A health clinic license that has been revoked is not eligible for re-licensure until two years after the date of revocation.

7-008.04C1 A health clinic seeking re-licensure must apply for an initial license and meet the requirements for initial licensure in 175 NAC 7-003.01.

7-008.04C2 The Department will process the application for re-licensure in the same manner as specified in 175 NAC 7-003.01.

History

Effective 2007-01-16

Chapter 8 Pharmacies

Neb. Admin. Code tit. 175, ch. 8 Pharmacies {#sec-175-nac-8 omnilex-key=us-ne-regs-official--title-175--175 NAC 8}

001. SCOPE AND AUTHORITY . These regulations govern licensure of Pharmacies. The regulations are authorized under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-475; the Pharmacy Practice Act, Neb. Rev. Stat. §§ 38-2801 to 38-28,116; the Uniform Controlled Substances Act, Neb. Rev. Stat. §§ 28-401 to 28-456.01 and 28-458 to 28-475; and the Prescription Drug Safety Act, Neb. Rev. Stat. §§ 71-2457 to 71-2483.

002. DEFINITIONS . Definitions set out in the Health Care Facility Licensure Act, Neb. Rev. Stat. §§ 71-401 to 71-475; the Pharmacy Practice Act, Neb. Rev. Stat. §§ 38-2801 to 38-28,116; the Uniform Controlled Substances Act, Neb. Rev. Stat. §§ 28-401 to 28-456.01 and 28-458 to 28-475 and the following apply to this chapter:

002.01 COMPLETE APPLICATION. An application that contains all of the information requested on the application, with attestation to its truth and completeness, and submitted with all required fees and documentation.

002.02 COMPLETE PETITION. A complete petition contains all of the requested information on a form provided by the Department, with attestation to it truth and completeness, signatures of the applicant(s), submitted with all required fees and documentation.

003. LICENSING REQUIREMENTS . An applicant for an initial license must submit a completed application provided by the Department and documentation that the applicant meets the requirements set in statute and this chapter.

003.01 PROVISIONAL PHARMACY LICENSE. To obtain a provisional pharmacy license, an applicant must substantially meet the requirements in the Health Care Facility Licensure Act and sections 175 NAC 8-006 through 175 NAC 8-008 of this chapter. A pharmacy license will be issued after a satisfactory initial inspection is completed.

003.02 RENEWAL. All pharmacy licenses expire annually on July 1. To renew a license an applicant for a renewal license must submit a complete application provided by the Department and documentation that the applicant meets the requirements in statute and in this chapter.

003.03 PERMANENTLY CLOSING A PHARMACY. When a licensee discontinues providing pharmacy services, the Department must be notified in writing within 15 days of the services being discontinued. The notice must include the following information:

(1) The sale or other disposition of legend drug, device, or biological inventory,

(2) The sale or other disposition of controlled substances and controlled substances invoices and inventory records, and

(3) The location of all patient records including prescription files.

003.03(A) RETURN OF DOCUMENTS AND FORMS. Upon permanent closure of the pharmacy, the licensee must return the pharmacy license to the Department and may return the following to the Department to be forwarded to the Drug Enforcement Administration (DEA):

(i) The pharmacy’s Drug Enforcement Administration (DEA) Registration, if any; and

(ii) All unused Drug Enforcement Administration (DEA) Forms for the pharmacy, if any.

003.03(B) PATIENT NOTIFICATION. When the permanent closing of a pharmacy is anticipated, the licensee is responsible for notifying patients of that pharmacy within 15 days of the permanent closing that they will need to seek service elsewhere. The notification can be accomplished through:

(i) Advertisement in a newspaper appropriate to the location of the pharmacy;

(ii) Written notice to patients of the pharmacy; or

(iii) Other such notice as is appropriate.

003.04 REINSTATEMENT. Unless otherwise stated, a request for reinstatement must submit complete application provided by the Department and meet the requirements of Neb. Rev. Stat. § 71-433, 71-456, and 175 NAC 8.

003.04(A) REINSTATEMENT PRIOR TO THE COMPLETION OF PROBATION. A licensee may petition for reinstatement prior to the completion of probation or suspension and must submit a complete petition form provided by the Department.

004. INSPECTIONS . For the purpose of assuring compliance, each licensee must prepare an annual Pharmacy Quality Assurance Report (PQAR).

004.01 PHARMACY QUALITY ASSURANCE REPORT (PQAR). The Pharmacy Quality Assurance Report (PQAR) is due 1 year from the date of the initial on-site inspection and annually thereafter. All licensees must ensure that the pharmacist in charge or the practitioner on behalf of the licensee, annually submits a completed Pharmacy Quality Assurance Report (PQAR) on a form provided by the Department, electronically, or upon request. A Pharmacy Quality Assurance Report (PQAR) self-inspection may be completed no more than 30 days before the due date of the report.

004.01(A) REPORTED INFORMATION. At a minimum, the Pharmacy Quality Assurance Report (PQAR) must provide information on the following:

(i) Standards for the Operations of a Pharmacy

(1) Staffing requirements;

(2) Storage requirements;

(3) Record keeping requirements;

(4) Dispensing requirements;

(5) Controlled substance dispensing requirement for emergency situations; and

(6) Disaster preparedness management;

(ii) Physical Plant Standards

(1) Equipment, facilities, and utilities;

(2) Shelving, counters, floor, inventory, fixtures, equipment, and utensils; and

(3) Reference material;

(iii) Sterile Compounding Requirements, if applicable for the facility

(iv) Non-sterile compounding requirements, if applicable for the facility.

004.01(B) VERIFICATION OF THE REPORT. The Pharmacy Quality Assurance Report (PQAR) must include a signed statement from the pharmacist in charge or the practitioner verifying that all information in the Pharmacy Quality Assurance Report (PQAR) is accurate, complete, and correct.

004.02 ANNUAL INSPECTION. All licensees are required to complete and submit the Department Pharmacy Quality Assurance Report (PQAR) form for an annual self-inspection, and may be subject to an on-site inspection to verify the pharmacy fully complies with all requirements.

004.02(A) SELF-INSPECTION. The Pharmacy Quality Assurance Report (PQAR) will fulfill the annual inspection requirement when the Department determines that the report indicates that the licensee is in full compliance with the Health Care Facility Licensure Act, the Controlled Substances Act, the Prescription Drug Safety Act, and this chapter. However, the report will not fulfill the annual inspection requirement when:

(i) The Department has determined, based on the review of the Pharmacy Quality Assurance Report (PQAR), that the pharmacy is not in compliance with the Health Care Facility Licensure Act, or this chapter;

(ii) The pharmacy failed to be in full compliance with the Health Care Facility Licensure Act, or this chapter at the time of its last inspection;

(iii) The licensee failed to submit a Pharmacy Quality Assurance Report (PQAR);

(iv) The pharmacy is randomly selected as part of the 25% of licensed pharmacies chosen annually for inspection; and

(v) Any other event that raises concerns about the maintenance, operation, or management of the pharmacy.

004.02(B) COMPLIANCE INSPECTION. An unannounced inspection may be conducted of the facility or service anytime the Department deems necessary, including, the passage of five years without an inspection.

005. GENERAL REQUIREMENTS . The following requirements are applicable to all pharmacy licenses.

005.01 LICENSE NOT TRANSFERABLE. Change of ownership or change of premises terminates the license. The new owner or owners must apply for a new pharmacy license.

005.02 NOTIFICATION. An applicant or licensee must notify the Department of any change as set forth in 175 NAC 8-005.03 through 8-005.08. The following information is required for all notifications:

(A) Current name and license number of the pharmacy or practitioner;

(B) Street address of pharmacy or practitioner;

(D) If a corporation the name of corporate officers;

(E) Mailing address(es) of owner(s), partners, or corporation;

(F) Reason for notifying the Department about a change in the existing license;

(G) A signed statement from the applicant or licensee verifying that all information is correct; and

(H) The required fee as specified in this chapter, if any.

005.03 CHANGE OF PHARMACIST IN CHARGE. The licensee must notify the Department within 1 business day when there is a change in the pharmacist-in-charge.

005.04 CHANGE OF OWNERSHIP OR PREMISES. The licensee must notify the Department in writing 15 days of when the pharmacy is sold, leased, discontinued, or moved to a new premises.

005.05 CHANGE OF NAME OF THE PHARMACY. The licensee must notify the Department in writing within 5 working days when there is a change in the name of the pharmacy.

005.06 DEATH OF A LICENSEE. The heirs or executor of the estate must notify the Department within 30 days of the death of a licensee.

005.07 AN ACCIDENT, NATURAL DISASTER, OR INTERUPTION IN UTILITY SERVICES. The licensee must notify the Department in writing by electronic mail, facsimile, or postal service within 24 hours of any change in environment which will adversely affect the potency, efficacy, safety or security of the drugs, devices, or biologicals in the pharmacy. The notification may be made by telephone if the event has affected the licensee’s capacity to communicate in writing.

005.08 FEES. The Following fees apply to this chapter:

(A) Initial pharmacy license fee is $625.

(B) Annual pharmacy license renewal fee is $625.

006. STANDARDS FOR THE OPERATION OF A PHARMACY . The licensee must comply with the Prescription Drug Safety Act, the Pharmacy Practice Act, the Controlled Substances Act, and the following:

006.01 STAFFING. Each licensee must have a pharmacist in charge or be a practitioner with the qualifications, training, and skills necessary to meet the requirements according to this chapter.

006.01(A) LICENSED PHARMACIST. Each licensee must employ a sufficient number of licensed pharmacists to safely meet the needs of the individuals seeking services at the pharmacy.

006.02 STORAGE REQUIREMENTS. All drugs, medical devices, and biologicals must be stored in a manner that meets the manufacturer’s labeled requirements or in the absence of manufacturer’s requirements in accordance with those listed in this chapter.

006.02(A) TEMPERATURE AND LABEL REQUIREMENTS. The licensee must provide equipment for the storage of drugs, devices, and biologicals at the proper temperature:

(i) Drugs, devices, or biologicals requiring refrigeration must be stored between 36 and 46 degrees Fahrenheit;

(ii) Drugs, devices, or biologicals requiring a freezer must be stored between -13 and 14 degrees Fahrenheit;

(1) For drugs, devices, or biologicals requiring a storage temp under -4 degrees Fahrenheit the temperature of the storage location must be within plus or minus 10 degrees;

(iii) Drugs, devices, or biologicals requiring storage in a cool place must be stored between 46 and 59 degrees Fahrenheit, or under refrigeration, between 36 and 46 degrees Fahrenheit, unless otherwise specified;

(iv) Drugs, devices, or biologicals requiring storage at controlled room temperature must be stored between 68 and 77 degrees Fahrenheit; and

(v) Other labeled storage instruction for drugs, devices, or biologicals must be followed.

006.02(B) SEPARATE STORAGE. Drugs, devices, biologicals, dietary supplements or substances used in compounding that require refrigeration cannot be stored in the same compartment as staff food or beverages.

006.02(C) MISBRANDED OR ADULTERATED DRUG STORAGE. All drugs which are misbranded or adulterated shall not be stored with saleable inventory.

007. RECORD KEEPING REQUIREMENTS . Complete and accurate records must be maintained as set out in this chapter.

007.01 SECURE RECORDS. The prescription inventory and prescription records of the pharmacy must be maintained in a secure location.

007.02 DISASTER PREPAREDNESS AND MANAGEMENT. The licensee must have and implement disaster preparedness plans and procedures to protect the potency, efficacy, safety, and security of the drugs, devices, or biologicals in the pharmacy in instances of natural or other disasters, disease outbreaks, interruption of utility services, or other similar situations. Such plans and procedures must address how the licensee will:

(A) Provide for the storage of drugs, devices, and biologicals at the proper temperature;

(B) Provide for the disposal of drugs, devices, and biologicals if the pharmacy determines their potency, efficacy, or safety has been adversely affected;

(D) Maintain patient records and inventory records.

008. PHYSICAL PLANT STANDARDS . A licensee must meet the requirements set out in this chapter.

008.01 ACCESS BY PHARMACIST. The licensee must provide the appropriate staff access to all equipment, facilities, and utilities appropriate for the accurate, efficient, and safe provision of the clinical services available in that pharmacy.

008.02 CONDITIONS. The licensee must assure the prescription department, including shelving, counters, floor, inventory, fixtures, equipment, and utensils are maintained in a clean, orderly, and sanitary manner that supports the scope of pharmacy services provided at the site.

008.03 REFERENCE MATERIAL. The licensee must provide the appropriate staff access to all reference material appropriate for the accurate, efficient, and safe practice of pharmacy. These references materials must be up to date, in either printed or electronic form, and available at all times while the practice of pharmacy is occurring.

History

Effective 2020-11-03

Chapter 9 Hospitals

Neb. Admin. Code tit. 175, ch. 9 Hospitals {#sec-175-nac-9 omnilex-key=us-ne-regs-official--title-175--175 NAC 9}

TITLE 175 HEALTH CARE FACILITIES AND SERVICES LICENSURE

CHAPTER 9 HOSPITALS

001. SCOPE AND AUTHORITY. These regulations govern the licensing of hospitals under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-475.

002. DEFINITIONS. The definitions set out in the Health Care Facility Licensure Act, Uniform Credentialing Act, 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.

002.01 HOSPITAL. Any type of licensed hospital, with the exception of a licensed long term care hospital.

002.02 HOSPITAL BEDS. The total number of licensed adult and pediatric beds which can be set up and used for a patient within 24-hours. Beds used in emergency rooms, stretchers, labor and recovery rooms, and bassinets for newborn infants are excluded from the total licensed bed count.

002.03 INPATIENT. A consumer who has medical practitioner orders admitting them to the hospital for 24-hour care and treatment.

002.04 MEDICAL STAFF BYLAWS. A set of rules and regulations adopted by the medical staff governing the medical staff activities at the facility.

002.05 MEDICATION ERROR. Any variance between the chart order or prescription, the five rights, and administration of the medication.

002.06 OUTPATIENT. A consumer who receives care for less than 24 continuous hours in an emergency department, outpatient department, or other licensed hospital location who does not have medical practitioner orders admitting them to the facility.

002.07 PATIENT. A consumer who receives inpatient or outpatient care and treatment at a hospital.

003. LICENSING REQUIREMENTS. To receive a license, an applicant must submit a complete application and meet the requirements for a license set out in statute, 175 NAC 1, and in this chapter. All standards referenced in this chapter can be obtained at Department of Health and Human Services, Licensing Unit, 301 Centennial Mall South, Lincoln NE 68509 or be viewed on the Department’s website.

004. GENERAL REQUIREMENTS. The following requirements are applicable to all hospital licenses.

004.01 EFFECTIVE DATE AND TERM OF LICENSE. A hospital license expires annually on December 31.

004.02 LICENSE NOT TRANSFERABLE. Change of ownership or premises terminates the license. If there is a change of ownership and the hospital remains on the same premises, the inspection as set out in this chapter is not required. If there is a change of premises, the hospital must pass the inspection specified in this chapter .

004.03 FEES. The fees for a hospital license are based on the number of licensed beds plus the number of outpatient surgeries reported in accordance with the Outpatient Surgical Procedures Data Act, Neb. Rev. Stat. § 81-6,114.

004.03(A) INITIAL AND RENEWAL FEES. Following are initial and renewal fees for hospitals:

(i) 1 to 50 Beds $1,750

(ii) 51 to 100 Beds $1,850

(iii) 101 or more Beds $1,950

004.03(B) OUTPATIENT SURGICAL FEES. Following are outpatient surgical fees for hospitals:

(i) 500 or fewer outpatient surgeries per year $275

(ii) 501 to 2,000 outpatient surgeries per year $350

(iii) More than 2,000 outpatient surgeries per year $425

004.04 FEES. The fees for a rural emergency hospital license are based on the following plus the number of outpatient surgeries reported in accordance with the Outpatient Surgical Procedures Data Act, Neb. Rev. Stat. § 81-6,114.

004.04(A) INITIAL LICENSURE FEE.

(i) Initial Licensure Fee $650

004.04(B) RENEWAL LICENSURE FEES.

(i) 1 to 50 unduplicated patient admissions in the past year $650

(ii) 51 to 200 unduplicated patient admissions in the past year $850

(iii) 201 or more unduplicated patient admissions in the past year $950

004.04(C) OUTPATIENT SURGICAL FEES. Following are outpatient surgical fees for hospitals:

(i) 500 or fewer outpatient surgeries per year $275

(ii) 501 to 2,000 outpatient surgeries per year $350

(iii) More than 2,000 outpatient surgeries per year $425

005. INSPECTIONS. Inspection requirements for licensed hospitals are outlined in the Health Care Facility Licensure Act and 175 NAC 1.

006. STANDARDS OF OPERATION, CARE AND TREATMENT. Each hospital is to be organized, managed, and administered by the licensee to ensure each patient receiving services at the facility receives necessary care and treatment in a safe manner, and in accordance with current standards of practice, the Health Care Facility Licensure Act, 175 NAC 1, and this chapter. Each hospital offsite location and mobile unit must meet the standards except where specified otherwise.

006.01 LICENSEE RESPONSIBILITY. The responsibilities of the licensee include:

(A) Implementing policies and procedures to govern the total operation and maintenance

of the facility;

(B) Maintaining hospital compliance with all applicable state and federal statutes, codes,

rules, and regulations;

(C) Ensuring the quality of all services, care, and treatment provided a patient whether those services, care or treatment are furnished by hospital staff or through contract with an outside entity;

(D) Designating an administrator in writing who is responsible for the day-to-day management of the hospital;

(i) Defining the duties and responsibilities of the administrator in writing;

(ii) Notifying the Department in writing within five working days if:

(1) A vacancy in the administrator position occurs including the name of who is responsible for the position until another administrator is appointed; and

(2) A vacancy in the administrator position is filled including the effective date and name of person appointed to that position;

(E) Determining which categories of practitioners are eligible candidates for appointment

to the medical staff;

(F) Ensuring that medical staff membership or clinical privileges in the hospital does not

depend solely upon certification, fellowship, or membership in a specialty body or society although board certification can be one permissible criterion;

(G) Appointing and reappointing medical staff members and delineating clinical privileges, according to credential review procedures established by the medical staff and approved by the governing authority;

(H) Establishing criteria for membership on the medical staff or clinical privileges, in collaboration with the medical staff;

(i) Making final decisions regarding medical staff recommendations for denial of appointments and reappointments, and for the denial limitation, suspension, or revocation of privileges, ensuring the practitioner has a right to be heard upon request;

(J) Ensuring the medical staff is accountable to the licensee for the quality of medical care and treatment provided;

(K) Ensuring a medical staff committee and a utilization review committee are formed and

operated for the purpose of reviewing care and treatment provided to provide a high standard of medical care and promote the efficient use of the hospital;

(L) Ensuring that any person working at and having any information or knowledge relating

to the medical and hospital care provided or the efficient use of the hospital facilities,

provides all related facts and information to the hospital medical staff committee or utilization review committee upon request by the committee or committees;

(M) Reviewing reports and making recommendations regarding all Quality Assurance Performance Improvement, Medical Staff, and Utilization Review Committee activities. Ensuring these reports are utilized to implement programs and policies to maintain and improve the quality of patient care and treatment;

(N) Establishing and promoting effective communication and coordination between the governing authority, the medical staff, administration, and the hospital departments;

(O) Approving the organization, bylaws, rules, and regulations, and policies and procedures of the medical staff and departments in the hospital; and

(P) Establishing visitation policies which are in the best interest of patients to ensure their

health and safety, and provide protection from communicable diseases, exposure to

dangerous substances, and hazardous equipment.

006.02 GOVERNING AUTHORITY RECORDKEEPING. If a licensee has a governing authority, it must hold regularly scheduled meetings and minutes of the meetings must be retained for a minimum of seven years.

006.03 ADMINISTRATION. The administrator is to plan, organize, and direct the day-to-day operations of the hospital. The administrator is directly responsible to the licensee and the governing authority, if any, in all matters related to the maintenance, operation, and management of the facility. The administrator’s responsibilities include:

(A) Being on the premises a sufficient number of hours to ensure adequate attention to the management of the hospital;

(B) Providing for the protection of patients’ health, safety, and well-being;

(D) Designating a substitute in writing, to act in their absence as needed;

(E) Being available during all hours of facility operation; and

(F) Ensuring the completion, maintenance, and submission of reports and records as required by federal or state statute, regulation, and the Department.

006.04 ADMINISTRATIVE RECORDS. Accurate and complete administrative records of each facility’s operation, including an annual report that summarized the scope and volume of services provided by the facility must be maintained and kept for a minimum of seven years.

006.05 PERMANENT PATIENT INDEX. A permanent patient index must be maintained that includes:

(A) Name and identification numbers of each patient;

(B) Dates of admission and discharge;

(D) Location to which patient was discharged.

006.06 CONSUMER SATISFACTION. A written process to measure consumer satisfaction with the services being provided by the facility must be established, implemented, and revised as necessary.

006.07 OFF-CAMPUS, SATELLITE LOCATIONS, AND MOBILE UNITS. All off-campus, satellite locations, or mobile units are to be approved by the Department and listed on the license prior to patient care and treatment being provided at a location.

006.08 MOBILE UNITS. Each mobile unit must have a designated location schedule available to the public at all times, identifying where the unit will be located so that unannounced inspections can occur as required in 175 NAC 1.

006.09 MEDICAL STAFF. Each hospital is to have a medical staff that is organized and functions in a manner consistent with the size, needs, and resources of the facility. The medical staff responsibilities are:

(A) Participating in the Quality Assurance Performance Improvement meetings;

(B) Abiding by hospital and medical staff policies;

(D) Reviewing the background, experience, training, and credentials of applicants for initial medical staff membership; and

(E) Recommending criteria and procedures for appointment and reappointment, and to delineate clinical privileging to ensure the provision of quality patient care and treatment.

006.09(i) MEDICAL STAFF APPOINTMENT. Membership on the medical staff will be limited to those disciplines specified in the medical staff bylaws, rules and regulations, or other similar governance document. Criteria for appointment and reappointment must include continuing licensure or authority to practice in Nebraska.

006.09(ii) CLINICAL PRIVILEGES. The medical staff is to establish a written process for the delineation of clinical privileges which includes:

(1) Each discipline and the procedures or tasks for which medical staff in that discipline must be privileged to perform;

(2) A process for the review of clinical privilege requests, including a competency component;

(3) A process for notification of clinical privilege decisions; and

(4) A process for appealing decisions to deny, limit, or otherwise modify privileges.

006.09(iii) MEDICAL STAFF BYLAWS. The medical staff must recommend and adhere to the medical staff bylaws. Medical staff bylaws must include:

(1) A description of how the medical staff is organized;

(2) The time frame for medical staff meetings and the rules for conducting business;

(3) Methods for evaluating clinical practice in the hospital;

(4) Criteria and procedures for membership and clinical privileges;

(5) The procedure for medical staff adoption and amendment of medical staff bylaws; and

(6) Provision for establishing a utilization review committee.

006.10 STAFFING. A licensee must maintain a sufficient number of staff with the required experience, orientation, training, and competency necessary to meet the care and treatment needs of patients and the operational needs of the hospital. Each hospital must be staffed 24-hours per day. All staff are to wear visible identification to identify them to patients or their designee by name and title. A written job description is to be on file outlining the minimum qualifications and job duties for each position. Any unlicensed staff who assist in the provision of care and treatment provided to patients, must be supervised by a health care professional. Staff cannot provide care or treatment that is outside the scope of practice permitted by the credential held by the individual.

006.11 STAFF CREDENTIALS. Staff credentials are to be verified prior to staff assuming assigned job duties, and the licensee must maintain evidence that such status is checked and maintained throughout the entire time of employment.

006.12 STAFF HEALTH STATUS. A health history screening for all staff must be completed prior to staff assuming job duties. A licensee must make sure staff health status is maintained in a manner to prevent the potential transmission of disease to patients, visitors, and other staff.

006.13 CRIMINAL BACKGROUND AND REGISTRY CHECKS. Criminal background and registry checks must be completed on any staff members who have direct and unsupervised access to or who provide care and treatment to patients at the facility. These checks must be completed prior to the staff having unsupervised contact with any patients at the facility. Documentation of such checks is to be maintained for as long as the staff member is employed at the facility.

006.13(A) CRIMINAL BACKGROUND CHECKS. A criminal background check must be completed through a governmental law enforcement agency or a private entity.

006.13(B) REGISTRY CHECKS. A check for adverse findings must include these Nebraska registries and similar registries in states where the individual has resided in the past 10 years:

(i) Nurse Aide Registry;

(ii) The Department’s abuse and neglect central registry; and

(iii)

(iv) Sex Offender Registry.

006.13(C) USE OF CRIMINAL BACKGROUND AND REGISTRY INFORMATION. Written policies and procedures are to be implemented and revised as necessary related to the use of information obtained through pre-employment criminal background and registry checks. These written policies and procedures are to include the following:

(i) Staff with adverse findings on the registries regarding abuse, neglect, or misappropriation must not be employed at the facility;

(ii) How information will be used in making hiring decisions;

(iii) Whether employment can begin prior to receiving the results of the checks, how the safety or property of patients will be safeguarded until the results are available, and what happens if the results have adverse findings; and

(iv) How to maintain documentation of this information.

006.14 STAFF TRAINING. Staff must receive initial and ongoing training and demonstrate competency before being assigned to independently perform job duties and assigned tasks. Training must be provided by a person qualified by education, experience, and knowledge in the subject area provided. The facility is to maintain the following documentation in each staff

member’s personnel file:

(A) Date and time training was provided;

(B) Summary of the information provided to staff;

(E) Staff sign in documentation; and

(F) Results of competency or other testing completed as a result of each training.

006.15 STAFF ORIENTATION. An orientation program must be provided for all new staff and for existing staff who are given new assignments. Documentation of this training must be maintained in each staff member’s personnel file. The initial orientation program is to include the following:

(A) Job duties and responsibilities;

(B) The facility sanitation and infection control program;

(D) Patient rights;

(E) Patient care policies and procedures;

(F) Personnel policies and procedures;

(G) Emergency preparedness and disaster procedures;

(H) Disaster preparedness plan;

(I) Reporting requirements for abuse, neglect, and exploitation in accordance with the Adult Protective Services Act, Neb. Rev. Stat. § 28-372, or in the case of a child in accordance with Neb. Rev. Stat. § 28-711, and with facility policies and procedures; and

(J) The facility hand hygiene program.

006.16 PATIENT RIGHTS. Each patient is to be afforded the opportunity to exercise his or her rights. Documentation that all patients or designee, when appropriate, have been informed of their rights in a manner and format they can understand must be kept in the medical record for each patient. Each patient has the right to:

(A) Respectful, safe care given by trained and competent staff;

(B) Be informed of their rights during admission in a manner and format they can understand;

(D) Make informed decisions regarding care and treatment options and be provided with information necessary to assist in making those decisions;

(E) Be informed of the possible consequences of refusing care and treatment, to freely make a choice, and to be free from retaliation from the facility and staff for choosing to refuse care and treatment options;

(F) Formulate advance directives and to have the facility comply with the directives unless the facility notified the patient or designee in writing they are unable to comply and the reasons the facility is unable to comply;

(G) Personal privacy and confidentiality of their medical records;

(H) Be free from abuse, neglect, and exploitation;

(I) View information contained in their own medical record within a reasonable time when requested, excluding limited circumstances where the attending physician determines and documents that disclosure to the patient would be harmful;

(J) Be free from restraints or seclusion used for staff convenience and not utilized to treat medical conditions;

(K) Receive services without discrimination based upon race, color, religion, gender, national origin, or payer source; however, hospitals are not required to provide uncompensated or free care and treatment unless otherwise required by law;

(L) Voice complaints and file grievances without discrimination or reprisal and have those complaints and grievances addressed within a reasonable period of time; and

(M) Receive visitors. The hospital may refuse access to any person for any of the following reasons:

(i) The patient refuses to see the visitor;

(ii) The presence of the visitor may be injurious to the health and safety of the patient;

(iii) The visitor’s behavior is unreasonably disruptive to the facility and the behavior is documented by the facility;

(iv) The presence of the visitor threatens the security of patients, staff, or facility property; or

(vi) The visitor is restricted by court order, the patient’s guardian or legal representative or designee.

006.17 ABUSE, NEGLECT AND EXPLOITATION. A licensee must address any situation where there is reason to believe that abuse, neglect, or exploitation of a patient has occurred by a staff member, volunteer, family member, visitor, or any other person as provided in the Adult Protective Services Act or Child Protective Services Act.

006.17(A) REPORTING. Any suspected abuse, neglect or exploitation of a patient must be reported to:

(i) The Department’s abuse and neglect central registry via telephone immediately; and

(ii) Local law enforcement as required by state and federal laws.

006.17(B) INVESTIGATION. Any incident of suspected abuse, neglect, or exploitation of a patient must be thoroughly investigated, and a written report of the investigation must be submitted to the Department within 5 working days of the occurrence.

006.17(C) PROTECTION. All patients must be protected throughout the investigation of any suspected abuse, neglect, or exploitation. Actions must be implemented as a result of the investigation to ensure patient safety and to prevent the potential for recurrence.

006.18 ADVANCED DIRECTIVES. Each licensee must comply with the requirements of the Health Care Power of Attorney Act and the Rights of the Terminally Ill Act. Patients or designees must be informed in a manner and format they can understand upon admission of the facility’s policies and procedures, and at the time of any change to the policies and procedures.

006.19 PATIENT EDUCATION RECORD KEEPING REQUIREMENTS. Documentation of all education provided to a patient, or their designee is to be retained in each patient’s medical record. This information needs to include:

(A) The name of the persons who were provided education and their relationship to the patient;

(B) Information provided; and

006.20 DISCHARGE PLANNING. Discharge planning must be provided for all patients and his or her designee which is to include:

(A) Development of a discharge plan which includes input from the patient or designee;

(B) Identification of the staff responsible for the discharge planning program;

(C) Education regarding identified diagnoses, treatment provided, medications, and follow up needed in a manner and format the patient or designee can understand;

(D) A complete and accurate list of community-based services, resources, and facilities for the patient or designee to choose from to meet their post-hospital care needs; and

(E) Any transfer of necessary medical information to facilitate continuity of care upon discharge.

006.20(i) DISCHARGE PLANNING RECORD KEEPING REQUIREMENTS. Documentation of all discharge planning and education provided to a patient or his or her designee must be retained in each patient’s medical record. This needs to include:

(1) The name of the persons who were involved in the discharge planning process and their relationship to the patient;

(2) Information provided; and

(3) Date and time the discharge information was provided to the patient or designee along with the name and title of the person providing the education.

006.21 PERSONAL POSSESSIONS. Patient personal possessions or belongings brought into the facility at the time of admission must be safeguarded. The facility must maintain documentation of patient personal items upon admission and must reconcile them with the patient and or designee upon discharge from the facility.

006.22 PLAN OF CARE. A plan of care is to be established according to each patient’s individual needs which must be kept current throughout the hospital stay. The plan of care must include a communication component which encompasses methods and interventions outlining how facility staff need to communicate with the patient and their designee in a manner and method the patient and designee can comprehend. The plan of care may be interdisciplinary when appropriate to meet a patient’s needs.

006.23 LABORATORY SERVICES. A licensee must provide clinical laboratory services either directly or through agreement, or contract, which comply with 42 U.S.C. 263a et seq. and 42 CFR Part 493. Laboratory services are to include:

(A) Identification of a physician who meets the qualifications for laboratory director, preferably a pathologist;

(B) Necessary laboratory services and testing as determined by the medical staff;

(C) Emergency laboratory services, including urinalysis, complete blood counts, blood typing and cross matching, and other necessary emergency laboratory services and tests as determined by the medical staff;

(D) Receipt and reporting of tissue specimens; and

(E) Which tissue specimens require macroscopic examination and which tissue specimens require both macroscopic and microscopic examination as determined by the medical staff.

006.23(i) LABORATORY SERVICES RECORD KEEPING. All laboratory testing reports and results must be maintained in the individual patient records to whom they apply.

006.23(ii) LABORATORY SERVICES PHYSICAL PLANT REQUIREMENTS. A licensee is to have dedicated laboratory areas for sample collection, protection, analyzing, testing and storage.

006.24 NUTRITIONAL SERVICES. Nutritional services must include:

(A) Assessment of a patient’s nutritional status by a licensed dietitian nutritionist or a licensed nutritionist;

(B) A therapeutic diet order for a patient may be written by the following professions, if approved by the medical staff and credentialed by the licensed hospital, in accordance with state and federal law:

(i) Medical practitioner; or

(ii) Licensed dietitian nutritionist or licensed nutritionist in accordance with the Medical Nutritional Therapy Practice Act ;

(D) A sufficient number of qualified and competent dietary and nutritional staff as determined by each individual hospital needs on duty;

(E) Menus to be planned, written, and followed;

(F) Meals are to be served to patients at appropriate times and intervals; and

(G) The Nebraska Food Code must be met at all times.

006.24(i) NUTRITIONAL SERVICES PHYSICAL PLANT REQUIREMENTS. If food preparation is provided onsite, a licensee is to have dedicated space and equipment for the preparation, storage, and processing of meals. Food service physical environment must comply with the Nebraska Food Code, except when used exclusively for activities or training purposes.

006.24(ii) DINING AREAS. If provided, dining areas for patients must have an outside wall with windows for natural light and ventilation and must not be in spaces used for sleeping, offices, or corridors. Each dining area needs to:

(1) Be furnished with tables and chairs that accommodate or conform to patient needs;

(2) Have a floor area of 15 square feet per patient in existing facilities; and

(3) Allow for group dining at the same time in either separate dining areas, a single dining area, dining in two shifts, or dining during open dining hours.

006.25 PHARMACY SERVICES. Medications, devices, and any biologicals must be under the supervision of a licensed Nebraska pharmacist or licensed Nebraska physician. The storage, control, handling, compounding, and dispensing of drugs, devices, and biologicals must be in accordance with state and federal law. Any licensee that has a pharmacy or engages in the practice of pharmacy must do so in accordance with the Pharmacy Practice Act. Each licensee must identify a qualified, competent Nebraska licensed pharmacist designated as the pharmacist-in-charge.

006.25(A) PHARMACY QUALITY ASSURANCE REPORT. All hospital pharmacies must complete and submit a Pharmacy Quality Assurance Report form annually to the Division of Public Health for review.

006.25(A)(i) DUE DATE. The Pharmacy Quality Assurance Report must be submitted no later than May 1 annually.

006.25(A)(ii) PLAN OF CORRECTION. If deficiencies are identified in the Pharmacy Quality Assurance Report the licensee must submit a plan of correction.

006.25(B) HOSPITAL PHARMACY CONTROLLED SUBSTANCES INVENTORY. All hospital pharmacies must complete and submit a biennial Controlled Substance Inventory to the Division of Public Health for review.

006.25(B)(i) DUE DATE. The Hospital Pharmacy Controlled Substances Inventory must be submitted no later than May 1 of even numbered years.

006.25(B)(ii) PLAN OF CORRECTION. If deficiencies are identified in the biennial Controlled Substances Inventory the licensee must submit a plan of correction.

006.26 MEDICATIONS, BIOLOGICALS, AND DEVICES. Medications, biologicals, and devices may only be provided to patients as legally prescribed by a medical practitioner and administered by a health care professional who has medication administration included in their

scope of practice and may only be dispensed by a Nebraska licensed pharmacist or a Nebraska licensed physician with a dispensing permit. Pharmacy services are to include:

(A) A current policy and procedure manual regarding the administration and handling of all medications and biologicals in the facility available to all staff at all times;

(B) A documented count of all controlled substances completed every shift;

(D) Written procedures for the self-administration of medication, if applicable;

(E) Medication error and adverse reaction reporting and documentation;

(F) Information related to interactions, contraindications, side effects, toxicology, dosage, indications for use, and routes of administration available to staff at all times;

(G) Emergency medications and biologicals;

(H) Checking for expired, mislabeled or otherwise unusable medications, devices or biologicals on a regular basis, and method of keeping them from being used for patients;

(I) Dispensing of medications and biologicals;

(J) If performed, compounding of medication must be done by personnel trained to compound, in compliance with written procedures for the process of compounding and in accordance with state and federal law;

(K) The use, storage of, and provision of sample medications and biologicals;

(L) Recording, reporting, and investigating the abuse or loss of any drugs and biologicals;

(M) Storage of all drugs, devices, and biologicals in secured areas, and in accordance with the manufacturer’s, distributor’s, packager’s, or dispensing pharmacist’s instructions regarding temperature, light, humidity, and other storage instructions;

(N) Information regarding all drugs, devices, and biologicals administered, provided, or dispensed to a patient must be recorded and maintained in the patient’s medical record. The record must contain the date of administration or provision; the identification of the person who administered or provided the medication, device or biological to the patient; the patient’s medication allergies and sensitivities; any refusal of medication by the patient or the patient’s designee; and any time a drug, device, or biological ordered by a medical practitioner has not been provided to the patient in accordance with the medical practitioner’s order;

(O) A complete and accurate record of all medications, devices, and biologicals received, stored, administered, provided, dispensed, or disposed of by the hospital must be kept and maintained for a minimum of 7 years; and

(P) Drugs, devices, and biologicals used as part of a clinical investigation must be maintained in a locked and separate area from all other drugs, devices, and biologicals, and must only be administered in accordance with the clinical study protocol.

007. PHYSICAL PLANT STANDARDS. Each building must be maintained in a manner that is safe, clean, and functional for the type of care and treatment provided. All hospital buildings must comply with the Health Care Facility Licensure Act, 175 NAC 1, the Nebraska State Fire Code, 2012 Edition Life Safety Code requirements, and this chapter. Each building must comply with the following physical plant requirements unless otherwise specified:

007.01 LAUNDRY SERVICES. Laundry service may be provided on-site by the facility or via contract and is to be provided in accordance with current standards of practice, and in a manner to reduce any risk of cross-contamination or infection. A separate clean laundry supply storage area that is conveniently located to care and treatment locations is to be provided.

007.01(A) ON-SITE LAUNDRY. When on-site laundry services are provided, water temperatures in laundry equipment must exceed 160 degrees Fahrenheit; or the facility must use an acceptable sanitizer or disinfectant in accordance with the manufacturer’s instructions.

007.01(B) CONTRACTED LAUNDRY. If contract services are used for laundry, separate dedicated areas for soiled laundry awaiting pickup and for clean laundry are to be provided.

007.01(C) BULK LAUNDRY. In new construction, if bulk laundry is performed, the facility is to have separate soiled areas for sorting and washing and separate clean areas for drying, folding, and mending with separate soaking sinks. Hand washing sinks must be located in the laundry area.

007.01(D) LINENS. An adequate supply of clean linens in good repair, with no holes, visibly worn areas, or stains must be maintained for patient use. Storage areas are to be conveniently located near patient care and treatment areas.

007.02 WASTE PROCESSING. Medical and general waste must be handled in accordance with current standards of practice to reduce the risk of cross-contamination or infection. This is to include separate areas to collect, contain, process, and dispose of waste produced within the facility; and keeping all facility areas free of vermin.

007.03 HOUSEKEEPING AND JANITORIAL SERVICES. A dedicated room with a service sink and space for storage of supplies, housekeeping, and janitorial equipment must be provided.

007.04 MEDICATION STATION. A dedicated medication station must be provided for the storage and distribution of medications, biologicals, and devices. Distribution may be done from a medicine preparation room or unit, from a self-contained medicine-dispensing unit, or by another system. If used, a medicine preparation room or unit must be under visual control of nursing staff and must contain a work counter, sink, refrigerator, and double-locked storage for controlled substances.

007.05 UTILITY AREA. A work area is to be provided where clean materials are assembled. The work area must contain a work counter, a handwashing fixture, and storage facilities for clean and sterile supplies. If the area is used only for storage and holding as part of a system for distribution of clean and sterile supply materials, the work counter and handwashing fixtures may be omitted.

007.06 EQUIPMENT AND SUPPLIES. Equipment and supplies required for care and treatment must be provided at the facility. The facility must have space to store, distribute, maintain, clean, and sanitize durable medical instruments, equipment, and supplies out of the path of normal traffic. Durable medical equipment is to be tested and calibrated in accordance with manufacturer’s recommendations. The documentation of testing results and calibrations are to be maintained for a minimum of seven years.

007.07 STERILE PROCESSING. If sterile processing is completed onsite, it must be done in accordance with current standards of practice.

007.08 ENDOSCOPE CLEANING AND REPROCESSING. Cleaning and reprocessing of contaminated endoscopes must be completed in accordance with current standards of practice, in a room dedicated for this function, which is separate from the area where endoscopic procedures are performed.

007.09 INPATIENT ROOMS. Inpatient rooms are to have sufficient space for sleeping, privacy, furniture, and belongings, and to provide inpatient care and treatment. These rooms must:

(A) Not be located in any garage, storage area, shed, or similar detached building;

(B) Not be accessed through a bathroom, food preparation area, laundry, or another patient room;

(C) Be located on an outside wall or atrium with a window with a minimum glass size of eight square feet per patient. The window is to provide an unobstructed view of at least 10 feet;

(D) Contain at least 25 cubic feet of storage volume per patient;

(E) Have a minimum floor area of 100 square feet for single patient rooms and 80 square feet per bed for multiple patient rooms, with a maximum of two beds in new construction; and

(F) Have doors that provide privacy yet not create seclusion or prohibit staff access for routine or emergency care.

007.10 TOILET ROOMS. Toilet rooms with hand washing sinks must be provided for patient use. Existing facilities must have a toilet and sink adjoining each bedroom or may have one shared toilet fixture per four licensed beds. Doors for toilet and bathing rooms must provide privacy yet not create seclusion or prohibit staff access for routine and emergency care as needed. In new construction, all toileting and bathing rooms used by patients with less than 500 square feet must not have doors that swing solely inward.

007.11 BATHING ROOMS. A bathing room consisting of a tub or shower must be provided adjacent to each bedroom or as a central bathing room on each floor where inpatient rooms are located. Tubs and showers are to be equipped with hand grips or other assistive devices as needed to meet patient needs.

007.12 ACTIVITY AREAS. If provided, activity areas are to have dedicated space for patient socialization and leisure time activities that must not be used for sleeping, offices, or as a corridor. The area may be combined with dining areas. The area is to:

(A) Have furnishings to accommodate group and individual activities;

(B) Have a floor area of at least 15 square feet per patient; and

007.13 CUBICLES. Patient care and treatment cubicles must have a minimum floor area of 60 square feet with at least three feet between bedsides and adjacent side walls or curtains.

007.14 EXAMINATION ROOMS. Each examination room must have a minimum floor area of 80 square feet and a minimum of three feet clear dimension around three sides of the examination table or chair.

007.15 ISOLATION ROOMS. The number and type of isolation rooms in a hospital are to be determined by the licensee based upon an infection control risk assessment and individual facility needs. Each facility must have at least one room capable of isolating patients which has an adjoining toilet room.

007.16 OBSERVATION AREAS. If medical observation, extended recovery, or behavior intervention is provided, the licensee must provide one or more appropriately equipped rooms for patients requiring close supervision based on the needs of the patient and the care and treatment provided. Each room is to:

(A) Ensure patient privacy;

(B) Have a system in place for the patient to call or summon for assistance if needed;

(D) Be void of unsafe wall, ceiling fixtures, and area with sharp edges;

(E) Have a way for staff to observe the patient from outside the room, so that all areas of the room are observable; and

(F) Be equipped to minimize the potential of the patient’s escape, injury, suicide, or hiding of restricted substances.

007.16(i) OBSERVATION AREA DOORS. Doors may be used to prevent escape and create seclusion where therapeutically required, such as for emergency protective custody, detoxification, and in psychiatric locations.

007.17 CORRIDORS. Building corridors must be wide enough to allow passage and be equipped as needed for the patient with safety and assistive devices to minimize injury. All stairways and ramps must have handrails.

007.18 OUTDOOR SPACES. Any outdoor area for patient usage is to be equipped and situated to allow for patient safety and abilities.

007.19 HANDWASHING SINKS. A handwashing sink equipped with towels and soap dispenser must be provided in close proximity of all examination, treatment, isolation, and procedure rooms; available to every four care and treatment cubicle locations; and a scrub sink must be provided near the entrance of each operating room.

007.20 PRIVACY. In multiple bed patient rooms, visual privacy, and window curtains must be provided for each patient. In new facilities and new construction, the curtain layout must totally surround each care and treatment location and not restrict access to the entrance to the room, lavatory, toilet, or enclosed storage facilities.

007.21 FINISHES. Special room finishes must be provided, including:

(A) Washable room finishes in procedure rooms, existing isolation rooms, sterile processing rooms, workroom, laundry, and food-preparation areas must have smooth, non-absorptive surfaces which are not physically affected by routine housekeeping cleaning solutions and methods. Acoustic and lay in ceilings, if used, must not interfere with infection control. Perforated, serrated cut, or highly textured tiles cannot be used.

(B) Scrubbable finishes in all operating rooms and new isolation rooms must have smooth, non-absorptive, non-perforated surfaces that are not physically affected by harsh germicidal cleaning solutions and methods.

007.22 BUILDING SYSTEMS. Building systems are to be designed, installed, and operated in a manner to provide for the safety, comfort, and well-being of the patient and must include the following:

007.22(A) CALL SYSTEMS. Call systems must be operable from procedure, treatment, operating rooms, recovery areas, toilet rooms, and bathing rooms. The system must transmit a receivable signal to on-duty staff which readily notifies staff and identifies the locations where the call was activated. The type of call system utilized must be able to be modified to meet individual patient needs. If patients are unable to activate the call, there must be a device the patient, designee, or staff can utilize to summon other staff for assistance as needed.

007.22(B) ELECTRICAL SYSTEM. An electrical system must have the capacity to maintain the care and treatment services that are provided.

007.23 ESSENTIAL POWER SYSTEM. A licensee must maintain an emergency power system for all essential care and treatment areas, lighting, medical gas systems, nurse call systems, and any area that utilizes general anesthetics or electrical life support systems.

007.23(A) FUEL SOURCE. Electrical support equipment must maintain essential power systems and must have an on-site fuel source. The minimum fuel source capacity must allow for non-interrupted system operations.

007.24 HEATING AND COOLING SYSTEMS. A licensee must provide a heating and air conditioning system to maintain inpatient room temperatures at a level comfortable for each patient. Floors in operating, procedure, and other locations subject to wet cleaning methods or body fluids must not have openings to the heating or cooling system.

007.24(A) Surgical areas must have heating and cooling systems that are capable of producing room temperatures at a range between 68 and 73 degrees Fahrenheit and humidity at a range between 30 and 60% relative humidity.

007.24(B) Airflow must move from clean to soiled locations. In new construction, air movement must be designed to reduce the potential of contamination of clean areas.

007.25 ILLUMINATION LEVELS. Minimum illumination levels which are measured at 30 inches above the floor in multiple areas in the room must be provided as follows:

(A) General purpose areas: 5-foot candles;

(B) General corridors: 10-foot candles;

(D) Reading and activity areas: 30-foot candles;

(E) Food preparation areas: 40-foot candles;

(F) Hazardous work surfaces: 50-foot candles;

(G) Care and treatment locations: 70-foot candles;

(H) Examination task lighting: 100-foot candles;

(I) Procedure task lighting: 200-foot candles; and

(J) Surgery task lighting: 1000-foot candles.

007.26 MEDICAL GAS SYSTEMS. Medical gas and vacuum by means of portable equipment or building systems as required for the type of care and treatment provided at the facility must be provided safely. The hospital must identify portable and system components and periodically test and approve all medical gas piping, alarms, valves, and equipment used for patient care and treatment. Documentation of such testing and approval must be retained for a minimum of 7 years. All medical gas systems must comply with the requirements of 153 NAC 1, the Nebraska State Fire Code, and Life Safety Code requirements as of February 23, 2021.

007.27 WATER AND SEWER SYSTEMS. An accessible and safe potable supply of water must be available and maintained. Where an authorized public water supply of satisfactory quality, quantity, and pressure is available, the facility must be connected to it and must use it exclusively. All water distribution systems must be protected with anti-siphon devices and air gaps to prevent contamination. All licensees must maintain a sanitary and functioning sewage system and the following:

(A) The collection, treatment, storage, and distribution potable water system of a facility that regularly serves 25 or more individuals must be constructed, maintained, and operated in accordance with The Nebraska Safe Drinking Water Act, and its implementing regulations;

(B) The collection, treatment, storage, and distribution potable water system of a facility that regularly serves less than 25 individuals on a regular basis must be maintained and operated as if it were a public water system in accordance with The Nebraska Safe Drinking Water Act, and its implementing regulations; and

(C) Continuously circulated, filtered, and treated water systems must be provided as required for the care and treatment equipment used.

007.28 VENTILATION SYSTEM. Exhaust and clean air must be provided to prevent the concentrations of contaminants which could impair health or cause discomfort to patients and employees.

007.28(A) MECHANICAL EXHAUST VENTILATION. Buildings with new construction must have a mechanical ventilation system which provides minimum air exchanges per hour at the following rates:

(i) Care and treatment areas, five exchanges per hour;

(ii) Procedure and isolation areas, 15 air exchanges per hour; and

(iii) Operating rooms, 20 air exchanges per hour.

008. OPTIONAL SERVICES AND REQUIREMENTS. A licensee may choose to provide any of the optional services outlined below. Services must be provided in accordance with current standards of practice and directed by a medical practitioner as determined by the facility unless specified otherwise. If these services are provided, the following are applicable:

008.01 CRITICAL CARE SERVICES. Critical care services such as intensive care, coronary care, intensive newborn nursery, burn unit, transplant center, or wound treatment center are to include:

(A) Supervision of each unit by a qualified and competent registered nurse;

(B) Qualifications and competency needed for each person assigned to work in the unit;

(D) Written admission and discharge criteria for each unit.

008.02 EMERGENCY SERVICES. Emergency services provided must be in compliance with the Emergency Medical Treatment and Labor Act; 42 CFR § 489.24; and 42 CFR § 489.20 (l), (m), (q), and (r), on the effective date of this chapter. This service must be provided under the direction of a practitioner who is trained in emergency care and management and is to include:

(A) 24-hour per day medical and nursing staff coverage, with medical staff and registered nurses on call;

(B) Personnel qualifications and competency needed to carry out the written emergency procedures and anticipated needs of the hospital; and

(C) Emergency drugs, devices, biologicals, equipment, and supplies must be on hand and immediately available for use in the emergency area to treat life-threatening conditions.

008.02(i) EMERGENCY SERVICES RECORDKEEPING REQUIREMENTS. An emergency log must be maintained that includes:

(1) Patient full name and date of birth;

(2) Date, time, and method of patient’s arrival to the emergency room;

(3) Physical findings;

(4) Name of treating practitioner;

(5) Disposition, including time, and location patient was discharged to;

(6) Documentation of assessments and any testing completed; and

(7) Documentation of any medications, biologicals, or devices provided to the patient.

008.02(ii) NOTIFICATION. If the facility ceases to provide emergency services, the Division of Public Health Licensure Unit needs to be notified in writing as soon as possible.

008.02(iii) EMERGENCY SERVICES PHYSICAL PLANT REQUIREMENTS. Dedicated space for emergency care and treatment must be provided which includes:

(1) A well-marked, illuminated, covered, and grade level entrance for both emergency

vehicle and pedestrian access;

(2) A waiting area for patients and visitors that is in the direct observation of the reception, triage, or control station;

(3) Storage areas for general medical and surgical emergency supplies, medications, and equipment which are under staff control and out of the path of normal traffic; and

(4) A toilet room with hand washing sink that is convenient to treatment or procedure rooms.

008.03 HEMODIALYSIS SERVICES. Hemodialysis services must satisfy all the elements of the Conditions of Coverage as an End-Stage Renal Disease facility 42 CFR § 405.2101, Subpart U, and 42 CFR § 494.62 on the effective date of this chapter and 175 NAC 1.

008.04 OBSTETRICAL AND NEWBORN SERVICES. Obstetrical and newborn services provided are to include:

(A) Written policies and procedures outlining the care and treatment for prenatal, postnatal, and newborn patients;

(B) Appropriate attire to be worn during labor, delivery, and in the nursery;

(D) Supervision of nursing care provided in labor, delivery, and in the nursery by a qualified registered nurse;

(E) Written directions outlining the use of oxytocic drugs and the administration of anesthetics, sedatives, analgesics, and any other drugs, devices, and biologicals in accordance with state and federal law;

(F) The flow of staff between the obstetric and newborn units, and other patient care areas;

(G) Staff responsibilities during induction or augmentation of labor;

(H) Visitation and attendance during the birth process;

(I) Required laboratory testing;

(J) Written transfer criteria for both mother and newborn;

(K) Discharge criteria, including written discharge instructions in a manner and format which the mother or their designee can understand;

(L) Reporting requirements;

(M) Emergency care, treatment, and equipment needed to be immediately available; and

(N) Written procedures outlining the identification and safeguarding of the newborn immediately after birth until discharge.

008.04(i) PERMANENT OBSTETRIC ADMISSION AND DISCHARGE PATIENT INDEX. An index must be maintained that includes:

(1) Full name and date of birth of the patient;

(2) The patient identification number assigned by the facility;

(3) Date and time of admission and discharge;

(4) Name of admitting physician or certified midwife;

(5) Type of anesthesia provided;

(6) Time of birth;

(7) Gender of newborn; and

(8) Place to which mother and newborn were discharged or transferred.

008.04(ii) OBSTETRICAL AND NEWBORN PHYSICAL PLANT REQUIREMENTS. Dedicated space and equipment for the provision of obstetrical and newborn services must be available.

008.05 PEDIATRIC SERVICES. Pediatric services are to include:

(A) Location of pediatric patients must be in an area apart from adult patients and newborn infants;

(B) Drugs, devices, biologicals, equipment, and supplies suitable for the treatment of pediatric patients;

(D) Conditions under which parents may stay or ‘room in’ with pediatric patients.

008.06 SURGICAL SERVICES. Surgical services are to include:

(A) Surgical services are provided only by medical practitioners who are privileged at the facility to conduct the specific surgical care and treatment they are privileged to provide;

(B) Restrictions on access to the surgical suite and recovery room areas;

(D) Sterilization and disinfection of equipment and supplies;

(E) Aseptic surveillance and practice;

(F) Responsibility for the supervision of the surgical suite and recovery room;

(G) Immediate availability of an emergency call system, cardiac monitor, defibrillator, suction, and emergency airway supplies;

(H) Availability of blood and blood products;

(I) The requirement for patient history and physical examination;

(J) The requirements for testing and disposal of surgical specimens;

(K) The circumstances that require the presence of an assistant during surgery;

(L) Discharge criteria;

(M) Reporting requirements;

(N) The procedures for handling infectious cases;

(O) Immediate post-surgical care; and

(P) Requirements for operative and surgical reports.

008.06(i) SURGICAL SERVICES RECORD KEEPING REQUIREMENTS. A roster must be maintained in the surgical suite which delineates the surgical privileges granted to each medical practitioner; and an up-to-date operating log must be maintained that includes:

(1) Full name, date of birth, and identification number of each patient;

(2) Date, starting and ending times for each surgical procedure;

(3) Surgical procedure or procedures performed;

(4) Name of the surgeon and any assistants;

(5) Name of nursing personnel, both scrub and circulating;

(6) Type of anesthesia utilized during the procedure; and

(7) The name and title of the person administering anesthesia.

008.06(ii) SURGICAL SERVICES PHYSICAL PLANT REQUIREMENTS. Dedicated space and equipment for the types of surgical procedures provided by the facility must be available, which includes:

(1) A preoperative patient area with sufficient space and equipment to accommodate both ambulatory and non-ambulatory patients under the direct visual control of the nursing staff;

(2) Operating rooms for major surgical procedures that require general or regional block anesthesia and support of vital bodily functions with a minimum floor area of 300 square feet and a minimum of 16 feet of clear dimension;

(3) Procedure rooms for invasive and minor surgical procedures performed in conjunction with oral, parental, or intravenous sedation or under analgesic or dissociative drugs have a minimum floor area of 200 square feet and a minimum of 14 feet clear dimension;

(4) Treatment rooms for procedures performed under topical, local, or regional anesthesia without pre-operative sedation have a minimum floor area of 120 square feet and a minimum of 10 feet clear dimension;

(5) A recovery area containing a medication station, hand washing sink, charting area, and equipment and supply storage space;

(6) A dressing area must be provided when the hospital provides outpatient surgeries which has patient dressing and toilet rooms separate from staff gowning areas; and

(7) Housekeeping and soiled utility areas exclusively for the surgical suite.

008.07 ANESTHESIA SERVICES. Anesthesia services are to include:

(A) Provision of anesthesia by medical or nurse anesthetist students under the supervision and direct oversight of an individual qualified to administer anesthesia in their scope of practice;

(B) Equipment maintenance;

(D) Infection control measures; and

(E) The maintenance, cleaning, and use of equipment to ensure patient safety and to minimize the risk of the transmission of infection.

008.08 REHABILITATION SERVICES. Rehabilitation services are to include:

(A) The scope and care of services provided at the facility;

(B) Staff qualifications, competency, and credentialing requirements;

(D) Coordination with other services in the hospital;

(E) Treatment plan documentation and record keeping requirements; and

(F) The maintenance, cleaning, and use of therapy equipment, to ensure patient safety and to minimize the risk of the transmission of infection.

008.09 RESPIRATORY CARE SERVICES. Respiratory care services are to include:

(A) Supervision by a qualified respiratory care practitioner;

(B) The provision of respiratory care services by qualified personnel, acting within their scope of practice;

(D) Treatment plan documentation and record keeping requirements; and

(E) Types of equipment needed to provide the scope of care provided in the facility, along with cleaning, maintenance, and calibration requirements.

008.10 OUTPATIENT SERVICES. Outpatient services are to include:

(A) The provision of outpatient services in accordance with medical practitioner orders;

(B) Staffing to meet the needs of the patients as determined by the facility;

(C) Documentation and record keeping requirements to integrate the outpatient medical record with the patient’s existing inpatient record, if applicable; and

(D) Equipment needed to provide the scope of care provided in the facility, along with cleaning, maintenance, and calibration requirements.

008.11 ALZHEIMER’S, DEMENTIA, AND RELATED CONDITIONS SERVICES. Licensees that provide inpatient services for patients with Alzheimer’s, dementia, and related conditions in a distinct unit must ensure:

(A) Personalized patient rooms;

(B) Activity areas;

(D) Features that support patient orientation to their surroundings;

(E) Areas for specialized treatment and care;

(F) Hand washing sinks;

(G) Secured storage for equipment and supplies;

(H) Call and security systems; and

(I) An area for medication storage and distribution.

008.12 SOCIAL WORK SERVICES. Social work services are to be directed by a certified social worker. Services must include:

(A) The scope and care of patients receiving social work services, including the role in intervention, discharge planning, and referral for patients;

(B) Assessment of personal and social functioning of patients;

(D) Coordination with other services provided to patients in the hospital.

008.13 PSYCHIATRIC OR MENTAL HEALTH SERVICES. Psychiatric or mental health services in a distinct unit are to ensure a therapeutic environment that provides for both patient and staff safety. Patient rooms must have:

(A) Tamper-resistant air distribution devices, lighting fixtures, sprinkler heads, and safety devices;

(B) Ventilation, exhaust, heating, and cooling components that are inaccessible to patients;

(D) Electrical outlets protected by ground fault interrupting devices.

008.14 IN PATIENT HOSPICE SERVICES. Inpatient hospice services provided in a distinct unit must have private patient rooms, space to accommodate overnight stays, dining, and visiting spaces for family and visitors.

009. SPECIFIC HOSPITAL REQUIREMENTS. Each licensee must choose which type of hospital they wish to operate, with specific requirements as set out in the Health Care Facility Licensure Act and this chapter.

009.01 CRITICAL ACCESS HOSPITAL REQUIREMENTS. A licensee of a critical access hospital must satisfy all of the elements of the Conditions for Participation for Critical Access Hospitals as set out in C.F.R § 485 Subpart F, and C.F.R. § 485.625 on the effective date of this chapter. Critical access hospitals must:

(A) Have 25 acute inpatient beds or less;

(B) Ensure the average length of stay for acute inpatients does not exceed 96-hours;

(D) Have a formal agreement with at least one licensee of an acute care hospital; and

(E) Have formal agreements for:

(i) Emergency and nonemergency transportation; and

(ii) Back up medical and emergency services.

009.02 GENERAL ACUTE HOSPITAL REQUIREMENTS. Each licensee of a general acute hospital must satisfy all the elements of the Conditions of Participation for Hospitals as set out in 42 C.F.R § 482 and 42 C.F.R § 482.15 on the effective date of this chapter.

009.03 LONG-TERM CARE HOSPITAL REQUIREMENTS. Each licensee of a long-term care hospital or distinct part of a hospital that provides the care and services of an intermediate care facility, a nursing facility, or a skilled nursing facility must meet all requirements specified in 175 NAC 12 and 175 NAC 1 except the administrator is not required to hold a current nursing home administrator’s license issued by the State of Nebraska.

009.04 PSYCHIATRIC OR MENTAL HOSPITAL REQUIREMENTS. Each licensee of a psychiatric or mental hospital must satisfy the Conditions of Participation for Psychiatric Hospitals as set out in 42 C.F.R § 482.60 through 482.62, and C.F.R. § 482.15 on the effective date of this chapter.

009.05 REHABILITATION HOSPITAL REQUIREMENTS. Each licensee of a rehabilitation hospital must satisfy all the elements of the Conditions of Participation for Hospitals as set out in 42 C.F.R § 482, and C.F.R. § 482.15 on the effective date of this chapter and the following:

(A) The direction and supervision of all rehabilitation services is provided by a fulltime physician member of the medical staff who is trained in rehabilitation medicine;

(B) Physical therapy, occupational therapy, speech pathology, and audiology, social work, psychological, and vocational services must be organized and supervised by qualified professional personnel credentialed in Nebraska when required and who have been approved by the licensee;

(C) A written preadmission screening procedure is implemented to review each prospective patient’s condition and medical history to determine whether the patient is likely to benefit significantly from an intensive inpatient rehabilitation program prior to accepting the patient for treatment;

(D) A plan of treatment for each inpatient is established, implemented, reviewed, and revised as needed by a physician in consultation with other professional personnel who provide services to the patient; and

(E) There must be a multidisciplinary team approach in the rehabilitation of each inpatient, as documented by periodic clinical entries made in the patient’s medical record to note the patient’s status in relationship to goal attainment. Team conferences must be held at least every two weeks to determine the appropriateness of treatment.

009.06 RURAL EMERGENCY HOSPITAL REQUIREMENTS. A licensee of a rural emergency hospital must satisfy all of the elements of the Conditions for Participation for Rural Emergency Hospitals as set out in C.F.R §§ 485.500 to 485.546 on the effective date of this chapter.

History

Effective 2026-07-19

Chapter 12 Skilled Nursing Facilities, Nursing Facilities, and Intermediate Care Facilities

Neb. Admin. Code tit. 175, ch. 12 Skilled Nursing Facilities, Nursing Facilities, and Intermediate Care Facilities {#sec-175-nac-12 omnilex-key=us-ne-regs-official--title-175--175 NAC 12}

001. SCOPE AND AUTHORITY . These regulations govern licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities. The regulations are authorized by and implement the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479, Alzheimer’s Special Care Disclosure Act, Neb. Rev. Stat. §§ 71-516.01 to 71-516.04, Neb. Rev. Stat. § 38-2419, Emergency Box Drug Act, Neb. Rev. Stat. §§ 71-2410 to 71-2417, Nebraska Nursing Home Act, Neb. Rev. Stat. §§ 71-6008 to 71-6037, and Neb. Rev. Stat. §§ 71-6039 to 71-6042.

002. DEFINITIONS . The definitions set out in the Health Care Facility Licensure Act, Neb. Rev. Stat. §§ 71-6038, 71-6721, 28-401, 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.

002.01 ABUSE. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

002.02 ACCIDENT. An unexpected, unintended event that can cause a resident bodily injury.

002.03 DEHYDRATION. A lack of sufficient water in the body.

002.04 DEVICE. An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is prescribed by a medical practitioner and dispensed by a pharmacist or other person authorized by law to do so.

002.05 DWELLING. A building that contains: living and sleeping areas; storage room(s); separate room(s) containing a toilet, lavatory, and bathtub or shower; and a kitchen area with a sink and cooking and refrigeration appliances.

002.06 EXPLOITATION. Taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion.

002.07 FACILITY. A skilled nursing facility, nursing facility, or intermediate care facility.

002.08 INCIDENT. An occurrence likely to have a grave outcome.

002.09 LICENSED NURSE. A licensed registered nurse or a licensed practical nurse.

002.10 MEDICATION ERROR. The preparation, provision or administration of medications which is not in accordance with:

(A) Physician orders; (B) Manufacturers specifications regarding the preparation and administration of the drug or biological; (C) Accepted professional standards and principles that apply to professionals providing services; or (D) The five rights.

002.11 MEDICATION ERROR RATE. Determined by calculating the percentage of errors. The numerator is the total number of errors that the survey team observes, both significant and non-significant. The denominator is called “opportunities for error” and includes all the doses the survey team observed being administered plus the doses ordered but not administered.

002.12 MENTAL ABUSE. The use of verbal or nonverbal conduct which causes or has the potential to cause a resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

002.13 MISAPPROPRIATION OF MONEY OR PROPERTY. The deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without the resident’s consent.

002.14 NEGLECT. The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

002.15 PHYSICAL ABUSE. Hitting, punching, slapping, pinching, kicking, or other actions causing injury to the body. Injury includes damage to bodily tissue caused by nontherapeutic conduct, including, but not limited to, fractures, bruises, lacerations, internal injuries, or dislocations and shall include, but not limited to, physical pain, illness, or impairment of physical function.

002.16 QUALIFIED PERSONNEL. Professional staff who are licensed, certified or registered to provide specialized therapy or rehabilitative services in accordance with applicable state laws.

002.17 SEXUAL ABUSE. Non-consensual sexual contact of any type with a resident.

002.18 SIGNIFICANT WEIGHT LOSS. 5% loss of body weight in 1 month, 7.5% loss of body weight in 3 months, or 10% body weight loss in 6 months.

002.19 SPECIALIZED REHABILITATIVE SERVICES. Services provided by qualified personnel, including but not limited to, physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and developmental disability.

002.20 SUFFICIENT FLUID. The amount of fluid needed to prevent dehydration and maintain health. The amount needed is specific for each resident and fluctuates as the resident’s condition fluctuates.

002.21 VERBAL ABUSE. The use of oral, written, or gestured language including disparaging and derogatory terms to residents or within their hearing distance.

003. LICENSING REQUIREMENTS AND PROCEDURES . To receive a license, an applicant must submit a complete application and meet the requirements for a license set out in statute, 175 NAC 1, and in this chapter. All standards referenced in this chapter can be obtained at the Department of Health and Human Services, Health Care Facilities and Services Licensure Unit, 301 Centennial Mall South, Lincoln, NE 68509 or be viewed on the Department’s website.

004. GENERAL REQUIREMENTS . These requirements are outlined in 175 NAC 1 and this chapter and are applicable to all licenses.

004.01 EFFECTIVE DATE AND TERM OF LICENSE. Skilled nursing facility, nursing facility, and intermediate care facility licenses expire on March 31st of each year.

004.02 LICENSE NOT TRANSFERABLE. Change of ownership or premises terminates the license. If there is a change of ownership and the facility remains on the same premises, the inspection in 175 NAC 12-005 is not required. If there is a change of premises, the facility must pass the inspection specified in 175 NAC 12-005.

004.03 FEES. The licensee must pay fees for licensure and services as authorized by Neb. Rev. Stat. § 71-434 and set forth below:

(A) Initial and renewal licensure fees:

(i) 1 to 50 Beds $1,550 (ii) 51 to 100 Beds $1,750 (iii) 101 or more Beds $1,950

(B) Duplicate license: $ 10

005. INSPECTIONS . Inspection requirements for licensees are set out in the Health Care Facility Licensure Act and 175 NAC 1.

006. STANDARDS OF OPERATION, CARE, AND TREATMENT . To provide adequate protection and promotion of the health, safety, and well-being of facility residents and compliance with state statutes, skilled nursing facilities, nursing facilities, and intermediate care facilities must meet the following in this section.

006.01 LICENSEE RESPONSIBILITIES. The responsibilities of the licensee include:

(A) Total operation of the facility; (B) Monitoring policies to assure the appropriate administration and management of the facility; (C) Ensuring the facility’s compliance with all applicable statutes and relevant regulations; (D) Periodically reviewing reports and recommendations regarding the quality assurance and performance improvement program and implementing programs and policies to maintain and improve the quality of resident care and treatment; (E) Appointing a Nebraska-licensed administrator who is responsible for the day-to-day management of the facility; (F) Defining the duties and responsibilities of the administrator in writing; (G) Notifying the Department in writing within 5 working days when a vacancy in the administrator position occurs, including who will be responsible for the position until another administrator is appointed; and (H) Notifying the Department in writing within 5 working days when the vacancy in the administrator position is filled, including the effective date, license number, and the name of the person appointed administrator.

006.02 ADMINISTRATOR. Every skilled nursing facility, nursing facility, and intermediate care facility must have a Nebraska-licensed administrator who is responsible for the overall management of the facility. Each administrator must be responsible for and oversee the operation of a facility in compliance with Neb. Rev. Stat. § 38-2419. The administrator must:

(A) Ensure compliance with statutes and regulations; (B) Plan, organize, and direct responsibilities delegated to the administrator by the licensee; (C) Maintain liaison, through meetings and periodic reports, among the governing body, medical and nursing staff, and other professional and supervisory staff of the facility; (D) Protect and promote residents’ health, safety and well-being; residents’ individuality, privacy and dignity; and residents’ participation in decisions regarding care and services; (E) Ensure staffing appropriate in number and qualification to meet the resident needs; (F) Designate an appropriate person to act as a substitute in the administrator’s absence who is responsible and accountable for management of the facility. The administrator remains responsible for the acts of the designated person. In case of an extended absence, an appropriate person means one who holds a current license or provisional license issued by the Department to act as a nursing home administrator; (G) Ensure that facility staff identify and review incidents and accidents, resident complaints and concerns, patterns and trends in overall facility operation such as provisions of resident care and service and take action to alleviate problems and prevent recurrence; (H) Ensure that a report is made on any alleged abuse of a resident by a staff member, volunteer, family member, visitor, or any other person to Adult Protective Services or local law enforcement as directed in the Adult Protective Services Act, Neb. Rev. Stat. § 28-372 and in the case of a child, Neb. Rev. Stat. § 28-711. All alleged abuse must be investigated, and residents protected from further abuse throughout the investigation; and (I) Ensure the establishment of a quality assurance and performance improvement committee and that the recommendations of the committee are addressed.

006.03 MEDICAL DIRECTOR. Each licensee must have a medical director who is a physician. The medical director is responsible for:

(A) Ensuring adequate medical practitioner availability and support; (B) Ensuring effective medical practitioner and facility compliance with requirements; (C) Evaluating and improving the quality of the care; and (D) Evaluating and improving the quality of the systems and processes that influence the care.

006.04 STAFF REQUIREMENTS. Sufficient number of staff with the required credentials, experience, orientation, training and competency necessary to meet the resident population’s requirements for assistance or provision of personal care, activities of daily living, supervision, supportive services and medical care where appropriate. Any unlicensed staff who assist in the provision of care and treatment provided to residents must be supervised by a health care professional. Staff cannot provide care or treatment that is outside the scope of practice permitted by the credential held by the individual.

006.04(A) EMPLOYMENT ELIGIBILITY. Each licensee must maintain evidence of the following in this section.

006.04(A)(i) STAFF CREDENTIALS. Staff credentials are to be verified prior to staff assuming assigned job duties, and the licensee must maintain evidence that such status is checked and maintained throughout the entire time of employment.

006.04(A)(ii) HEALTH STATUS. A health history screening for all staff must be completed prior to staff assuming job duties. A licensee is to ensure staff health status is maintained in a manner to prevent the potential transmission of disease to residents, visitors, and other staff.

006.04(A)(iii) CRIMINAL BACKGROUND AND REGISTRY CHECKS. Criminal background and registry checks must be completed on any staff members who have direct and unsupervised access to or who provide care and treatment to residents. These checks must be completed prior to the staff having unsupervised contact with any resident. Documentation of such checks is to be maintained for as long as the staff member is employed.

006.04(A)(iii)(1) CRIMINAL BACKGROUND CHECKS. Criminal background checks must be completed through a governmental law enforcement agency or a private entity that maintains criminal background information.

006.04(A)(iii)(2) REGISTRY CHECKS. A check for adverse findings must include the following registries:

(a) Nurse Aide Registry; (b) Adult Protective Services Central Registry; (c) Central Register of Child Protection Cases; and (d) Sex Offender Registry.

006.04(A)(iii)(3) USE OF CRIMINAL BACKGROUND AND REGISTRY INFORMATION. Written policies and procedures are to be implemented and revised as necessary related to the use of information obtained through pre-employment criminal background and registry checks. These are to include the following:

(a) How the criminal background and registry information, except for the Nurse Aide Registry, is used in making hiring decisions; (b) Whether employment can begin prior to receiving the criminal background and registry information, how the safety or property of residents will be safeguarded until the results are available, and what happens if the results have adverse findings; (c) How any decision to hire a person with a criminal background or adverse registry findings, except for the Nurse Aide Registry, is documented. Documentation must include the basis for the decision and how it will not pose a threat to resident safety or resident property; and (d) A person with adverse findings on the Nurse Aide Registry regarding resident abuse, neglect, or misappropriation of resident property cannot be employed.

006.04(B) TRAINING. The licensee must provide initial and ongoing training designed to meet the needs of the resident population. Training must be provided by a person qualified by education, experience, and knowledge in the area of the service being provided. Records of each orientation and in-service or other training program, including names of staff attending, subject matter of the training, names and qualifications of instructors, dates of training, length of training sessions and any written materials provided must be maintained in a format and location that is easily and readily accessible to an agent or employee of the Department for 7 years from the date of orientation or the date of the training.

006.04(B)(i) INITIAL ORIENTATION. Each employee must receive initial orientation within 2 weeks after beginning employment that includes at a minimum, but is not limited to:

(1) Resident rights; (2) Emergency procedures including fire safety and disaster preparedness plans including availability and notification; (3) Information on abuse, neglect, and misappropriation of money or property of a resident and reporting requirements according to the Adult Protective Services Act, and facility procedures; (4) Job duties and responsibilities; (5) Nursing staff must receive information on medical emergency directives; and (6) Alzheimer’s care and dementia care if the licensee cares for residents with Alzheimer’s or dementia.

006.04(B)(ii) ONGOING TRAINING. Each employee must receive ongoing training to ensure competency and continued compliance with regulations and facility policy. This training must include 4 hours of Alzheimer’s care and dementia care if the licensee cares for residents with Alzheimer’s or dementia.

006.04(B)(ii)(1) NURSE AIDE TRAINING. Ongoing training for nurse aides must consist of at least 12 hours per year on topics appropriate to the employee’s job duties, including meeting the physical, psychosocial, and mental needs of the residents.

006.04(B)(ii)(2) MEDICATION AIDES. When medication aides are utilized by the facility, there must be ongoing training to ensure competencies are met as provided in 172 NAC 95.

006.04(B)(ii)(3) DIRECTOR OF FOOD SERVICE. When the director of food service is not a qualified dietitian, the director must have at least 15 hours of continuing education related to dietetics each year, 5 hours of which relate to sanitation. Evidence of credentials and of continuing education must be available within the facility.

006.04(C) EMPLOYMENT RECORDS. Current employment records for each staff person must be maintained for 7 years from the date of termination of employment. Information kept in the record must include information on the length of service; orientation; in-service; competency testing; licensure, certification registration, or other credentials; health history screening; and previous work experience.

006.04(D) NURSING STAFF RESOURCES AND RESPONSIBILITIES. The licensee must provide sufficient nursing staff on a 24-hour basis, with specified qualifications as follows, to provide nursing care to all residents in accordance with resident care plans.

006.04(D)(i) DIRECTOR OF NURSING SERVICES. The licensee must employ a Director of Nursing Services as required by Neb. Rev. Stat. §§ 71-6018.01 and 71-6018.02. The Director of Nursing Services is responsible for the following:

(1) Administrative authority, function, and activity of the nursing department; (2) Orientation and in-service education of the nursing services staff; (3) Establishment and implementation of nursing services, objectives, standards of nursing practices, nursing policy and procedure manuals and written job descriptions for each level of nursing personnel; (4) Establishment and implementation of methods of coordination of nursing services with other resident services in meeting each resident’s needs; (5) Preadmission evaluation of residents; establishment and implementation of criteria for admission to the facility; (6) Recommendation of the number and levels of nursing personnel to be employed; (7) Nursing staff development; and (8) Establishment and implementation of complete nursing assessments and nursing care plans for residents, and ongoing evaluation and updating of care plans to reflect the current overall condition of the residents.

006.04(E) DIRECTOR OF NURSING VACANCY. The licensee must notify the Department in writing within 5 working days when a vacancy in the Director of Nursing Services position occurs, including who will be responsible for the position until a full-time Director of Nursing Services is secured. The Department must be notified in writing within 5 working days when the vacancy is filled indicating effective date, name, and license number of the person assuming Director of Nursing Services responsibilities.

006.04(F) CHARGE NURSE REQUIREMENT. Except when waived in accordance with Neb. Rev. Stat. §§ 71-6018.01 and 71-6018.02, skilled nursing facilities and nursing facilities must designate a licensed nurse to serve as a charge nurse on each tour of duty. Intermediate care facilities must designate a licensed nurse to serve as a charge nurse for 1 tour of duty each 24 hours.

006.04(F)(i) CHARGE NURSE. The charge nurse is responsible for the total nursing care delivered during the tour of duty on the assigned unit. A charge nurse is responsible for the following:

(1) The direct nursing care of the specific residents. Such care may be provided personally, or through assignment, delegation, or direction of duties to other nursing personnel, as appropriate; (2) Being knowledgeable and responsive to the physical and emotional needs of all residents; (3) Complete and accurate medication administration; (4) Participating in the review, revising and implementation of residents’ plans of care; (5) Notifying the Director of Nursing Services, physician, and family of changes in resident condition, i.e., injury, accident, or adverse change; and (6) Completing documentation describing nursing care provided, including resident response and status.

006.04(G) OTHER NURSING PERSONNEL. A sufficient number of qualified nursing personnel who are awake, dressed and assigned to resident care duties at all times must be provided. The licensee must ensure personnel who provide direct resident care meet the following requirements:

(i) Nurse Aides must meet the requirements in Neb. Rev. Stat. § 71-6039; (ii) Medication Aides must meet the requirements in Neb. Rev. Stat. §§ 71-6718 to 71-6742; (iii) Have the ability to speak and understand the English language or a language understood by a substantial portion of the facility’s residents; and (iv) When the licensee utilizes persons other than a licensed nurse or a nurse aide for the feeding of residents, the licensee must comply with Neb. Rev. Stat. § 71-6039.

006.04(H) DIETARY SERVICES STAFFING. Sufficient personnel competent to carry out the functions of the dietary services in a safe and timely manner must be provided.

006.04(H)(i) QUALIFIED DIETITIAN. A qualified dietitian must be employed on a full-time, part-time, or consultant basis. The qualified dietitian is responsible for the general guidance and direction of dietary services, assessing special nutritional needs, developing therapeutic diets, regular diets, developing and implementing in-service education programs, participating in interdisciplinary care planning when necessary, supervising institutional food preparation, service, and storage.

006.04(H)(ii) FOOD SERVICE DIRECTOR. A person to serve as the director of food service who receives scheduled consultation from a registered dietitian or licensed medical nutrition therapist must be designated if a qualified dietitian is not employed full-time.

006.04(H)(ii)(1) FOOD SERVICE DIRECTOR QUALIFICATIONS. To qualify as director of food service, the employee must be one of the following:

(a) A graduate of a dietetic technician program approved by the American Dietetic Association; (b) An individual with a bachelor’s degree in foods and nutrition; (c) An individual with an associate’s or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution in higher learning; (d) A graduate of a dietetic assistant program approved by the American Dietetic Association, qualifying for certification by the Dietary Managers Association; (e) A graduate of a dietary manager program approved by the Dietary Managers Association and qualifying for certification by the Dietary Managers Association; or (f) An individual who successfully completes a course in food service management offered by an accredited university, community college, or technical college, whose curriculum meets at least the minimum requirements of any of the programs described in 175 NAC 12-006.04 (H)(ii)(1), items (a) to (d), whether or not formally approved by the entities named in those sections.

006.04(H)(ii)(2) FOOD SERVICE DIRECTOR QUALIFICATIONS NOT MET. If the designated person does not meet the qualifications of a food service director, the licensee must have a written agreement with a qualified food service director for consultation and assistance on a regularly scheduled basis as required to meet the needs of the residents.

006.04(H)(ii)(3) FOOD SERVICE DIRECTOR RESPONSIBILITIES. The dietitian or director of food service is responsible for ensuring residents are provided with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. The director of food service or designee must participate in the interdisciplinary care plan for each resident.

006.04(I) SOCIAL SERVICES STAFFING. Sufficient staff to meet the social service needs of the residents must be provided.

006.04(I)(i) SOCIAL SERVICES DIRECTOR QUALIFICATIONS. A social services director must be designated to be responsible for arranging and integrating social services with other elements of the care plan. To qualify as social services director; the employee must have:

(1) A certificate issued by the Department to practice social work as a certified master social worker; (2) A Master of Social Work (M.S.W.) degree with 1-year experience in the provision of social services in a long-term care facility, or geriatric setting; (3) A graduate degree in social or behavioral sciences with a specialty in gerontology with 1-year experience in the provision of social services in a long-term care facility, or geriatric setting; (4) A Bachelor of Social Work degree from a college or university with an undergraduate social work program accredited by the Council on Social Work Education with 1-year of experience in the provision of social services in a long-term care facility or geriatric setting; (5) A Bachelor of Arts (B.A.) or Bachelor of Science (B.S.) degree in social or behavioral sciences with 1-year of experience in the provision of social service in a long-term care facility, or geriatric setting; (6) An Associate of Arts degree in social or behavioral sciences with 2 years of experience in the provision of social services in a long-term care facility, or the services of a qualified consultant; (7) Successfully completed a course of instruction in social services of at least 36 hours established by the Provider Associations; or (8) 2 years of experience in the provision of social services in a long-term care facility.

006.04(I)(ii) SOCIAL SERVICES DIRECTOR QUALIFICATIONS NOT MET. If the designated person does not meet the qualifications of a social service director, the licensee must have a written agreement with a qualified social worker for consultation and assistance on a regularly scheduled basis as required to meet the needs of the residents.

006.04(I)(iii) SOCIAL SERVICE DIRECTOR RESPONSIBILITIES. The social service director or designee must act as part of the interdisciplinary team in assessing the individual needs of the resident and participate in development and implementation of the interdisciplinary care plan. Social service interventions to assist the resident in meeting treatment goals, address resident needs and provide social service support in meeting resident needs and individuality must be implemented. The social service staff must establish and maintain relationships with the resident’s family or designee.

006.04(J) RESIDENT ACTIVITY STAFFING. Sufficient staff to provide activities of interest to residents must be provided.

006.04(J)(i) RESIDENT ACTIVITIES DIRECTOR QUALIFICATIONS. A qualified resident activities director must be designated. The activities director must meet 1 of the following qualifications:

(1) A qualified therapeutic recreation specialist with 1-year of experience in a long-term care facility or geriatric setting; (2) A licensed occupational therapist with 1-year of experience in a long-term care facility or geriatric setting; (3) A qualified therapeutic recreation assistant with 1-year of experience in a long-term care facility or geriatric setting; (4) An individual who has a Bachelor of Arts (B.A.) or Bachelor of Science (B.S.) degree in social or behavioral sciences with 1-year of experience in the provision of recreational services in a long-term care facility or geriatric setting; (5) An individual who has successfully completed a course of instruction in recreational services of at least 36 hours established by the provider associations, or a substantially equivalent course established by any other health care association or entity; or (6) Has 2 years of full-time experience in a resident activities program in a health care setting.

006.04(J)(ii) RESIDENT ACTIVITIES DIRECTOR QUALIFICATIONS NOT MET. If the designated person does not meet the qualifications of an activity’s director, the licensee must have a written agreement with a qualified consultant for consultation and assistance on a regularly scheduled basis as required to meet the needs of the residents.

006.04(J)(iii) RESIDENT ACTIVITIES DIRECTOR RESPONSIBILITIES. The activity director or designee must act as a member of the interdisciplinary team and participate in the development of the interdisciplinary care plan. The activity director is responsible for providing daily activities for residents to stimulate and promote the physical, spiritual, social, emotional, and intellectual well-being of each resident.

006.04(K) MEDICAL RECORDS STAFFING. Overall supervisory responsibility for the medical record service must be the responsibility of a full-time employee of the facility. Sufficient supporting personnel competent to carry out the functions of the medical record services must be provided.

006.05 RESIDENT RIGHTS. The operations of the licensee must afford residents the opportunity to exercise their rights in accordance with Neb. Rev. Stat. §§ 71-6019 to 71-6023 and the following:

(A) Be informed of their rights in writing;(B) Be fully informed in writing prior to or at the time of admission and during the resident’s 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; (C) Be fully informed of rights and responsibilities as a resident and of all rules and regulations governing resident conduct and responsibilities. This information must be provided prior to or at the time of admission and its receipt acknowledged by the resident in writing, or, in the case of residents already in the facility, upon the facility’s adoption or amendment of resident rights policies; (D) Be fully informed by a physician of the residents health and medical condition unless medically contraindicated; (E) Participate in the planning of total care and medical treatment, or to refuse treatment. A resident may participate in experimental research only upon informed written consent; (F) Exercise rights as a resident of the licensee and as a citizen of the United States; (G) Be free from chemical and physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident’s medical symptoms; (H) Be free from abuse, neglect and misappropriation of their money and personal property; (I) Refuse to perform services for the licensee; (J) Examine the results of the most recent survey of the licensee conducted by the Department; (K) Privacy in written communication including sending and receiving mail; (L) Have access to the use of a telephone with auxiliary aides where calls can be made in private; (M) Retain and use personal possessions, including furnishings, and clothing as space permits, unless to do so would infringe upon the rights and safety of other residents; (N) Self-administer medications if it is safe to do so; (O) Form and participate in an organized resident group that functions to address licensee issues; (P) Review and receive a copy of their permanent record, within 2 working days; (Q) Manage his or her personal financial affairs. Under specific written authorization by the resident, the licensee may assist in such management to the extent specified by the resident; (R) Receive confidential treatment of all information contained in his or her records, including information contained in an electronic data bank. Resident written consent or that of the resident’s designee is required for the release of information to persons not otherwise authorized under law to receive it; and (S) Be treated with consideration, respect, and full recognition of resident dignity and individuality, including privacy in treatment and in care for the residents personal needs.

006.06 COMPLAINTS AND GRIEVANCES. The licensee must establish and implement procedures for addressing complaints and grievances as outlined in 175 NAC 1 and this section.

006.06(A) SUBMISSION OF COMPLAINTS AND GRIEVANCES. The procedure for submitting complaints and grievances must be displayed in plain view of residents, employees, and others in a prominent location.

006.06(B) COMPLAINT AND GRIEVANCE RESOURCES. The licensee must ensure that the telephone numbers and addresses of the Department’s Investigations Unit and the state long term care ombudsman are readily available to residents, employees and others.

006.07 QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT. The licensee must have a quality assurance and performance improvement committee responsible for identifying issues which necessitate action, development and implementation of the action plan to correct problems and reevaluation of the problem to promote quality care and treatment provided to residents.

006.07(A) COMMITTEE PARTICIPANTS. The following individuals are to serve on the quality assurance and performance improvement committee:

(i) Director of Nursing Services; (ii) Medical Director or designee; and (iii) At least 3 other members of the facility’s staff.

006.07(B) OTHER PARTICIPANTS. The participation of other members of the facility staff as well as consultants on the quality assurance and performance improvement committee must be requested as necessary to identify issues which necessitate action and to participate in development and implementation of action plan to correct the problem and reevaluation of the problem.

006.07(C) COMMITTEE RESPONSIBILITIES. The quality assurance and performance improvement committee is responsible for:

(i) Identifying issues that necessitate action by the committee; (ii) Developing and implementing plans of action to correct identified problems; (iii) Monitoring the appropriateness and effectiveness of corrective actions; and (iv) Reevaluating corrective actions, revising of plans of corrective action, and revising licensee policies and clinical policies as necessary.

006.08 MEDICAL SERVICES. The medical care of each resident is to be supervised by a medical practitioner, and another medical practitioner is to supervise the medical care of the residents when their attending medical practitioner is unavailable.

006.08(A) ADMISSION CRITERIA. Each individual admitted to the licensee must have written approval of a recommendation for admittance from a medical practitioner. Each resident must have a history and physical examination completed by a medical practitioner within 30 days prior to or 14 days after admission. Each resident must remain under the care of a medical practitioner.

006.08(B) MEDICAL PRACTITIONER RESPONSIBILITIES. The medical practitioner must:

(i) Review the resident’s total program of care, including medications and treatments, at each visit required; (ii) Write, sign, and date progress notes at each visit; and (iii) Sign any order the medical practitioner gives.

006.09 CARE AND TREATMENT. The physical, mental and psychosocial needs of all residents are to be met in accordance with each resident’s individualized needs and physician orders.

006.09(A) RESIDENT ADMISSION AND RETENTION. The licensee must ensure the resident’s identified needs for care and treatment can be met both before admission and for retention.

006.09(A)(i) ADMISSION CRITERIA. The licensee must implement written criteria for admission to the facility. The written criteria must include how eligibility for admission is determined based on the following:

(1) Identification of resident need in relationship to care and treatment, including severity of presenting problem; and (2) Need for supervision and other issues related to providing care and treatment and licensee resources.

006.09(A)(ii) RETENTION OF RESIDENTS. The licensee must continue to provide care and treatment to residents as long as the licensee can continue to meet the identified needs for care, treatment, and supervision, and other issues related to providing care and treatment.

006.09(B) RESIDENT ASSESSMENT. A comprehensive, accurate, and reproducible assessment of each resident’s functional capacity designed to identify the resident’s abilities and needs must be completed as set out in this chapter. The assessment must include review and assessment of current and history of the following:

(i) Body systems and functions, including vital signs; (ii) Psychosocial function; (iii) Diagnoses, disease processes, and presenting symptoms; and (iv) Medication with therapeutic and adverse effects.

006.09(C) ASSESSMENT FREQUENCY. The comprehensive assessment is to be completed:

(i) No later than 14 days after the date of admission; (ii) By the end of the 14th calendar day following the determination that a significant change has occurred; and (iii) In no case less often than once every 12 months.

006.09(D) REVIEW OF ASSESSMENTS. A review of the comprehensive assessment of each resident is to be completed and documented no less than once every 3 months. As appropriate, the resident’s comprehensive assessment is to be revised to ensure accuracy of the assessment.

006.09(E) COMPREHENSIVE CARE PLANS. A comprehensive interdisciplinary care plan for each resident based on the comprehensive assessment must be developed and implemented to ensure the resident achieves optimal functional status and independence. The care plan must include and specify:

(i) An interdisciplinary evaluation of resident needs; (ii) Measurable objectives and timetables to meet a resident’s needs that are identified in the comprehensive assessment; (iii) The services that are to be furnished to attain or maintain the resident’s highest practicable well-being; (iv) Goals for the residents that are time limited and measurable; (v) A discharge plan based on the needs of the resident; and (vi) The discipline(s) responsible for providing specific care and the frequency of the interventions.

006.09(F) FREQUENCY OF CARE PLANS. Care plans are to be developed and implemented as follows:

(i) Within 24 hours of the resident’s admission, and a preliminary nursing assessment and nursing care plan that implements the medical practitioner’s admission orders must be completed; (ii) A comprehensive interdisciplinary care plan and discharge plan must be completed within 7 days after the completion of the comprehensive assessment; and(iii) The care plan is to be reviewed and revised at least quarterly or with change in condition or services provided. Review of the care plan must include an interdisciplinary evaluation of the resident’s progress relative to the goals established.

006.09(G) DISCHARGE PLANNING. A post discharge plan of care for any resident is to be developed when there is anticipated discharge to a home, same level, or a different level of care. The discharge plan of care must be developed with the participation of the resident and resident’s family.

006.09(G)(i) DISCHARGE SUMMARY. When a resident is discharged, a discharge summary must be completed and be available for release to authorized persons and agencies with the consent of the resident or resident’s designee. The discharge summary must include:

(1) Resident’s full name; (2) Medical record number; (3) Admission date; (4) Discharge date and time; (5) Name of attending medical practitioner; (6) Destination discharged to; (7) Recapitulation of resident’s stay; (8) Final diagnosis and resident status; (9) Date summary completed; and (10) Signature of the person completing the summary.

006.09(G)(ii) DISCHARGE TO ANOTHER SETTING. When a resident is discharged to a different facility setting or service, in addition to the information required in 175 NAC 12-006.09(G)(i), the discharge summary must include:

(1) Medically defined conditions; (2) Medical status measurement; (3) Functional status; (4) Sensory and physical impairments; (5) Nutritional status and requirements; (6) Special treatments and procedures; (7) Psychosocial status; (8) Discharge potential; (9) Dental condition; (10) Activities potential; (11) Rehabilitation potential; (12) Cognitive status; and (13) Drug therapy, including education.

006.09(H) PROVISION OF CARE AND TREATMENT. The necessary care and treatment to permit achievement and maintenance of optimal mental, physical, and psychosocial functional status and independence in accordance with the comprehensive assessment and plan of care for each resident must be provided.

006.09(H)(i) RESIDENT ABILITIES. Care and treatment is provided to improve or maintain a resident’s abilities when the resident is capable of some level of independence in performing these abilities. When the resident is not capable of independent functioning, the licensee is responsible for provision of these cares.

006.09(H)(i)(1) DIMINISHED ABILITIES. A resident is to receive the appropriate standards of care and treatment to prevent a diminution of the resident’s abilities unless circumstances of the individual’s medical condition demonstrates the diminution was unavoidable. This includes the residents ability to:

(a) Bathe, dress, and groom; (b) Transfer and ambulate; (c) Toilet; (d) Eat; and (e) Use speech, language, or other functional communication systems.

006.09(H)(i)(2) MAINTENANCE OR IMPROVEMENT IN ABILITIES. A resident is to receive the appropriate standards of care and treatment to maintain or improve the resident’s abilities as described in 175 NAC 12-006.09(H)(i)(1).

006.09(H)(i)(3) INABILITY TO SELF-PERFORM. A resident who is unable to carry out activities of daily living is to receive the appropriate standards of care and treatment to maintain good nutrition, grooming, and personal and oral hygiene.

006.09(H)(ii) VISION AND HEARING. Residents are to receive appropriate standards of care and treatment and assistive devices to maintain vision and hearing abilities. Residents, as needed, are to be assisted in:

(1) Making appointments; and (2) Arranging for transportation to and from the office of a practitioner or professional specializing in hearing and vision or provision of vision or hearing assistive devices.

006.09(H)(iii) SKIN INTEGRITY. A resident is to receive appropriate standards of care and treatment to maintain or improve skin integrity.

006.09(H)(iii)(1) PREVENT PRESSURE SORES. Appropriate standards of care and treatment are to be implemented to prevent a resident who enters the facility without a pressure sore from developing pressure sores unless the individual’s clinical condition demonstrates that pressure sores were unavoidable.

006.09(H)(iii)(2) PROMOTE HEALING. Appropriate standards of care and treatment are to be implemented for each resident with a pressure sore to promote healing, prevent infection and prevent other areas from occurring.

006.09(H)(iii)(3) OTHER OPEN AREAS. Appropriate standards of care and treatment are to be implemented to prevent a resident from developing skin excoriation, skin tears, other open areas unless the individual’s condition demonstrates that they were unavoidable.

006.09(H)(iv) URINARY AND BOWEL FUNCTION. Appropriate standards of care and treatment are to be implemented for residents who have or are at risk for elimination problems. Care and treatment must be provided to:

(1) Prevent urinary tract infection; (2) Restore bladder and bowel function unless the resident’s condition demonstrates that the loss in bladder and bowel function is unavoidable; (3) Keep residents free of odors not caused by a clinical condition; (4) Keep residents free from skin breakdown related to bladder or bowel incontinence; (5) Keep residents free of fecal impactions and signs of discomfort from bowel constipation; and (6) Ensure a resident who enters the facility without an indwelling catheter does not receive an indwelling catheter unless the resident’s clinical condition demonstrates that catheterization was necessary.

006.09(H)(v) RANGE OF MOTION. Appropriate standards of care and treatment are to be implemented to improve or maintain each resident’s range of motion unless the resident’s clinical condition demonstrates a decline in range of motion was unavoidable.

006.09(H)(vi) MENTAL AND PSYCHOSOCIAL FUNCTIONING. Appropriate standards of care and treatment are to be implemented to promote each resident’s mental and psychosocial functioning.

006.09(H)(vi)(1) SOCIAL SERVICE SUPPORT. Appropriate methods must be implemented to assist the resident in meeting treatment goals, address resident needs, and provide social service support in meeting each resident’s needs and individuality, including:

(a) Decreased social interaction; and (b) Increased withdrawn, angry, or depressive behaviors.

006.09(H)(vi)(2) PROVISION OF ACTIVITIES. Daily activities to stimulate and promote the physical, spiritual, social, emotional, and intellectual well-being of each resident are to be provided. The activity program must promote the resident’s self-respect, self-expression, and choice.

006.09(H)(vi)(3) SPECIAL NEEDS. Appropriate standards of care and treatment are to be implemented to prevent complications, infections, discomfort, and skin excoriations to residents receiving the following special services:

(a) Gastric tubes; (b) Colostomy, ureterostomy, or ileostomy care; (c) Parenteral and enteral fluids; (d) Injections; (e) Tracheostomy care; (f) Tracheal suctioning; (g) Respiratory care; (h) Foot care; and (i) Prostheses.

006.09(I) ACCIDENTS. Appropriate standards of care and treatment must be implemented to prevent resident accidents. The environment must be free from hazards over which the licensee has control.

006.09(I)(i) ACCIDENT POLICIES AND PROCEDURES. Policies and procedures must be implemented which address:

(1) Investigation, including documentation of the accidents to include identification and evaluation of individual resident causal factors; (2) Method for tracking and identification of trends; (3) Development of interventions to prevent the accident from recurring; and (4) Reevaluation of the effectiveness of the interventions.

006.09(J) NUTRITION. Appropriate standards of care and treatment must be implemented to maintain nutritional status of each resident.

006.09(J)(i) FOOD SERVICE. How each resident is to receive a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. When a licensee contracts for the services of an outside food service management company, the licensee remains responsible for compliance with this chapter.

006.09(J)(i)(1) UNPLANNED WEIGHT LOSS. A resident may not incur an unplanned significant weight loss or other indicator of malnourishment unless the resident’s clinical condition demonstrates that this is not possible. The licensee must evaluate current height and weight status of each resident. Each resident must have a recorded weight no less than monthly with follow-up on unexplained gains and losses. Alternative methods of anthropometric assessment may be used, and the results documented.

006.09(J)(ii) ASSISTIVE DEVICES. Assistive devices for eating are to be provided to residents who need them.

006.09(J)(iii) HYDRATION. Each resident must be provided with sufficient fluid intake to maintain proper hydration and health.

006.10 ADMINISTRATION OF MEDICATION. The licensee must implement policies and procedures to ensure residents receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and prevailing professional standards.

006.10(A) METHODS OF ADMINISTRATION OF MEDICATION. When the licensee is responsible for the administration of medication, it must be accomplished by the following methods:

006.10(A)(i) SELF-ADMINISTRATION. The licensee must allow residents of the facility to self-administer medication, with or without supervision, when resident assessment determines resident is capable of doing so.

006.10(A)(ii) LICENSED HEALTH CARE PROFESSIONAL. When the licensee utilizes licensed health care professionals for whom medication administration is included in the scope of practice, the licensee must ensure the medications are properly administered in accordance with prevailing professional standards.

006.10(A)(iii) PROVISION OF MEDICATION BY A PERSON OTHER THAN A LICENSED HEALTH CARE PROFESSIONAL. When the licensee utilizes persons other than a Licensed Health Care Professional in the provision of medications, the licensee must comply with Neb. Rev. Stat. §§ 71-6718 to 71-6742.

006.10(A)4(iv) FACILITY NOT RESPONSIBLE FOR MEDICATION ADMINISTRATION. When the licensee is not responsible for the administration or provision of medications, the licensee is responsible for the overall supervision, safety, and welfare of the resident.

006.10(B) MEDICATION RECORD. Each resident must have an individual medication administration record, which is to include the following:

(i) The name of the facility; (ii) The name of the resident; (iii) The room and bed number of the resident; (iv) Resident identification number; (v) The name of the medication prescribed; (vi) The strength of the individual dose; (vii) Directions for administration of the medication; (viii) Name of physician; and (ix) Drug allergies and sensitivities.

006.10(C) MEDICATION DOCUMENTATION. The dose administered to the resident must be properly documented on the medication record by the person who administered the drug, after the drug is administered. For oral medications, the actual act of swallowing must be observed.

(i) If the resident refuses the medication, the refusal and the reason for the refusal must be documented as refused on the medication record; and (ii) Medications must be administered by the same person who prepared the dose, except under single unit dose package distribution systems.

006.10(D) MEDICATION ERRORS. The licensee must ensure that its medication error rates are not 5% or greater, residents are free from significant medication errors, and the licensee has a system for recording and reporting medication errors and adverse medication effects to the prescribing medical practitioner.

006.11 DIETARY SERVICES. The licensee must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. In the event that a licensee contracts for the services of an outside food service management company, the licensee remains responsible for compliance with this chapter.

006.11(A) MENUS AND NUTRITIONAL ADEQUACY. The menus must:

(i) Be developed and implemented to meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, with provision for ensuring adequate intake of calories and fluids; (ii) Be designed to be compatible with the food preferences of the majority of the residents of the facility, with the physicians’ orders, and with the physical needs of each resident; (iii) Offer substitutes of similar nutritive value to residents who refuse food; and (iv) Include therapeutic diets when prescribed by the medical practitioner.

006.11(B) FREQUENCY OF MEALS. At least 3 meals daily, at regular times comparable to normal mealtimes in the community, must be provided.

006.11(C) FOOD SUPPLY. Supplies of staple foods for a minimum of a 7-day period and perishable foods for a 3-day period must be maintained on the premises. Food must be procured from sources approved or considered satisfactory by federal, state, or local authorities.

006.11(D) FOOD PREPARATION. Foods are to be prepared by methods that conserve the food’s nutritive value, flavor, and appearance. Foods must be attractively served at the proper temperatures. Recipe resources must be available.

006.11(E) FOOD CODE. The licensee must comply with the Food Code.

006.12 PHARMACOTHERAPY SERVICES. The licensee must provide routine and emergency drugs, devices and biologicals to its residents, or obtain them under an agreement. The storage, control, handling, administration, and provision of drugs, devices, and biologicals must be in accordance with state laws and regulations relating to same, and to the practice of pharmacy and medicine and surgery.

006.12(A) PHARMACOTHERAPY SERVICES SUPERVISION. The licensee must employ or obtain the services of a Nebraska-licensed pharmacist to provide for the development, coordination, and supervision of all pharmaceutical services. The pharmacist is responsible for:

(i) Consultation on all aspects of the provision of pharmacotherapy services in the facility; (ii) Ensuring that the pharmacotherapy service has procedures for control and accountability of all medications throughout the facility; (iii) Ensuring that medication records are in order and that an account of all Schedule II and III controlled substances is maintained and reconciled; (iv) Maintaining records of receipt and disposition of all controlled substances in sufficient detail to enable an accurate reconciliation; (v) Participation as an interdisciplinary team member related to medication regimen for the resident in the comprehensive assessment, assessment review, and care planning process; and (vi) Reviewing the drug regimen of each resident at least monthly and reporting any irregularities to the primary medical practitioner and Director of Nursing Services in accordance with standards of care. The drug regimen review must include a signed and dated statement that:

(1) No potential problems were found; (2) A problem was found but it was deemed not significant; (3) A significant problem was found; and (4) The statement must include a description of the situation and the information that was communicated to the individual with the authority to correct it, usually the medical practitioner.

006.12(B) CONTROLLED SUBSTANCES AND PRESCRIPTION DRUGS. The licensee must comply with the requirements of the Uniform Controlled Substances Act.

006.12(C) BULK SUPPLY. Any licensee may purchase bulk quantities of non-prescription drugs, devices, and biologicals and may administer these medications to individual residents in the facility only on the order of a medical practitioner.

006.12(D) DRUG ACCOUNTABILITY AND DISPOSITION. The licensee must implement procedures for storing and disposing of drugs, devices, and biologicals in accordance with State and local laws.

006.12(D)(i) DRUG STORAGE. All drugs, devices, and biologicals are to be stored in locked areas and stored in accordance with the manufacturer’s or pharmacist’s instructions for temperature, light, humidity, or other storage instructions. Drugs, devices and biologicals are to be stored in the container in which they are received from the pharmacy. Only authorized personnel who are designated by the licensee as responsible for administration or provision of medications may have access to the medications.

006.12(D)(i)(1) CONTROLLED SUBSTANCE STORAGE. The licensee must provide separately locked, permanently affixed compartments for storage of controlled medications listed in Schedule II of Neb. Rev. Stat. § 28-405, and other medications subject to abuse, except when the licensee uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

006.12(D)(i)(2) CONTROLLED SUBSTANCE COUNT. A shift count of all controlled substances in Schedules II and III must be completed by 2 persons with each initialing the separate medication control sheet for each medication when the count is completed. The individual medication administration record can serve as a record of the receipt and disposition of all other Controlled Substances.

006.12(D)(ii) COMPOUNDING, DISPENSING AND LABELING. Only the pharmacist, or a pharmacist intern under the direct supervision of the pharmacist, may compound or dispense drugs, devices or biologicals or make label changes. The licensee must ensure that labeling of drugs, devices, or biologicals are in accordance with Neb. Rev. Stat. § 71-476.

006.12(D)(iii) DISCONTINUED, OUTDATED, DETERIORATED DRUGS, DEVICES AND BIOLOGICALS. No discontinued, outdated, or deteriorated drugs, devices and biologicals may be used or be available for use.

006.12(D)(iv) SEPARATE STORAGE REQUIREMENT. Drugs, devices and biologicals for external use, as well as poisons, must be stored separately from all other medications.

006.12(D)(v) EMERGENCY BOX DRUG. Authorized personnel of the licensee may administer medications to residents in accordance with Neb. Rev. Stat. §§ 71-2410 through 71-2413.

006.12(D)(vi) MEDICATION INTEGRITY AND LABELING. All medications used are to be labeled in accordance with Neb. Rev. Stat. § 71-476 and currently accepted professional standards of care, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

006.12(D)(vii) DISPOSITION OF PRESCRIPTION MEDICATIONS. The licensee must properly dispose of all prescription medications that are discontinued or expired. Medications may not be saved for use by other residents or be shared with anyone.

006.12(D)(vii)(1) DISCHARGED RESIDENT MEDICATIONS. The licensee may send prescribed medication with a resident upon discharge only with the order of a medical practitioner, and all medication containers must be properly labeled by the dispensing pharmacy.

006.12(D)(vii)(2) DISCONTINUED MEDICATIONS. When any prescription medication is discontinued permanently or the resident has expired, the licensee must either:

(a) Return the medication to the dispensing pharmacy in accordance with Neb. Rev. Stat. § 38-28,107; (b) Properly dispose of any residue; or (c) Controlled substances must be disposed of in accordance with Neb. Rev. Stat. § 28-414.05(3).

006.13 SPECIALIZED REHABILITATIVE SERVICES. All nursing facilities and skilled nursing facilities must provide specialized rehabilitative services as ordered by the medical practitioner and identified in the resident’s comprehensive plan of care. The specialized rehabilitative services must be designed to maintain and improve the residents ability to function independently, to prevent, as much as possible, advancement of progressive disabilities, and to restore maximum function, independence and self-determination.

006.14 ALZHEIMER’S AND DEMENTIA CARE. A licensee that holds itself out to provide Alzheimer’s or dementia care must do so in accordance with Neb. Rev. Stat. §§ 71-516.01 through 71-516.04.

006.15 DENTAL SERVICES. The licensee must assist residents in obtaining routine and 24-hour dental care to meet the needs of each resident. The licensee must, if necessary, assist the resident in:

(A) Making appointments; (B) Arranging transportation to and from the dentist’s office; and (C) Referring residents with lost or damaged dentures, chewing difficulties, oral ulcerations, or oral pain to a medical practitioner.

006.16 OUTSIDE RESOURCES. If the licensee does not employ a qualified professional person to furnish a specific service required to meet the needs of a resident, the licensee must have the services furnished to residents by a person or agency outside the licensee under an arrangement or agreement. The licensee is responsible for obtaining services that meet professional standards that apply to professionals and the timeliness of the services.

006.17 RECORDKEEPING REQUIREMENTS. The licensee must maintain and safeguard clinical and other records in accordance with 175 NAC 1 and this chapter. These records must be maintained in accordance with accepted professional standards and practice.

006.17(A) CLINICAL RECORD. The clinical record must be complete and contain:

(i) The admission number of the resident; (ii) The insurance and payment numbers for the resident; (iii) The resident’s assessments, including those assessments performed by services under agreement with the licensee; (iv) The name of the attending medical practitioner, including the dentist; and (v) The interdisciplinary progress notes to include effect of care provided, residents’ response to treatment, change in condition, and changes in treatment.

006.17(B) ELECTRONIC RECORD SIGNATURES. If the licensee maintains a resident’s record by computer, electronic signatures are acceptable. If attestation is done on computer records, safeguards to prevent unauthorized access, and to provide for reconstruction of information must be in place.

006.17(C) RECORD RETENTION AND PRESERVATION. Resident clinical records must be maintained and preserved as required in 175 NAC 1 and this chapter. In case of a minor, records must be maintained for 7 years after the resident obtains majority under Nebraska law. In cases in which a licensee ceases operation, all records of each resident must be transferred to the health care facility to which the resident moves. All other resident records of a licensee ceasing operation must be disposed of by shredding, burning, or other similar protective measures in order to preserve the resident’s rights of confidentiality. Records or documentation of the actual fact of resident medical record destruction must be permanently maintained.

006.17(D) OTHER RESIDENT RECORDS. The licensee must maintain records pertaining to resident personal funds accounts as applicable, financial matters, resident possessions, and statements of resident rights and responsibilities. Resident possessions must be inventoried at time of admission, updated as needed, and accounted for upon discharge from the facility.

006.17(E) OTHER FACILITY RECORDS. The licensee must have and maintain the following records:

(i) A count of residents taken at the same hour each day and totaled at the end of 365 days. The total represents the number of “individual care days for the past 12 months”; (ii) Written policies and procedures that govern all services provided by the licensee. Policies and procedures must address all areas identified in 175 NAC 1 and this chapter; (iii) Written disaster plan; (iv) Contracts with outside resources to furnish required services not provided directly by the licensee; and (v) Records regarding operation and maintenance of the facility.

006.17(F) INSPECTION OF RECORDS. All records must be available for inspection and copying by authorized representatives of the Department.

006.18 INFECTION CONTROL. The licensee must maintain facility practices to provide a sanitary environment and to avoid sources and transmission of infections and communicable diseases. This includes the establishment and maintenance of an infection control program for the prevention, control, and investigation of infections and communicable disease as outlined in 175 NAC 1 and this chapter.

006.18(A) VACCINATIONS. The licensee must offer vaccinations to residents and staff in accordance with Neb. Rev. Stat. §§ 71-468 through 71-469.

006.18(B) PREVENTION OF CROSS-CONTAMINATION. The licensee must prevent cross-contamination between residents in provision of care, sanitation of equipment and supplies, and cleaning of resident’s rooms.

006.18(C) DISEASE TRANSMISSION. The licensee must prohibit employees known to be infected with any disease in communicable form to work in any area of the facility in a capacity in which there is a likelihood of the employee transmitting disease to residents or to other facility personnel, food, or food contact surfaces with pathogenic organisms.

006.18(D) HANDWASHING REQUIREMENT. The licensee must require staff to wash their hands after each direct resident contact for which handwashing is indicated by acceptable professional practice.

006.19 ENVIRONMENTAL SERVICES. The licensee must provide a safe, clean, comfortable, and homelike environment, allowing the resident to use personal belongings to the extent possible and in compliance with 175 NAC 1 and this chapter.

006.19(A) EQUIPMENT, FIXTURES, AND FURNISHINGS. The licensee must keep all equipment, fixtures, and furnishings clean, safe and in good repair.

006.19(A)(i) EQUIPMENT. The licensee must provide equipment adequate for meeting resident needs as specified in each resident’s care plan.

006.19(A)(ii) FURNISHINGS. Common areas and resident sleeping areas must be furnished with beds, chairs, sofas, tables, and storage items that are comfortable and reflective of resident needs and preferences.

006.19(B) PREVENTIVE MAINTENANCE. The licensee must establish and implement a process designed for routine and preventive maintenance of equipment and furnishings to ensure that such equipment and furnishings are safe and function to meet their intended use.

006.19(C) LINENS. The licensee is responsible for providing each resident with an adequate supply of clean bed, bath, and other linens as necessary for care and treatment of residents. The linens must be in good repair.

006.19(C)(i) STORAGE AND HANDLING. The licensee must establish and implement procedures for the storage and handling of soiled and clean linens.

006.19(C)(ii) LAUNDRY WATER TEMPERATURES. When the licensee launders bed and bath linens, water temperatures to laundry equipment must exceed 140 degrees Fahrenheit if laundry is not appropriately sanitized or disinfected by other acceptable methods in accordance with the manufacturer’s instructions or other documentation.

007. PHYSICAL PLANT STANDARDS . The facility must be designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided.

007.01 SUPPORT AREAS. The licensee may share the following support service areas among the detached structures, care, and treatment suites, and with other licensed facilities in this section.

007.01(A) DIETARY. If food preparation is provided on site, the licensee must dedicate space and equipment for the preparation of meals. Food service and facilities must comply with the Food Code, except when used only for training or activity purposes.

007.01(B) LAUNDRY. The licensee must provide laundry services. Such service may be provided by contract or on-site by the licensee. If contractual services are used, the licensee must provide areas for soiled linen awaiting pickup and separate areas for storage and distribution of clean linen. If on-site services are provided, the licensee must have areas dedicated to laundry.

(i) If the licensee provides personal laundry areas, the areas must be equipped with a washer and dryer for use by residents. In new construction, the licensee must have a conveniently located sink for soaking and hand washing of laundry; (ii) A bulk laundry area must be divided into separate soiled (sort and washer areas) and clean (drying, folding, and mending areas) rooms. In new construction and new facilities, a separate soaking and hand washing sink and housekeeping room must be provided in the laundry area; and (iii) Separate clean linen supply storage areas must be conveniently located in each care and treatment location.

007.01(C) WASTE PROCESSING. The licensee must provide areas to collect, contain, process, and dispose of medical and general waste produced within the facility in such a manner as to prevent the attraction of rodents, insects and vermin, and to minimize the transmission of infectious diseases.

007.01(D) HOUSEKEEPING ROOM. The licensee must have a room with a service sink and space for storage of supplies and housekeeping equipment.

007.02 CARE AND TREATMENT AREAS. The licensee must provide a physical environment that facilitates and supports the safety and dignity of residents and accommodates the needs of the resident population.

007.02(A) CARE AND TREATMENT AREA REQUIREMENTS. Care and treatment areas must contain a control point, medication station, and clean storage and utility room. The facility must not share these areas among detached structures.

007.02(A)(i) CONTROL POINT. The licensee must have an area or areas for charting and resident records, space for storage of emergency equipment and supplies, and call and alarm annunciation systems.

007.02(A)(ii) MEDICATION STATION. The licensee must have a medication station for storage and distribution of drugs and routine medications. Distribution may be done from a medicine preparation room or unit, from a self-contained medicine-dispensing unit, or by another system. If used, a medicine preparation room or unit must be under visual control of nursing staff and must contain a work counter, sink, refrigerator, and double-locked storage for controlled substances.

007.02(A)(iii) CLEAN STORAGE AND UTILITY ROOM. The licensee must have separate areas for soiled and clean materials. The area for soiled materials must contain a fixture for disposing waste and a handwashing sink.

007.02(B) EQUIPMENT AND SUPPLIES. The licensee must have services and space to distribute, maintain, clean and sanitize durable medical instruments, equipment, and supplies required for the care and treatment of residents.

007.02(B)(i) DURABLE MEDICAL EQUIPMENT. The licensee must ensure that durable medical equipment is tested and calibrated in accordance with the manufacturer’s recommendations.

007.02(B)(ii) EQUIPMENT STORAGE. The licensee must have space to store equipment, stretchers, wheelchairs, supplies, and linen out of the path of normal traffic.

007.02(C) REHABILITATIVE. If the licensee provides rehabilitative services, the licensee must have at least 1 treatment room or cubicle, an area for specialized treatment and care, a handwashing sink or sinks, storage for equipment and supplies, a call system, and areas to allow for resident toileting, dressing, and consultation.

007.02(D) MENTAL HEALTH. If the licensee provides a specialized area or unit designated for psychiatric or mental health services, the licensee must have space and equipment that allows for resident and staff safety. The area must have separate quiet and noisy activity areas, dining areas, private and group areas for specialized treatment and care, a handwashing sink or sinks, storage for equipment and supplies, and security systems. In rooms where care and treatment is provided to abusive or suicidal residents, the rooms must have:

(i) Tamper-resistant air distribution devices, lighting fixtures, sprinkler heads, and safety devices; (ii) Ventilation, exhaust, heating, and cooling components that are inaccessible to residents; (iii) Bedroom, toilet, and bathing room doors that are not lockable or capable of being obstructed from within; and (iv) Electrical outlets protected by ground fault interrupting devices.

007.02(E) OUTPATIENT AREAS. Areas designated for the care and treatment of clients not residing in the facility must comply with the following standards:

(i) Areas must not interfere with residents currently residing in the facility; (ii) Furniture and equipment must meet care and treatment needs; (iii) Toilets must be easily accessible from all program areas; and (iv) Sufficient inside and outside space that accommodates the full range of program activities and services.

007.03 CONSTRUCTION STANDARDS. The licensee must be designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of care and treatment to be provided and in compliance with Neb. Rev. Stat. § 71-439, 175 NAC 1, and this chapter.

007.03(A) INTERPRETATIONS. All dimension, sizes, and quantities noted herein must be determined by rounding fractions to the nearest whole number.

007.03(B) FLOOR AREA. Floor area is the space with ceilings at least 7 feet in height and excludes enclosed storage, toilets and bathing rooms, corridors, and halls. The space beyond the first 2 feet of vestibules and alcoves less than 5 feet in width is not included in the required floor area. In rooms with sloped ceilings, at least half of the ceiling must be at least 7 feet in height. Areas less than 5 feet in height are not included in the required floor area.

007.03(C) DINING AREAS. Dining areas must:

(i) Provide for natural light and ventilation; (ii) Be furnished with tables and chairs that accommodate or conform to resident needs; (iii) Have a floor area of 15 square feet per resident in existing facilities and 20 square feet per resident in new construction; (iv) Allow for group dining at the same time in either separate dining areas or a single dining area, dining in 2 shifts, or dining during open dining hours; and (v) Not be used for sleeping, offices, or corridors.

007.03(D) ACTIVITY AREAS. The licensee must have space for resident socialization and leisure time activities. Activity areas must:

(i) Provide for natural light and ventilation; (ii) Have furnishings to accommodate group and individual activities; (iii) Have a floor area of at least 15 square feet per resident residing in bedrooms and may be combined with dining areas; (iv) Not be used for sleeping, offices, or corridors; and (v) Be available to all residents.

007.03(E) BATHING ROOMS. The licensee must have a bathing room consisting of a tub or shower adjacent to each bedroom, or a central bathing room on each sleeping floor. Tubs and showers, regardless of location, must be equipped with hand grips or other assistive devices as needed by the resident.

(i) In new construction where a central bathing room is provided, the room must open off the corridor and contain a toilet and sink or have an adjoining toilet room; and (ii) The licensee must have 1 bathing fixture per 30 licensed beds.

007.03(F) TOILET ROOMS. Existing facilities must have a toilet and sink adjoining each bedroom or shared toilet facilities may be provided as follows:

(i) 1 toilet and sink per 8 licensed beds in existing facilities; (ii) 1 toilet and sink per 4 licensed beds in new facilities and new construction; and (iii) New construction must have a toilet room provided adjoining each resident bedroom or in each apartment or dwelling.

007.03(G) RESIDENT ROOM REQUIREMENTS. The licensee must have bedrooms which allow for sleeping, afford privacy, provide access to furniture and belongings, and accommodate the care and treatment provided to the resident.

007.03(G)(i) RESIDENT BEDROOMS. All resident bedrooms must:

(1) Not be located in any garage, storage area, shed, or similar detached building; (2) Be a single room located within an apartment, dwelling, or dormitory-like structure; (3) Not be accessed through a bathroom, food preparation area, laundry, or another bedroom; (4) Have a window with an unobstructed view of at least 10 feet; (5) Contain at least 45 cubic feet of enclosed storage volume per resident in dressers, closets or wardrobes; (6) Be located within 150 feet of a control point if nursing services are provided in the room; and (7) Allow for an accessible arrangement of furniture providing a minimum of 3 feet between the heads of the beds in multiple bedrooms.

007.03(G)(ii) EXISTING OR NEW FACILITY FLOOR AREAS. Resident bedrooms in an existing building and in new facilities must have at least the following floor areas:

(1) Single bedrooms: 100 square feet; (2) Multiple bedrooms: 80 square feet with a maximum of 4 beds; or (3) Apartments or dwellings: 110 square feet for 1 resident plus 100 square feet for each additional resident.

007.03(G)(iii) NEW CONTSTRUCTION FLOOR AREAS. Resident bedrooms in new construction must have at least the following floor areas:

(1) Single bedrooms: 120 square feet; (2) Multiple bedrooms: 100 square feet per bed with a maximum of 2 beds; or (3) Apartments or dwellings: 120 square feet for 1 resident plus 110 square feet for each additional resident.

007.03(H) ISOLATION ROOMS. Number and type of isolation rooms in the facility must be based upon infection control risk assessment of the facility.

(i) The licensee must make provisions for isolating residents with infectious diseases; and (ii) In new construction, if the licensee has a designated isolation room, the isolation room must be equipped with handwashing and gown changing facilities at the entrance of the room.

007.03(I) EXAMINATION ROOMS. Must have a minimum floor area of 80 square feet and a minimum of 3 feet clear dimension around 3 sides of the examination table or chair.

007.03(J) TREATMENT ROOMS. Treatment rooms used for procedures performed under topical, local, or regional anesthesia without pre-operative sedation, must have a minimum floor area of 120 square feet and a minimum of 10 feet clear dimension.

007.03(K) CORRIDORS. Corridors must be wide enough to allow passage and be equipped as needed for the residents to minimize injury. All stairways and ramps must have handrails.

007.03(L) DOORS. Doors must be wide enough to allow passage and be equipped for privacy, safety, and with assistive devices to minimize resident injury.

(i) Bedroom, toilet, and bathing room doors must provide privacy yet not create seclusion or prohibit staff access for routine or emergency care; and (ii) In new construction, all resident-used toilet and bathing rooms with less than 50 square feet of clear floor area must not have doors that swing solely inward.

007.03(M) OUTDOOR AREAS. The licensee must have an outdoor area for resident usage. It must be equipped and situated to allow for resident safety and abilities.

007.03(N) HANDWASHING SINKS. The licensee must have a handwashing sink equipped with towel and soap dispenser in all examination, treatment, isolation, and toilet rooms.

007.03(O) EMERGENCY TELEPHONE. The licensee must provide a non-coin operated telephone or telephones with emergency numbers for use by residents.

007.03(P) PRIVACY. Multiple bed resident rooms, visual privacy and window curtains must be provided for each resident. In new facilities, the curtain layout must totally surround each care and treatment location and not restrict access to the entrance to the room, lavatory, toilet, or enclosed storage.

007.03(Q) FINISHES. The licensee must have washable room finishes in isolation rooms, clean workrooms, and food preparation areas with smooth non-absorptive surfaces that are not physically affected by routine housekeeping cleaning solutions and methods. Acoustic lay-in ceilings, if used, must not interfere with infection control. Perforated, tegular, serrated cut, or highly textured tiles are not acceptable.

007.04 BUILDING SYSTEMS. Licensees must have building systems that are designed, installed, and maintained to remain operational.

007.04(A) WATER AND SEWER SYSTEMS. A licensee must have an accessible, adequate, safe, and potable supply of water and a sanitary and functioning sewage system that is maintained in compliance with applicable federal and state statutes and regulations.

007.04(B) HOT AND COLD-WATER SYSTEM. Hot and cold water must be provided to all handwashing and bathing locations. The hot water system must have the capacity to provide continuous hot water in a temperature range as required by 175 NAC 1.

007.04(C) HEATING AND COOLING SYSTEMS. The licensee must have a heating and air conditioning system capable of maintaining the following:

(i) In existing and new facilities, a temperature of at least 70 degrees Fahrenheit during heating conditions and that does not exceed 85 degrees Fahrenheit during cooling conditions; (ii) In new construction, a temperature of at least 75 degrees Fahrenheit during heating conditions and that does not exceed 80 degrees Fahrenheit during cooling conditions; (iii) Airflow must move from clean to soiled locations. In new construction, air movement must be designed to reduce the potential of contamination of clean areas; and (iv) Openings to the heating and cooling system must not be located where subject to wet cleaning methods or body fluids.

007.04(D) VENTILATION SYSTEM. The licensee must have ventilation that prevents the concentrations of contaminants that impair health or cause discomfort to residents and employees.

007.04(E) ELECTRICAL SYSTEM. The licensee must have an electrical system that has sufficient capacity to maintain care and treatment services provided. The electrical system must be properly grounded. Light levels are measured at 30 inches above the floor in multiple areas in the room being evaluated and the readings are averaged. The facility must have minimum illumination levels as follows:

(i) General purpose areas: 5-foot candles; (ii) General corridors and resident living areas: 10-foot candles; (iii) Personal care and dining areas: 20-foot candles; (iv) Reading and activity areas: 30-foot candles; (v) Food preparation areas: 40-foot candles; (vi) Hazardous work surfaces: 50-foot candles; (vii) Care and treatment locations: 70-foot candles; (viii) Examination task lighting: 100-foot candles; and (ix) Reduced night lighting in resident rooms where nursing services are provided and resident-used toilet and bathing rooms and corridors.

007.04(F) ESSENTIAL POWER SYSTEM. The licensee must have an emergency power generator for any care and treatment location with electrical life support equipment. Existing and new facilities must maintain emergency power for essential care and treatment equipment and lighting, medical gas systems, and nurse call systems.

(i) In facilities constructed on or after the effective date of this chapter, emergency power must be provided for essential care and treatment equipment, lighting, nurse call systems, ventilation, heating, and medical gas systems; and (ii) Facilities with electrical life support equipment must have an essential power system with an on-site fuel source. The minimum fuel source capacity must allow for non-interrupted system operation.

007.04(G) CALL SYSTEMS. The licensee must have a call system that is operable from resident beds, resident-used toilet and bathing areas, and examination and treatment areas. The system must transmit a receivable (visual, audible, tactile, or other) signal to on-duty staff which readily notifies and directs the staff to the location where the call was activated.

007.04(H) MEDICAL GAS SYSTEM. The licensee must safely provide medical gas and vacuum by means of portable equipment or building systems as required by residents receiving care and treatment.

History

Effective 2024-05-29

Chapter 14 Home Health Agencies

Neb. Admin. Code tit. 175, ch. 14 Home Health Agencies {#sec-175-nac-14 omnilex-key=us-ne-regs-official--title-175--175 NAC 14}

001. SCOPE AND AUTHORITY. These regulations govern licensing of home health agencies under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479.

002. DEFINITIONS. Definitions set out in the Health Care Facility Licensure Act, the Uniform Credentialing Act, the Medication Aide Act, 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.

002.01 ABUSE Any knowing, intentional, or negligent act or omission on the part of a person which results in physical abuse, sexual abuse, verbal abuse, or mental abuse, unreasonable confinement, cruel punishment, exploitation, or denial of care, treatment, or services to a consumer.

002.02 BRANCH OFFICES. Those locations from which the parent home health agency has been approved by the Department to provide the same full range of care, treatment, and services provided by the parent home health agency issued the license within a portion of the total approved geographic area served by the parent home health agency. Branch offices are a part of the parent home health agency and share administration, supervision, and services with the parent home health agency on a daily basis.

002.03 CAREGIVER. Has the same meaning as caretaker found in Neb. Rev. Stat. § 71-6721.

002.04 CERTIFIED SOCIAL WORKER. An individual who holds an active master social worker certificate issued by the Department.

002.05 CHEMICAL RESTRAINT. A psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms.

002.06 CONSUMER’S RESIDENCE. The actual place of temporary or permanent residence of a person, used as that person’s home, other than a hospital or nursing home.

002.07 DEVICE. An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is prescribed by a medical practitioner and dispensed by a pharmacist or other person authorized by law to do so.

002.08 DIALYSIS. The process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood. Types of dialysis include hemodialysis and peritoneal dialysis.

002.09 DIRECT SUPERVISION. The responsible practitioner is physically present in the consumer care, treatment and service area and is available to assess, evaluate and respond immediately. Direct supervision does not mean the responsible practitioner must be in the same room or looking-over-the-shoulder of the staff providing care, treatment, or services to the consumer.

002.10 EXPLOITATION. The taking of property of a consumer by means of undue influence, breach of a fiduciary relationship, deception, or extortion or by any unlawful means.

002.11 FULL-TIME BASIS. Provision of services for a continuous 24-hour period.

002.12 GEOGRAPHIC AREA SERVED. Includes all counties pre-approved by the Department where the home health agency can provide care, treatment, and services. Counties must be contiguous with the county where the parent home health agency is located.

002.13 HOME. The consumer’s permanent or temporary residence, other than a hospital or a nursing home.

002.14 HOME CARE EQUIPMENT AND SUPPLIES. Equipment or supplies used in the consumer’s home and needed by the consumer to maintain the consumer’s highest level of function in the home.

002.15 HOME HEALTH AIDE SERVICES. The use of a trained, supervised paraprofessional to provide one or more of the following: personal care, assistance with activities of daily living, or basic therapeutic care to consumers of a home health agency.

002.16 INTERMITTENT BASIS. The provision of services for less than 4 hours in any 24-hour period.

002.17 INTRAVENOUS THERAPY. Initiating and monitoring therapy related to substances that are administered intravenously.

002.18 MEDICALLY FRAGILE PERSON. An individual whose medical condition is unstable, requires medical or nursing judgment, and whose physical status may or may not be frail or fragile.

002.19 MEDICATION REMINDERS. Verbal reminders to a person to take the person’s medication which does not include touching or handling of the medication or the container where the medication is stored. Medication reminders do not include administration or provision of medication as defined in the Medication Aide Act and 172 NAC 95 and 96.

002.20 MENTAL ABUSE. Humiliation, harassment, threats of punishment or deprivation, or other actions causing mental anguish.

002.21 NEGLECT. A failure to provide care, treatment, or services necessary to avoid physical harm or mental anguish of a consumer.

002.22 PARENT HOME HEALTH AGENCY. The home health agency issued the license and is responsible for consumer admissions; care, treatment, and services provided to consumers; implementation of the plan of care; and ensuring administrative and supervisory control of its branch offices.

002.23 PART-TIME BASIS. The provision of services for less than 24 hours but more than 4 hours in any 24-hour period.

002.24 PHYSICAL ABUSE. Hitting, slapping, pinching, kicking, or other actions causing injury to the body.

002.25 PHYSICAL RESTRAINT. Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the consumer’s body that the consumer cannot remove easily and that restricts freedom of movement or normal access to the consumer’s own body.

002.26 PRACTITIONER. A nurse practitioner, osteopathic physician, physician, or physician assistant.

002.27 SEXUAL ABUSE. Sexual harassment, sexual coercion, or sexual assault.

002.28 STAFF. An individual who is a direct or contracted employee of the home health agency.

002.29 SUPERVISION. The authoritative guidance which is given by a qualified person of the appropriate discipline. Supervision includes initial direction and periodic indirect and direct monitoring of services.

002.30 THERAPEUTIC SERVICE. Any or all of the following services: skilled nursing care; physical therapy; speech-language pathology; occupational therapy; respiratory care; home health aide services; social work services; intravenous therapy; and dialysis.

002.31 VERBAL ABUSE. The use of oral, written, or gestured language including disparaging or derogatory terms to consumers or within their hearing distance of the consumer or within the consumer’s sight.

003. LICENSING REQUIREMENTS. To receive a license, an applicant or licensee must submit a complete application, must meet the service and staffing requirements shown below, and must meet all requirements set out in statute, in 175 NAC 1-003, and in this chapter.

003.01 INITIAL LICENSURE FEES. The fees for home health agencies are set out below:

(A) Initial License $650.

003.02 RENEWAL LICENSURE FEES. The fees for renewal of a home health agency license are set out below:

(A) 1 to 50 unduplicated consumer admissions in the past year $650; (B) 51 to 200 unduplicated consumer admissions in the past year $850; and (C) 201 or more unduplicated consumer admissions in the past year $950.

003.03 SERVICES AND STAFFING. The home health agency must:

(A) Be primarily engaged in providing skilled nursing care or a minimum of 1 other therapeutic service including physical therapy, speech-language pathology, occupational therapy, respiratory care, home health aide services, social work services, intravenous therapy, or dialysis. These services must only be provided in approved counties; (B) Only accept a consumer for admission to the agency when the agency can meet the consumer’s needs for care, treatment, and services; (C) Be responsible for coordination of all consumer services, the agency agrees to provide for the consumer, when the agency provides more than one service to a single consumer; (D) Assure when services are provided under arrangement with another entity, agency or with an individual, such services must be subject to a written contract conforming to the requirements of 175 NAC 14; and (E) Assure a supervising registered nurse is available or on call to the staff during all hours that skilled nursing care, home health aide services, or any combination of these services are provided for consumers.

004. INSPECTIONS. The licensee must be available for unannounced, onsite inspections at the parent and branch locations during all hours of care, treatment, and services are provided for consumers and during business hours required for state inspectors.

005. GENERAL REQUIREMENTS. The licensee must meet all requirements shown at 175 NAC 1-005.03 through 1-005.07 and this chapter.

005.01 NOTIFICATIONS. The licensee must:

(A) Meet notification requirements at 175 NAC 1-005.01 (A), (D), (E), (G)(i), (G)(iii); (B) Notify the Department in writing at least 30 working days before the home health agency would like to add a service or branch office; and (C) Notify the Department in writing within 24 hours of a consumer’s death which occurred while staff were present, or scheduled to be present, in the consumer’s home to provide care, treatment, or services and the consumer’s death was due to:

(i) Suicide; (ii) A violent act; (iii) Drowning; or (iv) During or immediately after a restraint or seclusion was utilized.

005.02 EFFECTIVE DATE AND TERM OF LICENSE. The home health agency license expires on January 31 of each year.

005.03 CHANGE OF OWNERSHIP OR PREMISES. Change of ownership terminates the license. Change of premises does not terminate the license of a home health agency.

005.04 BRANCH OFFICES. The parent home health agency is responsible for all care, treatment, and services provided at the parent and branch locations. All deficient practices cited at any home health agency branch or parent location apply to all locations under that licensee’s home health agency license. A branch office is not required to independently meet licensure requirements but must meet supervision requirements for branch offices as shown below. Branch offices must:

(A) Be approved by the Department before becoming operational; (B) Provide the same full range of care, treatment, and services provided by the parent home health agency issued the license within a portion of the total approved geographic area served by the parent home health agency; (C) Be part of the parent home health agency and share administration, supervision, and services with the parent home health agency on a daily basis; (D) Be located sufficiently close to the parent home health agency to share administration, supervision, and services with the parent home health agency on a daily basis; (E) Have onsite supervisory visits by the home health agency administrator or the administrator’s designated person of the parent home health agency at least once a month with documentation of these supervisory visits being maintained at the parent home health agency location; (F) Maintain copies of all agency policies, procedures, and forms at the branch location; (G) Maintain complete clinical records for all branch consumer’s care, treatment, and services; and (H) Maintain in the parent home health agency for all consumers receiving services from branch offices the following:

(i) Consumer identifying information; (ii) Name, address, and telephone number of consumer’s practitioner; (iii) Consumer diagnosis; (iv) The services being provided to the consumer; and (v) The above information must be maintained until the complete clinical record is either stored at the parent home health agency or can be destroyed.

005.05 SIGNAGE. The licensee must place a sign, on the agency’s entrance door, which contains the agency’s name and physical address as they appear on the home health agency license issued by the Department.

006. CONSTRUCTION. The construction requirements at 175 NAC 1 do not apply to a home health agency.

007. PHYSICAL PLANT. The licensee, when sharing space with another entity that does not have common ownership with the licensee, must ensure the home health agency has a unique physical address to ensure mail is secured against unauthorized access and must ensure a separate entrance to the home health agency space to ensure verbal communications are protected against unauthorized access.

008. RECORDKEEPING. The licensee must meet all recordkeeping requirements at 175 NAC 1 and in this chapter and must prevent unauthorized access to agency records by other entities sharing the space.

009. ENVIRONMENTAL SERVICES. The environmental requirements set out in 175 NAC 1 do not apply to a home health agency.

010. STANDARDS OF OPERATION, CARE, AND TREATMENT. The licensee has the responsibility to determine, implement, and monitor policies that govern the total operation and maintenance of the agency and to assure protection to home health consumers and compliance with state statutes and regulations. All services provided by the licensee must be provided in accordance with the Health Care Facility Licensure Act, the Uniform Credentialing Act, the Medication Aide Act, the regulations adopted under those Acts, medical practitioner orders, the practitioner-approved written plan of care, and prevailing standards of practice.

010.01 LICENSEE. The licensee is responsible for compliance with statutes and regulations, the management, and fiscal affairs of the home health agency and for making written policies and procedures available to staff and consumers. All services are to be provided in accordance with accepted standards of practice. Each employee is to report suspected abuse, neglect, or exploitation of a consumer served by the home health agency in accordance with the Adult Protective Services Act or the Child Protection Act, as applicable, and to the Administrator. The licensee must:

(A) Select and employ an administrator, and a back-up administrator, as described in this chapter; (B) Implement written policies and procedures for the operation and administration of the home health agency which include:

(i) Range of services to be provided; (ii) Approved geographic area served; (iii) Personnel, policies, procedures, and job descriptions for each staff position, which includes minimum qualifications for the position; (iv) Criteria for admission, discharge; and transfer of consumers, which ensures only individuals whose needs can be met by the home health agency staff will be admitted as consumers; (v) A process for authorized staff to obtain and incorporate written and verbal practitioner and other medical practitioner diagnostic, therapeutic, and medication orders into the consumer’s plan of care; (vi) Consumer care policies and procedures; (vii) A process for disposal of controlled drugs maintained in the consumer’s home when those drugs are no longer needed by the consumer or are expired; and (viii) A process for use and removal of records and conditions for release of information;

(C) Maintain documentation demonstrating that the requirements of this chapter are met; and (D) Have records available for inspection and copying by authorized representatives of the Department.

010.02 ADMINISTRATION. The licensee must set out the duties and responsibilities of the administrator in writing. The administrator must report and be directly responsible to the licensee in all matters related to the maintenance, operation, and management of the home health agency. The licensee must organize, manage, and administer resources to assure each consumer admitted for services receives the necessary level of care, treatment, and services in a manner consistent with the consumer’s needs and desires.

010.02(A) ADMINISTRATOR QUALIFICATIONS. The administrator and back-up administrator must:

(i) Be a practitioner holding an active credential under the Uniform Credentialing Act to practice as a practitioner in Nebraska; (ii) Be a registered nurse holding an active credential under the Uniform Credentialing Act to practice as a registered nurse in Nebraska or authority based on the Nurse Licensure Compact to practice as a registered nurse in Nebraska; (iii) Be a Nursing Home Administrator holding an active credential under the Uniform Credentialing Act to practice as a Nursing Home Administrator in Nebraska; or (iv) Be an individual with:

(1) A bachelor’s degree in health care administration, physical therapy, occupational therapy, speech-language pathology, respiratory therapy, or related field; and (2) 2 years or more of full-time work experience in home health care or related health care program.

010.02(B) ADMINISTRATOR RESPONSIBILITIES. The administrator is responsible for the management of the agency to the extent authority is delegated by the licensee. A back-up administrator must be designated in writing to act in the absence of the administrator. The administrator has the following responsibilities:

(i) Ensuring staff’s compliance with all applicable statutes, regulations, and rules; (ii) Overseeing and being responsible for the provision and coordination of consumer care, treatment, and services; (iii) Organizing and directing the agency’s ongoing functions; (iv) Maintaining communication between the licensee and staff; (v) Employing sufficient number of staff with appropriate training and skills to meet consumers’ care, treatment, and service needs identified in consumers’ plan of care and in accordance with job descriptions; (vi) Implementing written personnel policies, job descriptions, and current agency policies and procedures; (vii) Ensuring written policies, procedures and forms are individualized for the home health agency and contain effective dates and revisions dates; (viii) Ensuring the home health agency maintains a copy of all active policies, procedures and forms and are available for staff use; (ix) Ensuring the home health agency maintains a copy of all inactive policies, procedures, and forms for a minimum of 7 years after the document becomes inactive; (x) Ensuring an investigation is completed on suspected abuse, neglect, exploitation, or misappropriation of money or property and take action to prevent recurrence and to protect all agency consumers from or the potential for such until the investigation is completed; (xi) Providing orientation for new staff, scheduled in-service education programs, and opportunities for continuing education of the staff; (xii) Maintaining appropriate personnel and administrative records; (xiii) Ensuring the completion, maintenance, and submission of reports and records as required by the Department; and (xiv) Supervising branch offices. Onsite supervision of branch staff must be provided by the administrator or the administrator’s designated person of the parent home health agency at least once a month. Documentation of these visits must be maintained at the parent home health agency.

010.03 MEDICAL DIRECTOR. A licensee providing respiratory care services through a respiratory care practitioner, must:

(A) Have a medical director; and (B) Meet the requirements in Neb. Rev. Stat. § 38-3214.

010.04 STAFF REQUIREMENTS. The licensee must maintain a sufficient number of staff with the required training and skills to provide the services listed on the agency license and to meet the needs of each consumer accepted for care, treatment, or services in a safe and timely manner.

010.04(A) EMPLOYMENT ELIGIBILITY. Each licensee must maintain evidence of the following:

010.04(A)(i) CRIMINAL BACKGROUND CHECKS. Completed pre-employment criminal background checks for each direct care staff member through a governmental law enforcement agency or a private entity that maintains criminal background information.

010.04(A)(ii) REGISTRY CHECKS. Completed pre-employment checks for each direct care staff for adverse findings on the following Nebraska registries:

(1) Nurse Aide Registry; (2) Adult Protective Services Central Registry; (3) Central Registry of Child Protection Cases; and (4) Sex Offender Registry.

010.04(A)(iii) HIRING DECISIONS. The licensee must:

(1) Determine how to use the criminal background and registry information, except for the Sex Offender Registry and the Nurse Aide Registry, in making hiring decisions; (2) Decide whether employment can begin prior to receiving the criminal background and registry information; and (3) Document any decisions to hire a person with a criminal background or adverse registry findings, except for the Sex Offender Registry and the Nurse Aide Registry. The documentation must include the basis for the decision and how it will not pose a threat to consumer safety or consumer property.

010.04(A)(iv) ADVERSE FINDINGS. The licensee cannot employ a person with adverse findings on the Sex Offender Registry or on the Nurse Aide Registry.

010.04(A)(v) HEALTH STATUS. The licensee must implement written policies and procedures regarding the health status of staff to prevent transmission of disease to consumers. The licensee must complete a health screening for each staff prior to the staff having contact with or providing direct care, treatment, or services for any consumer.

010.04(B) EMPLOYMENT RECORD. A current employment record must be kept for each staff which includes:

010.04(C) ORIENTATION. An orientation program must be provided for all new staff and as needed, for existing staff who are given new assignments. Such training must be documented in the employment record. The orientation program must include:

(i) Job duties and responsibilities; (ii) Organizational structure; (iii) Consumer rights; (iv) Consumer care policies and procedures; (v) Personnel policies and procedures; and (vi) Reporting abuse, neglect, and exploitation in accordance with state law.

010.04(D) TRAINING. All staff must receive training in order to perform job responsibilities and include training to perform particular procedures or to provide specialized care.

010.04(D)(i) RECORDS. The licensee must maintain records of each orientation and other training program, including the signature of staff attending, subject-matter of the training, the names and qualifications of instructors, dates of training, length of training sessions, and any written materials provided.

010.04(E) INDIVIDUALS UNDER HOURLY OR PER-VISIT CONTRACTS. If individuals or entities under hourly or per-visit contracts are utilized there must be a written contract between the licensee and the individual or entity. The licensee must maintain a copy of all active contracts and retain copies of discontinued contracts for seven years after the contract is discontinued. The contract must include:

(i) A statement that consumers are accepted for care only by the parent home health agency; (ii) A description of the services and the manner in which they are to be provided; (iii) A statement that the contractor must conform to all applicable agency policies, including those related to qualifications; (iv) A statement that the contractor is responsible for participating in the development of plans of care; (v) A statement that the services are controlled, coordinated, and evaluated by the parent agency; (vi) The procedures for submitting clinical and progress notes, scheduling consumer care, and continuing periodic consumer evaluations; and (vii) The procedures for determining charges and reimbursement.

010.04(F) SKILLED NURSING CARE. Skilled nursing care must be provided by registered or licensed practical nurses. A registered nurse must be available or on call to the staff during all hours that skilled nursing care is provided.

010.04(F)(i) CRITERIA. Criteria and need for skilled nursing care includes:

(1) Services of such complexity that they can be safely and effectively performed only by or under the supervision of a registered nurse; (2) Services not normally requiring skilled nursing care, but which, because of special medical complications, become skilled nursing care because they need to be performed or supervised by a registered nurse; and (3) The above services when needed to prevent a consumer’s further deterioration or preserve a consumer’s current capabilities even if recovery or medical improvement is not possible.

010.04(F)(ii) PROVIDED BY A REGISTERED NURSE. When skilled nursing care is ordered by a practitioner, the following specific services must be provided by a registered nurse:

(1) Initial nursing assessment visit to a consumer requiring skilled nursing care; (2) Reevaluation of the consumer’s nursing needs; (3) Provision of services requiring specialized nursing skill; (4) Initiation of preventive and rehabilitative nursing procedures; (5) Coordination of services; and (6) Supervision of other nursing personnel.

010.04(F)(iii) PROVIDED BY A REGISTERED NURSE OR LICENSED PRACTICAL NURSE. When skilled nursing care is ordered by a practitioner, the following specific services may be performed by a registered nurse or by a licensed practical nurse if the licensed practical nurse is under the supervision of a registered nurse:

(1) Implementing the plan of care and necessary revisions to the plan of care. A registered nurse must review the plan of care as often as the severity of the consumer’s condition requires, but at least every 62 days; (2) Preparation of clinical and progress notes; (3) Informing the practitioner, and other personnel of changes in the consumer’s conditions and needs; (4) Teaching other nursing personnel; and (5) Teaching the consumer and caregiver for the purpose of meeting nursing and other related needs.

010.04(G) HOME HEALTH AIDE AND MEDICATION AIDE. Each licensee that employs or contracts home health aides or medication aides must meet the following requirements for training and testing prior to providing care and services to consumers and for providing services:

(i) Use only home health aides qualified to provide home health care pursuant to Neb. Rev. Stat. §§ 71-6601 to 71-6615. Any home health aide not acting as such for a period of 3 years must repeat the 75-hour training course; (ii) Provide direction by using an aide care plan and assignment sheet written by a registered nurse and through registered nurse supervision of home health aides. The licensee must ensure a registered nurse is available or on call to the staff during all hours that home health aide or medication aide services are provided. Any other task the licensee chooses to have a home health aide perform must not include a task which requires a credential; (iii) Provide in-service training as required by Neb. Rev. Stat. § 71-6606; (iv) Only allow home health aides to perform acts permitted in Neb. Rev. Stat. § 71-6605; (v) If the licensee uses unlicensed individuals to provide medication the individuals must be registered as a Medication Aide; (vi) Verify and document the competency of all home health aides prior to an aide providing services in a consumer’s home. The competency evaluation items are set out at Neb. Rev. Stat. § 71-6608.01 in subdivisions (1)(b) through (1)(m). All competency evaluations must be performed by a registered nurse through observation and a written or oral examination. A consumer or individual are to be included in the observation portion of the competency evaluation for the requirements in Neb. Rev. Stat. § 71-6608.01 in subdivisions (1)(c), 1(i), 1(i)(i) through 1(i)(vi), (1)(j) and (1)(k). The competency evaluation for the requirements at Neb. Rev. Stat. § 71-6608.01 in subdivisions (1)(a), (1)(b), (1)(d) through (1)(h), (1)(l) and (1)(m) are to be included in the written or oral examination; (vii) Use a home health aide care plan and supervision that meets the requirements in Neb. Rev. Stat. § 71-6607 and which includes:

(1) An initial evaluation visit to each consumer by a registered nurse:

(a) Prior to home health aide services being provided; (b) A written plan of care developed by a registered nurse and approved by the practitioner. The registered nurse is responsible for reviewing the plan as often as the severity of the consumer’s condition requires, and at least every 62 days. If the home health aide provides only personal care or activities of daily living the clinical record does not need to contain a practitioner’s order for the care; and (c) Consumer-specific written instructions for each consumer;

(2) Documentation of each visit made by a home health aide; and

(viii) Ensure each home health aide provides services in accordance with the practitioner-approved written plan of care and the home health aide care plan.

010.04(H) PHYSICAL THERAPY. Physical therapy services must be provided by a physical therapist A physical therapist must make an initial evaluation visit to each consumer for whom the practitioner orders home physical therapy services and must devise a written plan of care for the practitioner’s approval. The physical therapist must review this plan of care as often as the severity of the consumer’s condition requires, but at least every 62 days.

010.04(I) SPEECH-LANGUAGE PATHOLOGY. Speech-language pathology services must be provided by a speech-language pathologist. A speech-language pathologist must make an initial evaluation visit to each consumer for whom the practitioner orders home speech-language pathology services and must devise a written plan of care for the practitioner’s approval. The speech-language pathologist must review this plan of care as often as the severity of the consumer’s condition requires, but at least every 62 days.

010.04(J) OCCUPATIONAL THERAPY. Occupational therapy services must be provided by an occupational therapist. An occupational therapist must make an initial evaluation visit to each consumer for whom the practitioner orders home occupational therapy services and must devise a written plan of care for the practitioner’s approval. The occupational therapist must review this plan of care as often as the severity of the consumer’s condition requires, but at least every 62 days.

010.04(K) RESPIRATORY CARE. A respiratory care practitioner or physician must make an initial evaluation visit to each consumer for whom the practitioner orders home respiratory care services and must devise a written plan of care for the approval of the consumer’s practitioner and the agency’s medical director. The respiratory care practitioner, practitioner along with the agency’s medical director, must review this plan of care as often as the severity of the consumer’s condition requires, but at least every 62 days.

010.04(L) SOCIAL WORK SERVICES. Social work services must be provided by a certified social worker with a master’s or doctoral degree and who has 1 year of social work experience in a health care setting. A certified social worker must make an initial evaluation visit to each consumer for whom the practitioner orders social work services and must devise a written plan of care for the practitioner’s approval. The certified social worker must review this plan of care as often as the severity of the consumer’s condition requires, but at least every 62 days.

010.04(M) DIALYSIS. Home dialysis services must be provided by a registered nurse trained in dialysis. A registered nurse, trained in dialysis, must make an initial evaluation visit to each consumer for whom the practitioner orders dialysis and must devise a written plan of care for the practitioner’s approval. The registered nurse must review this plan of care as often as the severity of the consumer’s condition requires, but at least once every 62 days. Home dialysis services include:

(i) Hemodialysis; and (ii) Peritoneal dialysis.

010.04(N) INTRAVENOUS THERAPY. All intravenous therapy services must be provided by a registered nurse. A registered nurse must make an initial evaluation visit to each consumer for whom the practitioner orders home intravenous therapy and must devise a written plan of care for the practitioner’s approval. The registered nurse must review the plan of care as often as the severity of the consumer’s condition requires, but at least every 62 days. Home intravenous therapy includes, but is not limited to:

(i) Total parenteral nutrition (TPN); (ii) Hydration therapy; (iii) Chemotherapy; (iv) Antibiotic therapy; and (v) Blood and blood products.

010.05 CONSUMER RIGHTS. The licensee must establish a bill of rights that will be equally applicable to all consumers. The licensee must provide the consumer or designee a written notice of the consumer’s rights before providing care, treatment, or services to the consumer Documentation showing the consumer or designee has received and understands the intent of the consumer’s rights must be maintained.

010.05(A) RIGHTS. The consumer must have the right to:

(i) Choose the home health agency that provides his or her care; (ii) Participate in the planning of his or her care and to receive appropriate instructions and education regarding the plan, prior to the care being provided and as changes are made in the plan of care; (iii) Request information about his or her diagnosis, prognosis, and treatment, including alternatives to care and risks involved, in terms consumers and their families or designees can readily understand; (iv) Refuse home health care and to be informed of possible health consequences of this action; (v) Care given without discrimination as to race, color, creed, sex, age, or national origin; (vi) Be admitted for service only if the licensee has the ability to provide safe, professional care at the level of intensity needed and to reasonable continuity of care; (vii) Confidentiality of all records, communications, and personal information; (viii) Review all health records pertaining to the consumer, unless the practitioner has documented otherwise in the medical record; (ix) Receive both an oral and written explanation regarding termination if services are terminated for any reason other than discharge and receive information regarding community resources. Consumers must receive at least a 2 week notice prior to termination of services. When a consumer is discharged by the practitioner’s written order, a 2 week notice is not required. A 2 week notice is not required when consumer services are being terminated based on an unsafe care environment in the consumer’s home, consumer non-compliance with the plan of care, or failure to pay for services rendered; (x) Voice complaints or grievances and suggest changes in service or staff without fear of reprisal or discrimination. Complaints made by the consumer or designee received by the licensee regarding care or treatment must be investigated. The licensee must document both the existence and the resolution of the complaint. The consumer or designee must be informed of the outcome and resolution of the complaint or grievance; (xi) Be fully informed of agency policies and charges for services, including eligibility for third-party reimbursement, prior to receiving care; (xii) Be free of verbal, physical, and psychological abuse and to be treated with dignity; (xiii) Have his or her property treated with respect; and (xiv) Receive information regarding advance directives.

010.05(B) ADVANCE DIRECTIVES. The home health agency must inform and distribute written information to the consumer or designee, in advance, concerning its policies on advance directives, including a description of applicable state law.

010.05(C) IN-HOME ASSESSMENT AND CONSENT. Authorized agents of the Department have the right, with the consent of the consumer or designee, to visit consumer’s homes during the provision of home health services in order to make an assessment of the quality of care being given to consumers.

010.05(C)(i) CONSENT. Consumer or designee whose home is to be visited by an authorized representative of the Department must be notified by the licensee or the Department before the visit, to obtain a verbal consent for the visit. A written consent form clearly stating that the consumer voluntarily agrees to the visit must be presented to and signed by the consumer or designee prior to observation of care or treatment by the Department representative. The licensee must arrange this visit.

010.05(C)(ii) RIGHT TO REFUSE. All consumers have the right to refuse to allow an authorized representative of the Department to enter his or her home for the purposes of assessing the provision of home health services.

010.06 CONSUMER CARE, TREATMENT, AND SERVICES. Home health services must include but are not limited to:

(A) A practitioner’s order for care, treatment, or services to be provided in the consumer’s home; (B) A consumer’s care must follow a written plan of care devised by a registered nurse or qualified professional of the appropriate discipline after an initial visit to the consumer’s home;

(i) The plan of care must be approved by the consumer’s practitioner; and (ii) The plan of care must be reviewed periodically by a registered nurse or other qualified professional of the appropriate discipline as often as the severity of the consumer’s condition requires, but at least every 62 days;

(C) A licensee that provides more than one service to a single consumer must be responsible for coordination of those services to assure that the services effectively complement one another and support the objectives in the plan of care; and (D) A written summary report of the care, treatment, and services provided to the consumer must include pertinent facts from the clinical notes and progress notes and must be sent to the consumer’s attending practitioner as often as the severity of the consumer’s condition requires, but at least every 62 days.

010.07 ADMINISTRATION OR PROVISION OF MEDICATIONS. Consumers must receive medications only as legally prescribed by a medical practitioner, in accordance with the practitioner-approved plan of care, the 5 rights, and prevailing professional standards.

010.07(A) METHODS OF ADMINISTRATION. When the licensee is responsible for the administration of medications, it must be accomplished by the following methods:

010.07(A)(i) SELF-ADMINISTRATION OF MEDICATIONS. Consumers must be allowed to self-administer medications, with or without supervision, when the licensee determines that the consumer is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner. The licensee must implement written policies to address consumer self-administration of medication, including:

(1) Storage and handling of medications; (2) Inclusion of the determination that the consumer may self-administer medication in the consumer plan of care; and (3) Monitoring the plan to assure continued safe administration of medications by the consumer.

010.07(A)(ii) LICENSED HEALTH CARE PROFESSIONAL. When the licensee uses a licensed health care professional for whom medication administration is included in the scope of practice, the licensee must ensure the medications are properly administered in accordance with prevailing professional standards and state and federal law.

010.07(A)(iii) PROVISION OF MEDICATION BY A PERSON OTHER THAN A LICENSED HEALTH CARE PROFESSIONAL. When the licensee uses a person other than a licensed health care professional in the provision of medications, the licensee must use individuals who are registered medication aides and must comply with the Medication Aide Act and 172 NAC 95 and 96.

010.07(A)(iv) MAINTAIN OVERALL SUPERVISION, SAFETY, AND WELFARE OF CONSUMERS. When the licensee is not responsible for medication administration and provision, the licensee retains responsibility for overall supervision, safety, and welfare of the consumer.

010.07(B) ADVERSE REACTIONS AND MEDICATION ERRORS. Each licensee must report any adverse reactions to a medication by the consumer and any medication errors in administration or provision of prescribed medications to the consumer’s practitioner immediately upon discovery. A written report of the adverse reaction and medication error must be completed immediately upon discovery and kept in the consumer’s record. Errors include any variance from the 5 rights or the prescription.

010.08 RECORDKEEPING REQUIREMENTS. Licensee must have a clinical record for each consumer and provide relevant information from this clinical record to the personnel providing services in the consumer’s home. A licensee must maintain and safeguard consumer rosters and clinical records from unauthorized use, loss, and unintended destruction.

010.08(A) CONTENT. The clinical record must contain sufficient information to identify the consumer clearly, to justify the diagnosis, care, treatment, and services, and to document the results of care, treatment, and services accurately. The licensee must provide pertinent current and past medical history to the licensed personnel providing services on its behalf. All clinical records must contain the following:

(i) Identification data and consent forms; (ii) The name and address of the consumer’s physician, or physicians and practitioners; (iii) The practitioner’s signed order for home health care and the practitioner approved plan of care, must include, when appropriate to the services being provided:

(1) Medical diagnosis; (2) Medication orders; (3) Dietary orders; (4) Activity orders; and (5) Safety orders;

(iv) Initial and periodic assessments and care plan by disciplines providing services; (v) Signed and dated admission, observation, progress, and supervisory notes; (vi) Copies of written summary reports sent to the practitioner; (vii) Diagnostic and therapeutic orders signed by the practitioner; (viii) Reports of treatment and clinical findings; and (ix) Discharge summary report.

010.08(B) CENTRALIZED. All clinical information pertaining to the consumer’s care must be centralized in the consumer’s clinical record maintained by the parent home health agency or by a branch of the home health agency.

010.08(C) TIMELY ENTRIES. Entries into the consumer’s clinical record for care, treatment, and services provided must be written within 24 hours and incorporated into the consumer’s clinical record within 7 working days. When a Medication Administration Record (MAR) is used by the home health agency, entries into the consumer’s Medication Administration Record (MAR) must be made by the staff member who administered or provided the medication to the consumer immediately after administration or provision of the medication and incorporated into the consumer’s clinical record within 7 working days.

010.08(D) PROVIDER INDENTIFICATION. Entries must be made by the person providing services, must contain a statement of facts personally observed, and must be signed with full name. Initials may be used if identified in the clinical record.

010.08(E) VERBAL ORDERS. All practitioner’s verbal orders for care, treatment, services, and medications must be signed and incorporated into the clinical record within 30 days.

010.08(F) SECURED. Clinical records must be secured in locked storage and electronic records must be password protected. consumer’s or legal designee’s written consent must be required for release of information not otherwise authorized by law.

010.08(G) CONSUMER ROSTER. The licensee must maintain a daily consumer roster which clearly identifies all consumers scheduled and accepted for care, treatment, or services by the agency. The consumer roster must include information necessary to identify each consumer and the care, treatment, and services to be provided by the agency.

010.08(H) CONSUMER TRANSFERS. If a consumer is transferred to another health care facility or agency, information necessary or useful in care and treatment of the consumer must be promptly forwarded in writing to the appropriate facility or agency with the consent of the consumer or the consumer’s legal designee.

History

Effective 2024-05-05

Chapter 15 Respite Care Service

Neb. Admin. Code tit. 175, ch. 15 Respite Care Service {#sec-175-nac-15 omnilex-key=us-ne-regs-official--title-175--175 NAC 15}

001. SCOPE AND AUTHORITY. These regulations govern licensing of respite care services under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479.

002. DEFINITIONS. Definitions set out in the Health Care Facility Licensure Act, 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.

002.02 AGREEMENT OF PARTICIPATION. A written agreement negotiated between the respite care service and the consumer served or designee.

002.03 CAREGIVER. A caregiver, for the purpose of this chapter, has the same meaning as caretaker found in Neb. Rev. Stat. § 71-6721.

002.05 EVALUATION. A written action plan based on the identified needs of the consumer and the strategy for providing care to meet those needs.

002.06 EXPLOITATION. The taking of property of a consumer by means of undue influence, breach of a fiduciary relationship, deception, or extortion or by any unlawful means.

002.07 FOOD CODE. As defined in Neb. Rev. Stat. § 81-2,244.01 and as published by the Nebraska Department of Agriculture, except for compliance and enforcement provisions.

002.08 FREE-STANDING RESPITE CARE SERVICE FACILITY. The physical location where respite care services are provided, other than the consumer or caregiver’s home is a free-standing respite care service facility.

002.09 MENTAL ABUSE. Humiliation, harassment, threats of punishment or deprivation, or other actions causing mental anguish.

002.10 NEGLECT. A failure to provide care, treatment, or services necessary to avoid physical harm or mental anguish of a consumer.

002.11 PHYSICAL ABUSE. Hitting, slapping, pinching, kicking, or other actions causing injury to the body.

002.12 SERVICE PLAN. A written action plan based on evaluation and assessment data that identifies the consumer’s needs and the strategy for addressing care, treatment, and services to meet those needs within the scope of the respite care service.

002.13 SEXUAL ABUSE. Sexual harassment, sexual coercion, or sexual assault.

002.14 SUPERVISION. The daily observation and monitoring of the consumer by direct care staff and oversight of staff by the Administrator or Administrator’s designee.

002.15 5 RIGHTS. The meaning found in Neb. Rev. Stat. § 71-6721.

003. LICENSING REQUIREMENTS. For all applications for initial licensure, renewal and reinstatement, an applicant or licensee must meet all requirements at 175 NAC 1-003, except for those items as shown below, must meet the setting requirements as shown below, and must include the licensure fees as shown below.

003.01 RESPITE CARE SERVICE SETTINGS. Respite care services may be provided in the following settings:

(A) The home of the consumer; (B) The home of the caregiver or designee; or (C) A site that serves as a free-standing respite care service facility.

003.02 APPLICATION EXCEPTIONS. When respite care services are provided in the home of the consumer, caregiver or designee, the items shown at 175 NAC 1-003.02 are not required as part of the application.

003.03 INITIAL AND RENEWAL LICENSURE FEES. The fees for respite care services are set out below:

(A) Programs that provide service through volunteers $50 (B) Programs with license capacity of 8-16 $250 (C) Programs with license capacity of 17-50 $350 (D) Programs with license capacity of 51 and up $450

004. INSPECTIONS. When respite care services are provided in the home of the consumer, caregiver, or designee, the physical plant inspection requirements at 175 NAC 1-004 do not apply.

005. GENERAL REQUIREMENTS. The following requirements are applicable to all licensees.

005.01 NOTIFICATIONS. Notification requirements for respite care services include:

(A) A Free-standing respite care service facility is only required to meet notification requirements at 175 NAC 1-005 (A), (D), (E), (F), (G)(i) through (G)(v), and must notify the Department in writing at least 30 working days before the facility would like to increase license capacity, would like a change in the building, would like a change in location, or would like a change in the usage of the building; and (B) A respite care service providing care, treatment or services in the home of the consumer, caregiver or designee, is only required to meet notification requirements at 175 NAC 1-005 (A), (D), (E), (G)(i), (G)(iii), must notify the Department in writing at least 30 working days before the facility would like to increase license capacity or would like a change in location, and must notify the Department in writing within 24 hours of a consumer’s death which occurred while staff were providing, or scheduled to be providing, respite care services and the consumer’s death was due to:

(i) Suicide; (ii) A violent act; (iii) Drowning; or (iv) During or immediately after a restraint or seclusion was utilized.

005.02 EFFECTIVE DATE AND TERM OF LICENSE. A respite care service license expires on October 31 of each year.

005.03 CHANGE OF OWNERSHIP. Change of ownership or premises terminates the license. If there is a change of ownership and the respite care service remains on the same premises, the inspection in 175 NAC 1-004 and 175 NAC 15-004 is not required. If a respite care service changes premises, it must pass the inspection specified in 175 NAC 1-004 and 175 NAC 15-004.

005.04 OCCUPANCY. A free-standing respite care service must not serve more consumers at one time than the maximum occupancy for which the respite care service is licensed.

006. CONSTRUCTION. When respite care services are provided in the home of the consumer, caregiver, or designee, the construction requirements at 175 NAC 1-006 do not apply.

007. PHYSICAL PLANT. A free-standing respite care service must meet all requirements shown at 175 NAC 1-007 and the additional requirements below. When respite care services are provided in the home of the consumer, caregiver, or designee, the physical plant requirements at 175 NAC 1-007 and 175 NAC 15-007 do not apply.

007.01 ENVIRONMENTAL SERVICES. A licensee operating a free-standing respite care service facility must maintain a safe, clean, comfortable environment. Every detached building on the same premises used for care must comply with these regulations.

007.02 LINENS. Linens must be provided and maintained in good repair. A written policy must be implemented and revised, as necessary, to provide for the safe storage and handling of soiled and clean linens.

007.03 FOOD SERVICE. If food preparation is provided on site there must be dedicated space and equipment for the preparation and serving of meals. Such food preparation, serving, physical environment, and equipment must comply with the Food Code.

007.04 DESIGNED AND EQUIPPED. A site must be designed to meet the needs of consumers served. The licensee should consider factors such as appropriate and sufficient space, accessibility, equipment, furnishings, lighting, noise control, room temperatures, and ventilation.

007.05 LAUNDRY. If laundry services are provided the service may be provided by contract or on-site.

(A) CONTRACT. If contractual laundry services are used, areas for soiled linen awaiting pickup and separate areas for storage and distribution of clean linen must be provided and used. (B) ON-SITE. If on-site laundry services are provided, areas dedicated to laundry that include a washer and dryer must be provided. In new construction, the licensee must provide a conveniently located sink for soaking and hand washing of laundry.

007.06 CONSUMER LIVING AREAS. Living areas must have beds, chairs, sofas, tables, and storage items that are comfortable and reflective of individual needs. A garage, barn, shed, or similar structure cannot be a consumer living area.

007.07 DINING AREAS. Adequate space for dining, socialization, and leisure activities must be provided.

007.08 BEDROOMS. If care is provided to individuals that exceeds 24 hours, consumer bedrooms must be provided and allow for sleeping, afford privacy, provide access to belongings, provide adequate storage, and accommodate the care provided to the consumer.

007.09 TOILET ROOMS. Toilet rooms with hand washing sinks that are adequate to meet the needs of the consumers served must be provided.

007.10 BATHING ROOMS. If care is provided to an individual exceeding 24 hours, a bathing room that is adequate to meet the needs of the consumer must be available. When provided, the bathing room must have a tub or shower. Tubs and showers used by consumers must be equipped with handgrips or other assistive devices as needed by the consumer.

007.11 ADDITIONAL SERVICES. If additional medical or therapy services are provided there must be adequate space to assure privacy and appropriate care.

007.12 OUTDOOR AREAS. Any outdoor area for consumer usage must be equipped and situated for consumer safety and abilities.

008. RECORDKEEPING. All licensees must establish, implement, and update, as necessary, policies, procedures, and processes for recordkeeping.

009. ENVIRONMENTAL SERVICES. All licensees operating a free-standing respite care service must establish, implement, and update, as necessary, policies, procedures, and processes for environmental services.

010. STANDARDS OF OPERATION AND CARE. To provide adequate protection to consumers and to be in compliance with state statutes, all respite care services must meet the following requirements:

010.01 LICENSEE. The licensee must determine, implement, and monitor policies to assure that the service is administered and managed appropriately. The licensee’s responsibilities include:

(A) Maintain the respite care service’s compliance with all applicable state statutes and relevant rules and regulations; (B) Ensure the quality of all services and care provided to consumers, whether furnished by the respite care service staff or through contract with the respite care service; (C) Ensuring consumers are provided with a stable and supportive environment, through respect for the rights of consumers and responsiveness to consumer needs; (D) Ensuring that staff levels are sufficient to meet the consumers’ needs; (E) Monitoring policies and procedures to assure the appropriate administration and management of the respite care service; and (F) Designating an administrator who is responsible for the day-to-day management of the respite care service and defining the duties and responsibilities of the Administrator in writing.

010.02 ADMINISTRATOR. The licensee must designate an administrator and a backup administrator to be in charge of the day-to-day operation of the respite care service. In a free-standing respite care service site, the administrator or backup administrator must be onsite during the hours of operation. The administrator is responsible for planning, organizing, and directing the day-to-day operation of the respite care service. The administrator must report all matters related to the maintenance, operation, and management of the respite care service and be directly responsible to the licensee or to the person, or persons, delegated governing authority by the licensee. The administrator’s responsibilities include:

(A) Being responsible for the respite care service’s compliance with rules and regulations; (B) Being responsible for the respite care service’s promotion of consumer self-direction and participation in decisions which incorporate independence, individuality, privacy, and dignity; (C) Maintaining sufficient number of staff with appropriate training and skills to meet consumers’ needs as defined in the consumer’s agreement of participation and service plan; (D) Providing written personnel policies, job descriptions, and current service policies and procedures all of which are consistent with prevailing professional and practice standards and that are made available to all personnel; (E) Maintaining personnel and administrative records; (F) Providing orientation for new staff, schedule in-service education programs and opportunities for continuing education for the staff; (G) Designating a backup administrator to act in the administrator’s absence who must be responsible for and accountable for management of the respite care service; (H) Monitoring that agreements of participation and service plans are established, implemented, and revised, as necessary, to meet the consumers’ needs; (I) Monitoring staff, including contracted staff, identify and review incidents and accidents, consumer complaints and concerns, patterns, and trends in overall operation such as provisions of consumer care, treatment, and service, and take action to alleviate problems and prevent recurrence; (J) Developing procedures that require the reporting of any evidence of abuse, neglect or exploitation of any consumer served by the respite care service in accordance with Neb. Rev. Stat. § 28-372 of the Adult Protective Services Act or in the case of a person under the age of 18, in accordance with Neb. Rev. Stat. § 28-711; (K) Ensuring an investigation is completed on suspected abuse, neglect, exploitation, or misappropriation of money or property and take action to prevent recurrence until the investigation is completed; (L) Ensuring written policies, procedures and forms are individualized for the respite care service and contain effective dates and revisions dates; (M) Ensuring the respite care service maintains a copy of all active policies, procedures and forms which are available for staff use; and (N) Ensuring the respite care service maintains a copy of all inactive policies, procedures, and forms for a minimum of 7 years after the document becomes inactive.

010.03 STAFF REQUIREMENTS. A sufficient number of staff with the required training and skills necessary to meet the consumers’ requirements for assistance or provision of personal care, activities of daily living, health maintenance activities, supervision, and support health and safety must be maintained. Care to consumers must be provided in a safe and timely manner.

010.03(A) EMPLOYMENT ELIGIBILITY. Each licensee must maintain evidence of the following:

010.03(A)(i) CRIMINAL BACKGROUND CHECKS. Complete pre-employment criminal background checks are done on each direct care staff member through a governmental law enforcement agency or a private entity that maintains criminal background information.

010.03(A)(ii) REGISTRY CHECKS. A check is completed for each direct care staff for adverse findings on the following Nebraska registries:

(1) Nurse Aide Registry; (2) Adult Protective Services Central Registry; (3) Central Register of Child Protection Cases; and (4) Sex Offender Registry.

010.03(A)(iii) HIRING DECISIONS. The licensee must:

010.03(A)(v) HEALTH STATUS. Written policies and procedures must be implemented and revised, as necessary, regarding the health status of staff to prevent transmission of disease to consumers. The licensee:

(1) Must complete a health screening for each staff person prior to the staff person having contact with or providing direct care, treatment, or services for consumers; and (2) May, in its discretion, based on the health screening, require a staff person to have a physical examination.

010.03(B) STAFF TRAINING. The licensee must provide staff with sufficient training to meet consumer needs for care.

010.03(B)(i) ORIENTATION. The licensee must provide staff with orientation prior to staff having direct responsibility for care and services to consumers. The training must include:

(1) Job duties and responsibilities; (2) Consumer rights; (3) Consumer service agreements; (4) Infection control practices including hand washing techniques, personal hygiene, and disposal of infectious material; (5) Information on any physical and mental special care needs of the consumers; (6) Emergency procedures and information regarding advance directives; (7) Information on abuse, neglect, and misappropriation of money or property of a consumer and reporting procedures; and (8) Disaster preparedness plans.

010.03(B)(ii) ONGOING TRAINING. Ongoing in-services or continuing education for staff must be provided. A record of such education must be maintained and include the date of the training, the topic, and participants.

010.03(C) EMPLOYMENT RECORD. A current employment record must be maintained for each staff person. The record must contain at a minimum, information on orientation, in-services, employment eligibility information, and health history screening.

010.03(D) STAFFING RESOURCES. Written policies and procedures must be implemented and revised, as necessary, to provide appropriate supervision of consumers. Staffing resources and training must be sufficient to meet the level of supervision and provision of care, treatment, and services necessary to meet the consumers’ needs and are provided in a safe and timely manner. Services must meet the needs of the consumer and be provided in accordance with instructions and directions from the caregiver.

010.03(D)(i) SUPERVISION. The licensee must establish, implement, and revise, as necessary, policies and procedures regarding appropriate consumer supervision.

010.04 CONSUMER RIGHTS. Consumer rights must be protected and promoted. Written policies and procedures must be implemented and revised, as necessary, to ensure consumers are given the opportunity to exercise his or her rights. At a minimum, each consumer must have the right to:

(A) Respectful and safe care by competent personnel; (B) Be free from abuse, neglect, exploitation, and to be treated with dignity; (C) Receive respite care services without discrimination based upon race, color, religion, sex, age, ancestry, or national origin; (D) Confidentiality of all records, communications, and personal information; (E) Be free of chemical and physical restraints; (F) Voice complaints or grievances and suggest changes without fear of reprisal; and (G) Be informed of changes in policies, procedures, and charges for care, treatment, and services.

010.05 DESIGNEE AND CAREGIVER RIGHTS. Each designee or caregiver must have the right to:

(A) Be informed of any changes in the respite care service description as indicated in 175 NAC 15-010.07; (B) Voice complaints without discrimination or reprisal against themselves or the consumer and have those complaints addressed; (C) Be informed of consumer and designee or caregiver rights during admittance; and (D) Be informed of changes in policies, procedures, and charges for care, treatment, and services.

010.06 DESIGNEE RIGHTS. Each designee must have the right to formulate advance directives and have the licensee comply with the directives unless the licensee notifies the consumer or designee of an inability to do so as required by law.

010.07 SERVICE DESCRIPTION. A written description which explains the range of respite care services that can be provided must be available to staff, consumers, caregivers, designees, and members of the public. The description must include the following:

(A) Goals and objectives of the licensee; (B) Hours and days when care is provided; (C) Description of the types of consumers to be served, including age, sex, care needs, and any other relevant characteristics; (D) Composition of staff and his or her qualifications; (E) Job responsibilities of staff; and (F) The system used for the reporting, investigating, and resolving allegations of consumer abuse, neglect, and exploitation.

010.08 ADMISSION, EVALUATION, ASSESSMENT, AND DISCHARGE OF CONSUMERS. Written policies and procedures must be implemented and revised, as necessary, for consumer admission and discharge, consumer evaluation, and development of a written, consumer-specific agreement of participation and service plan. The plan must be developed with consumer or designee participation.

010.08(A) ADMISSION CRITERIA & DECISIONS. The licensee must have written criteria for admission that includes each level and components of care, treatment and services provided. The decision to admit a consumer must be is based upon the admission criteria and the capability to meet the identified needs of the consumer.

010.08(B) AGREEMENT OF PARTICIPATION. The license must develop and have an agreement of participation with the consumer or designee. This agreement must be updated, as needed, to ensure it meets the consumers’ needs. This agreement must meet the following requirements:

(i) The service to be provided within the scope of the respite care service; and (ii) The responsibilities of the consumer or designee.

010.08(C) SERVICE PLAN. The licensee must evaluate each consumer, and when necessary, have the consumer assessed by a licensed professional of the appropriate discipline, and must have a written service plan which identifies how care, treatment, and services are to be provided to the consumer by the licensee to meet the consumers’ needs. The service plan must be updated, as needed, to ensure it meets the consumers’ needs. The service plan must have a strategy for addressing care, treatment, and services to meet those needs within the scope of the respite care service and must address the following basic needs of the consumer:

(i) Health; (ii) Psychosocial; and (iii) Functional.

010.08(D) DISCHARGE CRITERIA AND DECISIONS. The licensee must have written criteria for the discharge of consumers. The decision to discharge a consumer must be based upon the licensee’s discharge criteria.

010.09 ADMINISTRATION OR PROVISION OF MEDICATIONS. Consumers must receive medications only as legally prescribed by a medical practitioner in accordance with the 5 rights and with prevailing professional standards.

010.09(A) METHODS OF ADMINISTRATION OF MEDICATION. When the licensee is responsible for the administration of medication, it must be accomplished by the following methods:

010.09(A)(i) SELF-ADMINISTRATION OF MEDICATIONS. Consumers may be allowed to self-administer medications, with or without visual supervision, when the licensee determines that the consumer is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner. Written policies and procedures must be implemented and revised, as necessary, regarding self-administration of medication and must include the following:

010.09(B) MAINTAIN OVERALL SUPERVISION, SAFETY, AND WELFARE OF CONSUMERS. When the licensee is not responsible for medication administration or provision, the licensee still retains responsibility for overall supervision, safety, and welfare of the consumer.

010.09(C) REPORTING OF MEDICATION ERRORS AND ADVERSE REACTIONS TO A MEDICATION BY THE CONSUMER. When the licensee provides for medication administration or provision, the licensee must implement, and revise, as necessary, policies and procedures for reporting any adverse reactions to a medication by a consumer and any medication errors in administration or provision of any medications to the consumer. Such reports must be made to the consumer, the consumer’s designee, and the consumer’s licensed practitioner immediately upon discovery and a written report of the adverse reaction and medication error prepared. Errors must include any variance from the 5 rights and any variance between the prescription and the administration or provision of the medication.

010.09(D) STORAGE OF MEDICATION. Except when the respite care service is provided in the consumer’s home, all medications must be stored in locked areas and stored in accordance with the manufacturer’s instructions for temperature, light, humidity, or other storage instructions. If children under the age of 13 are being served, all medications must be locked.

010.09(E) ACCESS TO MEDICATION. Except when the respite care service is provided in the consumer’s home, the licensee must only permit authorized staff who are designated by the licensee to be responsible for administration or provision of medications have access to medications.

010.09(F) MEDICATION RECORD. The licensee must maintain medication records with sufficient detail to assure that:

(i) Consumers receive the medications authorized by a licensed health care professional; (ii) The respite care service is alerted to theft or loss of medication; and (iii) An individual medication administration record is maintained for each consumer. This record must include:

010.09(G) DISPOSAL OF MEDICATIONS. The licensee must destroy medications that are discontinued by the licensed health care professional and those medications which are beyond the expiration date. The licensee must develop, implement, and revise, as necessary, policies and procedures to identify who will be responsible for disposal of medications and how disposal will occur in compliance with state and federal law.

010.10 FOOD SERVICE. Food must be served as specified in the consumer service plan, agreement of participation, and may include special diets. When the licensee provides food service, meals and snacks must be appropriate to the consumer’s needs and preferences and must meet daily nutritional requirements.

010.10(A) MENUS. When the licensee provides food service, menus must be planned and written based on the Food Guide Pyramid, or equivalent, and modified to accommodate special diets and texture adaptations as needed by the consumers. Menus must be made accessible to consumers, caregivers, and designees.

010.11 CONSUMER INFORMATION. The licensee must obtain written, accurate consumer information from the consumer and caregiver. The licensee must ensure a permanent record for all consumers. The record must be established prior to the provision of care, treatment, or services for each consumer and contain documentation completed immediately after the provision of such.

010.11(A) RECORDS. Consumer records must contain information as required in 175 NAC 1 and the following additional information:

(i) Significant medical conditions; (ii) Medications and any special diet; (iii) Designated physician or registered nurse; (iv) Consumer’s agreement of participation; (v) Consumer’s service plan; (vi) Any unusual event or occurrence; and (vii) Daily documentation of assistance with activities of daily living, personal care, health maintenance activities, or supervision, when provided for the consumer.

010.11(B) CONSUMER IDENTIFICATION. The licensee must implement, and revise, as necessary, a system for identifying a consumer when there are multiple consumers at a site.

History

Effective 2024-05-05

Chapter 16 Hospice Services

Neb. Admin. Code tit. 175, ch. 16 Hospice Services {#sec-175-nac-16 omnilex-key=us-ne-regs-official--title-175--175 NAC 16}

001. SCOPE AND AUTHORITY . These regulations govern licensing of hospice services under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479.

002. DEFINITIONS . Definitions set out in the Health Care Facility Licensure Act, 175 Nebraska Administrative code (NAC) 1, and the following apply to this chapter.

002.02 ADVANCE DIRECTIVES. Advance directives include living wills, durable powers of attorney, powers of attorney for health care, or other instructions recognized by state law that relate to the provision of medical care if the individual becomes incapacitated.

002.03 APARTMENT. A portion of a building that contains living and sleeping areas; storage room(s); separate room(s) containing a toilet, lavatory, and bathtub or shower; and a kitchen area with a sink, cooking, and refrigeration appliances.

002.04 BASIC THERAPEUTIC CARE. Basic therapeutic care has the meaning found in Neb. Rev. Stat. § 71-6602.

002.05 BATHING SERVICES. Assisting an individual to perform bathing activities including, but not limited to, performing a sponge bath, a bed bath, a tub bath, or a shower. This includes, but is not limited to, assisting an individual into and out of the tub bath or shower.

002.06 BEREAVEMENT COUNSELING. Counseling services provided to the consumer and the consumer’s family prior to the consumer’s death and to the family after the consumer’s death.

002.07 BEREAVEMENT SERVICES. Services provided under the supervision of a qualified professional including a plan of care for bereavement service that reflects family needs and a clear delineation of services to be provided for not less than one year following the death of the hospice consumer.

002.08 CAREGIVER. A caregiver has the same meaning as caretaker found in Neb. Rev. Stat. § 71-6721.

002.09 CERTIFIED SOCIAL WORKER. A person who has received a baccalaureate or master’s degree in social work from an approved educational program and holds a current certificate issued by the Department.

002.10 CHEMICAL RESTRAINT. A psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms.

002.11 DEVICE. An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including any component, part, or accessory, which is prescribed by a medical practitioner and dispensed by a pharmacist or other person authorized by law to do so.

002.12 DWELLING. A building that contains living and sleeping areas; storage rooms; separate rooms containing a toilet, lavatory, and bathtub or shower; and a kitchen area with a sink and cooking and refrigeration appliances.

002.13 EMPLOYEE. An employee, for the purpose of this chapter, is an employee of the hospice or, if the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is appropriately trained and assigned to the hospice. Employee also refers to a volunteer under the jurisdiction of the hospice.

002.14 EXPLOITATION. The taking of property of a consumer by means of undue influence, breach of a fiduciary relationship, deception, or extortion, or by any unlawful means.

002.15 FOOD CODE. The Nebraska Food Code as defined in Neb. Rev. Stat. § 81-2,244.01 and as published by the Nebraska Department of Agriculture, except for compliance and enforcement provisions in the food code.

002.16 GEOGRAPHIC AREA SERVED. Includes all counties pre-approved by the Department where the hospice can provide hospice care, treatment, and services. Counties must be contiguous with the county where the parent hospice is located and travel distance between the county seat for the parent hospice to the county seat for all Department-approved counties must not exceed 150 miles.

002.17 HEALTH CARE. Any treatment, procedure, or intervention to diagnose, cure, care for, or treat the effects of disease, injury, and degenerative conditions.

002.18 HOME. The consumer’s permanent or temporary residence.

002.19 HOME HEALTH AIDE. Home health aide has the meaning found in Neb. Rev. Stat. § 71-6602.

002.20 HOME HEALTH AIDE SERVICES. The use of a trained, supervised paraprofessional to provide one or more of the following: personal care, assistance with activities of daily living, or basic therapeutic care, to consumers of a hospice or hospice service.

002.21 HOMEMAKER. A person employed by, or a volunteer of, a hospice to provide domestic services including, but not limited to, meal preparation, laundry, light housekeeping, errands, and chore services as defined by hospice policy.

002.22 HOSPICE INTERDISCIPLINARY TEAM. The attending physician, hospice medical director, registered nurse, certified social worker, pastoral or other counselor, and, as determined by the interdisciplinary plan of care, providers of special services, such as mental health services, pharmacy services, home health aides, trained volunteers, dietary services, and any other appropriate health services, to meet the physical, psychosocial, and spiritual needs which are experienced during the final stages of illness, dying, and bereavement.

002.23 HOSPICE CONSUMER. A consumer who is diagnosed as terminally ill with a medical prognosis that the consumer’s life expectancy is 6 months or less if the illness runs its normal course and who with informed consent is admitted into a hospice program.

002.24 INPATIENT. A person who receives, or is to receive, 24-hour care, treatment, or services and is admitted to the hospital or inpatient facility by a physician.

002.25 INPATIENT HOSPICE FACILITY. A facility in which the hospice provides inpatient care, treatment, or services directly for respite and general inpatient care.

002.26 MEDICAL DIRECTOR. A hospice employee or contracted individual who is a doctor of medicine or osteopathy who is responsible for the overall coordination of medical care, treatment and services provided by the hospice.

002.27 MEDICAL PRACTITIONER. Any licensed physician, osteopathic physician, dentist, podiatrist, optometrist, chiropractor, physician assistant, certified registered nurse anesthetist, advanced practice registered nurse, or certified nurse midwife.

002.28 MEDICATION REMINDERS. Verbal reminders to a person to take the person’s medication which does not include touching or handling of the medication or the container where the medication is stored. Medication reminders do not include administration or provision of medication as defined in the Medication Aide Act and related regulations.

002.29 MENTAL ABUSE. Humiliation, harassment, threats of punishment or deprivation, or other actions causing mental anguish.

002.30 MULTIPLE LOCATIONS. Those locations from which the parent hospice has been approved by the Department to provide the same full range of hospice core services provided by the parent hospice issued the license within a portion of the total approved geographic area served by the parent hospice. Multiple locations are part of the parent hospice and share administration, supervision, and services with the parent hospice on a daily basis.

002.31 NEGLECT. Failure to provide care, treatment, or services necessary to avoid physical harm or mental anguish of consumer.

002.32 PALLIATIVE CARE. Treatment directed at controlling pain, relieving other physical and emotional symptoms, and focusing on the special needs of the hospice consumer and hospice consumer’s family as they experience the dying process rather than treatment aimed at cure or prolongation of life.

002.33 PARENT HOSPICE. The hospice issued the license and is responsible for consumer admissions; care, treatment, and services provided to consumers and the consumer’s family; implementation of the plan of care; and ensuring administrative and supervisory control of its multiple locations.

002.34 PHYSICAL ABUSE. Hitting, slapping, pinching, kicking, or other actions causing injury to the body.

002.35 PHYSICAL RESTRAINT. Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the consumer’s body that the consumer cannot remove easily and that restricts freedom of movement or normal access to the consumer’s own body.

002.36 PHYSICIAN. An individual authorized to practice as a physician under the Uniform Credentialing Act to practice medicine and surgery or osteopathic medicine and surgery.

002.37 RESPITE. An interval of rest or relief provided for the caregiver of a consumer who is a recipient of hospice services.

002.38 RESPITE CARE. A person or any legal entity, not otherwise licensed under the Health Care Facility Licensure Act, which provides short term care or related services on an intermittent basis to persons with special needs when the person’s regular caregiver is unavailable to provide such care or services and such care or services are not provided at a health care facility licensed under the Act.

002.39 SEXUAL ABUSE. Sexual harassment, sexual coercion, or sexual assault.

002.40 STAFF. An individual who is a direct or contracted employee of the hospice. Staff also refers to a volunteer of the hospice.

002.41 SUPERVISION. The daily observation and monitoring of the consumer by direct care staff and oversight of staff by the administrator or administrator’s designee.

002.42 TERMINAL CONDITION. An incurable and irreversible medical condition caused by injury, disease, or physical illness which, to a reasonable degree of medical certainty, will result in death within six months regardless of the continued application of medical treatment including life-sustaining procedures.

002.43 VERBAL ABUSE. The use of oral, written, or gestured language including disparaging and derogatory terms to consumers or within hearing distance of the consumer or within the consumer’s sight.

002.44 VOLUNTEER. An individual specifically trained and supervised to provide support and supportive services to the hospice consumer and hospice consumer’s family under the supervision of a designated hospice volunteer coordinator. A volunteer does not include an individual who provides care, treatment, home health aide services, or medication aide services.

002.45 5 RIGHTS. 5 rights have the meaning found in Nebr. Rev. Stat. § 71-6721.

003. LICENSING REQUIREMENTS . To receive a license, an applicant or licensee must submit a complete application, must meet the hospice service settings and services and staffing requirements below, and meet all requirements set out in statute, in 175 NAC 1-003, and in this chapter.

003.01 HOSPICE SERVICE SETTINGS. Hospice services may be provided in the home of the consumer or a site that serves as an inpatient hospice facility.

003.02 SERVICES AND STAFFING. To operate as a hospice service a hospice must be primarily engaged in providing care, treatment, and services to terminally ill consumers including bereavement counseling. Hospice services must only be provided in approved counties and must include the following:

(A) Nursing services, physician services, and drugs and biologicals routinely available on a 24-hour basis; and (B) All other covered services available on a 24-hour basis to the extent necessary to meet the needs of consumers for care, treatment or services that are reasonably necessary for the palliation and management of terminal illness and related conditions.

003.03 APPLICATION EXCEPTIONS. When hospice services are provided in the home of the consumer, the items shown at 175 NAC 1-003.02 are not required as part of the application.

003.04 INITIAL LICENSURE FEES. Following are initial licensure fees for hospice services:

(A) For other than inpatient $450 (B) For an inpatient hospice facility $650

003.05 RENEWAL LICENSURE FEES. Following are renewal licensure fees for hospice services:

(A) For other than inpatient:

(i) 0 to 50 consumer admissions during the previous 12 months $450 (ii) 51 to 200 consumer admissions during the previous 12 months $550 (iii) 201 and over consumer admissions during the previous 12 months $600

(B) For an inpatient hospice facility:

(i) 0 to 50 consumer admissions during the previous 12 months $650 (ii) 51 to 200 consumer admissions during the previous 12 months $850 (iii) 201 and over consumer admissions during the previous 12 months $950

004. INSPECTIONS . The hospice service must meet all inspection requirements shown at 175 NAC 1 except when hospice services are provided in the home of the consumer, the physical plant standards and physical plant inspection do not apply to such homes.

005. GENERAL REQUIREMENTS . The following requirements are applicable to all licensees as shown below:

005.01 NOTIFICATIONS. Notification requirements are shown below:

(A) An inpatient hospice facility must meet notification requirements at 175 NAC 1-005 (A), (B), (C)(i), (C)(ii), (D), (E), (F), (G)(i) through (G)(v), and must notify the Department in writing at least 30 working days before the facility would like to increase their license capacity, would like a change in the building, or would like a change in the usage of the building; and (B) A hospice service providing care, treatment or services in the home of the consumer, must meet notification requirements at 175 NAC 1-005 (A), (D), (E), (G)(i), (G)(iii); must notify the Department in writing at least 30 working days before the hospice would like to add a county or add a multiple location; and must notify the Department in writing within 24 hours of a consumer’s death which occurred while staff were present, or scheduled to be present, in the consumer’s home to provide care, treatment, or services and the consumer’s death was due to:

(i) Suicide; (ii) A violent act; (iii) Drowning; or (iv) During or immediately after a restraint or seclusion was utilized.

005.02 EFFECTIVE DATE AND TERM OF LICENSE. A hospice license expires on June 30th of each year.

005.03 CHANGE OF OWNERSHIP. Change of ownership or for an inpatient hospice facility, a change of premises terminates the license. If there is a change of ownership and the inpatient hospice facility remains on the same premises and there are no changes to the hospice’s daily operations or direct-care staff, the inspection in 175 NAC 1 and 175 NAC 16 is not required. If an inpatient hospice facility changes premises, it must pass the inspection specified in 175 NAC 1 and 175 NAC 16.

005.04 OCCUPANCY. An inpatient hospice facility must not serve more consumers at 1 time than the maximum occupancy for which the inpatient hospice facility is licensed.

005.05 MULTIPLE LOCATIONS. The parent hospice is responsible for all care, treatment, and services provided at the parent and multiple location offices. All deficient practices cited at any hospice multiple location office or parent location apply to all locations under the licensee’s hospice license. A multiple location office is not required to independently meet licensure requirements but must meet supervision requirements for multiple location offices as shown below. A hospice must not have more than 2 multiple location offices per hospice license. Multiple location offices must:

(A) Be pre-approved by the Department before becoming operational; (B) Provide the same full range of hospice services provided by the parent hospice issued the license within a portion of the total Department-approved geographic area served by the parent hospice; (C) Be part of its parent hospice and share administration, supervision, and services; (D) Be located no more than 120 miles from the parent hospice; (E) Have onsite supervisory visits by the hospice administrator or the administrator’s designated person of the parent hospice at least once a month with documentation of these supervisory visits being maintained at the parent hospice location; (F) Maintain copies of all parent hospice policies, procedures, and forms at each multiple location office; (G) Maintain complete clinical records for all multiple location office consumer’s care, treatment, and services; and (H) Maintain in the parent hospice for all consumers receiving services from multiple location offices the following:

(i) Consumer identifying information; (ii) Name, address, and telephone number of the consumer’s attending physician; (iii) Consumer diagnoses; (iv) The service being provided to the consumer; and (v) The above information must be maintained until the complete clinical record is either stored at the parent hospice or can be destroyed.

006. CONSTRUCTION . Construction requirements at 175 NAC 1 do not apply to hospice services provided by the hospice in the consumer’s home.

007. PHYSICAL PLANT . Physical plant requirements in 175 NAC 1 and 175 NAC 16 do not apply to hospice services provided in the consumer’s home. An inpatient hospice facility must meet all physical plant requirements shown at 175 NAC 1 and the additional requirements shown below. All buildings must be designed, constructed, and maintained in a manner that is safe, clean, and functional for the care, treatment and services provided.

007.01 DIETARY. If food preparation is provided on site, there must be dedicate space and equipment for the preparation and serving of meals. Such food preparation, serving, physical environment, and equipment must comply with the Food Code.

007.02 DINIING AREAS. Dining areas must have an outside wall with windows for natural light and ventilation and meet the following requirements:

(A) Dining areas must be furnished with tables and chairs that accommodate or conform to consumer needs; (B) Dining areas must have a floor area of 15 square feet per consumer in existing facilities and 20 square feet per consumer in new construction; (C) Dining areas must allow for group dining at the same time in either separate dining areas or a single dining area, or dining in 2 shifts, or dining during open dining hours; and (D) Dining areas must not be used for sleeping, offices, or corridors.

007.03 LAUNDRY. Laundry services must be provided. This service may be provided by contract or on-site by the licensee.

007.03(A) CONTRACT. If contractual laundry services are used, areas for soiled linen awaiting pickup and separate areas for storage and distribution of clean linen must be utilized.

007.03(B) ONSITE. If onsite laundry services are provided there must be areas dedicated to laundry that include a washer and dryer. In new construction, there must be a conveniently located sink for soaking and hand washing of laundry.

007.03(C) SANITATION. When bed and bath linens are cleaned, water temperatures to laundry equipment must be 160 degrees Fahrenheit or higher. Laundry may be appropriately sanitized or disinfected by another acceptable method in accordance with the manufacturer’s instructions or other documentation.

007.04 LINENS. There must be an adequate supply of bed, bath, and other linens as necessary for each consumer. The linen must be clean and in good repair.

007.06 COSMETOLOGY AND BARBER. If cosmetology and barber services, as defined in the Cosmetology, Electrology, Esthetics, Nail Technology; and Body Art Practice, Neb. Rev. Stat. §§ 38-1001 to 38-10,171 and the Practice of Barbering, Neb. Rev. Stat. §§ 71-201 to 71-248 must be provided such services must be provided in conformance with those statutes.

007.07 PHARMACY. If pharmacy or pharmaceutical services are provided, they must be provided in conformance with the statutes and regulations governing such practice.

007.08 HOUSEKEEPING ROOM. There must be a room with a service sink and space for storage of supplies and housekeeping equipment.

007.09 CARE AND TREATMENT AREAS. The following care and treatment areas cannot be shared among detached structures or with other licensed health care facilities or services. Care and treatment areas must comply with the following standards.

007.09(A) STAFF AREAS. There must be the following support areas for each distinct care and treatment suite of bedrooms:

007.09(A)(i) CONTROL POINT. An area for charting, consumer records, and call and alarm annunciation systems.

007.09(A)(ii) MEDICATION STATION. A medication station for storage and distribution of drugs and routine medications. Distribution may be done from a medicine preparation room or unit, from a self-contained medicine-dispensing unit, or by another system. If used, a medicine preparation room or unit must be under visual control of nursing staff and must contain a work counter, sink, refrigerator, and double-locked storage for controlled substances.

007.09(A)(iii) CONSUMER FACILITIES. Space for consumer care, treatment, services, and consultation, and a visiting area allowing for consumer privacy.

007.09(A)(iv) UTILITY AREAS. A work area where clean materials are assembled. The work area must contain a work counter, a handwashing fixture, and storage facilities for clean and sterile supplies. If the area is used only for storage and holding as part of a system for distribution of clean and sterile supply materials, the work counter and handwashing fixtures may be omitted. There must be separate work areas or holding rooms for soiled materials. A workroom for soiled materials must contain a fixture for disposing of wastes and a hand washing sink.

007.09(B) EQUIPMENT AND SUPPLY. There must be services and space to distribute, maintain, clean, and sanitize durable medical instruments, equipment, and supplies required for the care, treatment, and services performed.

007.09(B)(i) DURABLE MEDICAL. Hospice must ensure that the durable medical equipment must be tested and calibrated in accordance with the manufacturer’s recommendations.

007.09(B)(ii) STERILE PROCESSING. There must be areas for decontamination and sterilizing of durable medical instruments and equipment. Separate central sterile processing and waste processing facilities must be used. There must be separate soiled rooms for sorting and decontamination, and clean rooms for sterilizing and processing rooms. There must be hand washing sinks in both clean and soiled rooms.

007.09(B)(iii) EQUIPMENT STORAGE. There must be space to store equipment, stretchers, wheelchairs, supplies, and linen out of the path of normal traffic.

007.09(B)(iv) EQUIPMENT. There must be equipment adequate for meeting the consumer’s needs as specified in the contracts, consumer service agreements, and consumer care plans.

007.10 BATHING ROOMS. There must be a bathing room consisting of a tub or shower adjacent to each bedroom or provide a central bathing room on each floor. Tubs and showers regardless of location must be equipped with hand grips or other assistive devices as needed or desired by the consumer. In new construction a central bathing room must open off the corridor and contain a toilet and sink or have an adjoining toilet room. There must be at least 1 bathing fixture for each 8 licensed beds in new facilities and new construction.

007.11 TOILET ROOMS. Existing or new facilities must have a toilet and sink adjoining each bedroom or shared toilet facilities with a minimum number of 1 toilet and sink fixture per 2 licensed beds. New construction must have a toilet and sink fixture provided adjoining each consumer bedroom or in each apartment or dwelling.

007.12 SLEEPING ROOMS. There must be bedrooms which allow for sleeping, afford privacy, provide access to furniture and belongings, and accommodate the care and treatment provided to the consumer.

007.12(A) BEDROOMS. Bedrooms must:

(i) Be a single room located within an apartment, dwelling, or dormitory-like structure; (ii) Not be accessed through a bathroom, food preparation area, laundry, or another bedroom; (iii) Be located on an outside wall or an atrium with an operable window opening to allow natural ventilation with a minimum glass size of 10% of the required bedroom floor area for the number of room consumers. The window must provide an unobstructed view of at least 10 feet; (iv) Contain at least 25 cubic feet of enclosed storage volume per consumer in dressers, closets, or wardrobes; (v) Allow for an accessible arrangement of furniture; which provides a minimum of three feet between beds in rooms with multiple beds; and (vi) Be separate from a room containing a water closet, lavatory, and bathtub or shower; and separate from a kitchen area with a sink, cooking appliance, and refrigeration equipment when located in an apartment or dwelling.

007.12(B) EXISTING OR NEW FACILITY. Sleeping areas in existing and new facilities must have at least the following floor areas.

(i) Floor areas for single bed sleeping rooms must be 100 square feet. (ii) Floor areas for multiple bed sleeping rooms must be 80 square feet per consumer with a maximum of 2 beds.

007.12(C) NEW CONSTRUCTION. Sleeping areas in new construction must have at least the following floor areas.

(i) Floor areas for single bed sleeping rooms must be 120 square feet. (ii) Floor area for apartments or dwellings must have 150 square feet for one consumer plus 110 square feet for each additional consumer with a maximum of 1 consumer in any single bedroom.

007.13 ISOLATION ROOMS. The licensee must have the capability to provide isolation rooms based on infection control risk assessment of the consumers. There must be provisions for isolating consumers with infectious diseases. In new construction, the inpatient hospice facility must equip isolation rooms with hand washing and gown changing facilities at the entrance of the room.

007.14 CORRIDORS. Corridors must be wide enough to allow passage and be equipped with safety and assistive devices to minimize injury and to meet the needs of the consumer. All stairways and ramps must have handrails.

007.15 DOORS. Doors must be wide enough to allow passage and be equipped for privacy, safety, and with assistive devices to minimize consumer injury. All bedroom, toilet, and bathing room doors must provide privacy yet not create seclusion or prohibit staff access for routine or emergency care. In new construction, all consumer-used toilet and bathing rooms with less than 50 square feet of clear floor area must not have doors that swing inward.

007.16 OUTDOOR AREAS. An outdoor area for consumer usage must be provided. It must be equipped and situated to protect consumers and to promote the abilities of consumers.

007.17 HAND WASHING SINKS. A hand washing facility equipped with sink, disposable towels, and soap dispenser must be in all examination, treatment, isolation, and procedure rooms.

007.18 PRIVACY. Visual privacy and window curtains must be provided for each consumer. In new facilities the curtain layout must totally surround each care and treatment location which will not restrict access to the entrance to the room, lavatory, toilet, or enclosed storage facilities.

007.19 FINISHES. Room finishes must meet the following:

(A) Washable room finishes provided in existing isolation rooms, clean workrooms, and food-preparation areas must have smooth, non-absorptive solutions and methods. Acoustic lay-in ceilings, if used, must not interfere with infection control. Perforated, tegular, serrated cure, or highly textured tiles are not acceptable; and (B) Scrubbable room finishes provided in new isolation rooms must have smooth, non-absorptive, non-perforated surfaces that are not physically affected by harsh germicidal cleaning solutions and methods.

007.20 ADDITIONAL SERVICES. If additional medical or therapy services are provided there must be adequate space provided to assure privacy and provision of appropriate care, treatment, and services.

007.21 BUILDING SYSTEMS. Building systems must be designed, installed, and operated in a manner to provide for the safety, comfort, and well-being of the consumer and must include at a minimum, the following:

007.21(A) CALL SYSTEMS. Call systems must be operable from procedure, treatment, operating rooms, recovery areas, toilet rooms and bathing rooms. The system must transmit a receivable, tactile, visual, or other type of signal to on-duty staff which readily notifies staff to the location where the call was activated. When wireless call systems are used, they must have dedicated devices in all consumer toilet and bathing areas to promptly summon staff to the call location.

007.21(A)(i) NEW CONSTRUCTION. New construction in locations where consumers are unable to activate the call system must have a device where staff can summon other staff for assistance as needed.

007.21(B) ELECTRICAL SYSTEM. The electrical system must have the capacity to maintain the care and treatment services that are provided and that properly grounds care and treatment areas.

007.21(B)(i) NEW CONSTRUCTION. New construction and new facilities must have ground fault circuit interrupters protected outlets in all wet areas and within 6 feet of all hand washing sinks.

007.21(C) ESSENTIAL POWER SYSTEM. All existing and new facilities must maintain an emergency power system for all essential care and treatment areas, lighting, medical gas systems, nurse call systems, and any general anesthetics or electrical life support systems.

007.21(D) ELECTRICAL SUPPORT EQUIPMENT. Facilities with electrical support equipment must maintain essential power systems and must have an on-site fuel source. The minimum fuel source capacity must allow for non-interrupted system operations.

007.22 HOT WATER SYSTEM. There must be hot and cold water to all hand washing and bathing locations.

007.23 HEATING AND COOLING SYSTEMS. Airflow must move from clean to soiled locations. Floors in operating, procedure, and other locations subject to wet cleaning methods or body fluids must not have opening to the heating and cooling system.

007.23(A) CENTRAL AIR DISTRIBUTION. In new construction, central air distribution and return systems must have the following dust rated filters:

(i) General areas: 30 +%; and (ii) Procedure and operating rooms: 90 +%.

007.23(B) AIR MOVEMENT. In new construction, air movement must be designed to reduce the potential of contamination of clean areas.

007.24 ILLUMINATION LEVELS. All facilities must provide minimum illumination levels which are measured at 30 inches above the floor in multiple areas in the room as follows:

(A) Toilet Rooms 30 foot candles; (B) Corridors 10 foot candles; (C) Laundry 30 foot candles; (D) Medication station 75 foot candles; (E) Care and treatment locations 70 foot candles; (F) Procedure task lighting 200 foot candles; and (G) Surgery 1000 foot candles.

007.25 MEDICAL GAS SYSTEMS. The facility must safely provide medical gas and vacuum by means of portable equipment or building systems as required by the type of care and treatment provided at the clinic. All medical gas systems must comply with the requirements of 153 NAC 1.

007.26 VENTILATION SYSTEM. All facilities must provide exhaust and clean air to prevent the concentrations of contaminants which impair health or cause discomfort to consumers and employees.

007.26(A) MECHANICAL EXHAUST VENTILATION. New construction must provide a mechanical exhaust ventilation system at a rate of 10 air exchanges per hour for the following areas:

(i) Windowless toilets; (ii) Bathing areas; (iii) Laundry rooms; and (iv) Housekeeping rooms.

007.26(B) MECHANICAL VENTILATION SYSTEM. New construction must provide mechanical ventilation system air exchanges per hour at the following rates:

(i) Care and treatment areas 5 ACH; (ii) Procedure and isolation areas 15 ACH; and (iii) Operating rooms 20 ACH.

007.27 WATER AND SEWER SYSTEMS. There must be an accessible and safe potable supply of water. Where a public water supply system is available, the facility must be connected to it and must use it exclusively. All water distribution systems must be protected with anti-siphon devices and airgaps to prevent contamination. All facilities must maintain a sanitary and functioning sewage system and the following:

(A) If the facility operates its own water supply system it must be operated as if it is a public water supply system and in compliance with The Nebraska Safe Drinking Water Act and Title 179, Regulations Governing Public Water Systems; and (B) Continuously circulated filtered and treated water systems must be provided as required for care and treatment equipment used in the facility.

008. RECORDKEEPING . The licensee must meet all recordkeeping requirements at 175 NAC 1. The licensee when providing other than inpatient hospice services and sharing space with another entity, must ensure the hospice service has a unique physical address to ensure mail is secured against unauthorized access and must ensure a separate entrance to the hospice service space to ensure verbal communications are protected against unauthorized access.

009. ENVIRONMENTAL SERVICES . The licensee must have a written process for performing routine and preventative maintenance on equipment and furnishings. Equipment and furnishings must be safe and function to meet the intended use.

010. STANDARDS OF OPERATION, CARE, AND TREATMENT . Each licensee must assure protection to hospice consumers and compliance with state statutes and regulations. All services provided by the licensee must be provided in accordance with the Health Care Facility Licensure Act, The Uniform Credentialing Act, the Medication Aide Act, the regulations adopted under those Acts, physician orders, the physician-approved written plan of care, and prevailing standards of practice.

(A) Ensure all services are provided in accordance with accepted standards of practice and oversee the management and fiscal affairs of the hospice; (B) Require each employee to report any evidence of abuse, neglect, or exploitation of a consumer served by the hospice service in accordance with the Adult Protective Services Act or the Child Protection Act, as applicable; (C) Ensure any suspected abuse, neglect, or exploitation is reported to the Administrator; and (D) Ensure consumers are only discharged for cause based on an unsafe care environment in the consumer’s home, consumer non-compliance, including disruptive, abusive, or uncooperative behavior to the extent that delivery of care to the consumer or the ability of the licensee to operate effectively is seriously impaired, or failure to pay for services;

(i) The licensee must make a serious effort to resolve the problems presented by the behavior or situation to assure that the proposed discharge is not due to the consumer’s use of necessary hospice services, must document the problems and the efforts made to resolve the problems in the consumer’s medical record, and must obtain a written physician’s order from the consumer’s attending physician and the hospice medical director concurring with the discharge.

010.02 ADMINISTRATION. The licensee must set out the duties and responsibilities of the administrator in writing. Whether employed, elected, contracted, or appointed, the administrator must report and be directly responsible to the licensee in all matters related to the maintenance, operation, and management of the hospice service. The licensee must ensure each consumer receives care, treatment, and services that optimize the consumer’s comfort and dignity in a manner which is consistent with consumer, family, or designee needs and desires.

010.03 ADMINISTRATOR. A licensee must have an administrator who has training and experience in hospice care or a related health care program. The administrator must be a person responsible for the daily management of the hospice to the extent authority is delegated by the licensee. An equally qualified backup administrator must be designated in writing to act in the absence of the administrator. The administrator must have the following responsibilities:

(A) Ensuring staff’s compliance with all applicable statutes, regulations, and rules; (B) Overseeing and being responsible for the provision and coordination of consumer care, treatment, and services; (C) Organizing and directing the hospice’s ongoing functions; (D) Maintaining communication between the licensee and staff; (E) Employing sufficient number of staff with appropriate training and skills to meet consumers’ care, treatment, and service needs identified in consumers’ plan of care and in accordance with job descriptions; (F) Implementing written personnel policies, job descriptions, and current hospice policies and procedures that are made available to all personnel; (G) Ensuring written policies, procedures and forms are individualized for the hospice service and contain effective dates and revisions dates; (H) Ensuring the hospice service maintains a copy of all active policies, procedures and forms which are available for staff use; (I) Ensuring the hospice service maintains a copy of all inactive policies, procedures, and forms for a minimum of 7 years after the document becomes inactive; (J) Ensuring an investigation is completed on suspected abuse, neglect, exploitation, or misappropriation of money or property and take action to prevent recurrence and to protect all consumers from or the potential for such until the investigation is completed; (K) Providing orientation for new staff, scheduled in-service education programs, and opportunities for continuing education of the staff; (L) Maintaining appropriate personnel and administrative records; (M) Ensuring the completion, maintenance, and submission of reports and records as required by the Department; and (N) Supervising multiple location offices. Onsite supervision of multiple location staff must be provided by the administrator or the administrator’s designated person of the parent hospice service at least once a month. Documentation of these visits must be maintained at the parent hospice service.

010.04. MEDICAL DIRECTOR. A licensee must have a medical director who is a hospice employee or a contracted person who is a doctor of medicine or osteopathy. The medical director must have overall responsibility for the medical component of the hospice’s consumer care program.

010.05 STAFF REQUIREMENTS. The licensee must have sufficient staff with the required training and skills to provide the services as necessary to meet the needs of each consumer accepted for care, treatment, or services in a safe and timely manner. There must be job descriptions for each staff position, which includes minimum qualifications required for the position.

010.05(A) EMPLOYMENT ELIGIBILITY. Each licensee must maintain evidence of the following:

010.05(A)(i) CRIMINAL BACKGROUND CHECKS. Complete pre-employment criminal background checks for each direct care staff member through a governmental law enforcement agency or a private entity that maintains criminal background information.

010.05(A)(ii) REGISTRY CHECKS. Complete pre-employment checks for each direct care staff for adverse findings on the following Nebraska registries:

(1) Nurse Aide Registry; (2) Adult Protective Services Central Registry; (3) Central Registry of Child Protection Cases; and (4) Sex Offender Registry.

010.05(A)(iii) HIRING DECISIONS. The licensee must:

010.05(A)(iv) ADVERSE FINDINGS. The licensee must not employ a person with adverse findings on the Sex Offender Registry or on the Nurse Aide Registry.

010.05(A)(v) HEALTH STATUS. The licensee must implement written policies and procedures regarding the health status of staff to prevent transmission of disease to consumers. The licensee must complete a health screening for each staff person prior to the staff person having contact with or providing direct care, treatment, or services for consumers.

010.05(B) EMPLOYMENT RECORD. A current employment record must be kept for each staff person which includes:

010.05(C) INITIAL ORIENTATION. An orientation program must be provided for all new staff and as needed, for existing staff who are given new assignments. Such training must be documented in the employment record. The orientation program must include:

(i) Job duties and responsibilities; (ii) Organizational structure; (iii) Consumer rights; (iv) Consumer care policies and procedures; (v) Personnel policies and procedures; and (vi) Reporting requirements for abuse, neglect, and exploitation in accordance with state law and with hospice policies and procedures.

010.05(D) TRAINING. All staff must receive training in order to perform job responsibilities.

010.05(D)(i) ONGOING TRAINING. Each licensee must provide ongoing and continuous in-services or continuing education for staff. A record must be maintained including date, topic, and participants.

010.05(D)(ii) SPECIALIZED TRAINING. Each licensee must provide training of staff to permit performance of particular procedures or to provide specialized care, whether as part of a training program or as individualized instruction. This training must be documented in employment records.

010.05(D)(iii) RECORDS. The licensee must maintain records of each orientation and in-service or other training program, including the signature of staff attending, subject-matter of the training, the names and qualifications of instructors, dates of training, length of training sessions, and any written materials provided.

010.05(E) INDIVIDUALS UNDER HOURLY OR PER VISIT CONTRACTS. If individuals or entities under hourly or per visit contracts are utilized, there must be a written contract between the licensee and the individual or entity. The licensee must maintain a copy of all active contracts and retain copies of discontinued contracts for seven years after the contract is discontinued. The contract must include:

(i) A statement that consumers are accepted for care only by the parent hospice; (ii) A description of the services and the manner in which they are to be provided; (iii) A statement that the contractor must conform to all applicable hospice policies, including those related to qualifications; (iv) A statement that the contractor is responsible for participating in the development of plans of care; (v) A statement that the services are controlled, coordinated, and evaluated by the parent hospice; (vi) The procedures for submitting clinical and progress notes; scheduling consumer care, treatment, and services; and ongoing periodic consumer evaluations; and (vii) The procedures for determining charges and reimbursement.

010.06 CONSUMER RIGHTS. The licensee must implement a written bill of rights that is equally applicable to all consumers. The licensee must protect and promote the exercise of these rights. All consumers, guardians, or authorized designees upon the commencement of services must be given a copy of the bill of rights. The licensee must maintain documentation showing that it has complied with these requirements. Consumers must have the right to:

(A) Choose care providers and communicate with those providers; (B) Participate in the planning of their care and receive appropriate instruction and education regarding the plan; (C) Request information about their diagnosis, prognosis, and treatment, including alternatives to care and risks involved, in terms that they and their families or designee can readily understand so that they can give their informed consent; (D) Refuse care and be informed of possible health consequences of this action; (E) Receive care without discrimination as to race, color, creed, sex, age, or national origin; (F) Exercise religious beliefs; (G) Be admitted for service only if the licensee has the ability to provide safe, professional care at the level of intensity needed; (H) Receive the full range of services provided by the licensee; (I) Confidentiality of all records, communications, and personal information; (J) Review and receive a copy of all health records pertaining to them; (K) Receive both an oral and written explanation regarding discharge if the consumer moves out of the hospice’s service area or transfers to another hospice; or if the hospice determines the consumer is no longer terminally ill. Information regarding community resources must be given to the consumer or the consumer’s designee; (L) Voice complaints and grievances and suggest changes in service or staff without fear of reprisal or discrimination and be informed of the resolution; (M) Be fully informed of hospice policies and charges for services, including eligibility for third-party reimbursement, prior to receiving care; (N) Be free from verbal, physical, and psychological abuse and to be treated with dignity; (O) Expect pain relief through measures implemented to ensure the consumer’s comfort; (P) Expect all efforts will be made to ensure continuity and quality of care in the home and in the inpatient setting; (Q) Have his or her person and property treated with respect; (R) Be informed, in advance, about the care to be furnished, and any changes in the care to be furnished; (S) Formulate advance directives and have the licensee comply with the directives unless the licensee notifies the consumer or designee of the inability to do so; and (T) Be free from physical and chemical restraints that are not medically necessary.

010.07 CONSUMER CARE AND TREATMENT. Hospice services must include:

010.07(A) PLAN OF CARE. A written plan of care must be established and maintained for each consumer admitted to a hospice program. A registered nurse must complete an initial assessment to evaluate the consumer’s immediate physical, psychosocial, emotional, and spiritual needs. This assessment initiates the plan of care. The care provided to the consumer must be in accordance with this plan.

010.07(A)(i) ESTABLISHMENT OF THE INITIAL PLAN. A comprehensive plan must be established, within 5 calendar days of the initial assessment, by the attending physician, who must be selected by the consumer or consumer’s designee in the hospice records and who has primary responsibility for the consumer’s care, treatment, and services; the medical director; and interdisciplinary team.

010.07(A)(ii) REVIEW OF THE PLAN. Updates of the comprehensive assessment must be accomplished by the interdisciplinary team in collaboration with the consumer’s attending physician, if any, or a physician assistant or advanced practice registered nurse affiliated with the attending physician and must consider changes that have taken place since the initial assessment. It must include information on the consumer’s progress toward desired outcomes, as well as a reassessment of the consumer’s response to care. Updates of the comprehensive assessment must be accomplished as frequently as the condition of the consumer requires, but no less frequently than every 15 days.

010.07(A)(iii) CONTENT OF THE PLAN. The plan must include an assessment of the consumer’s needs and identification of the services including the management of discomfort and symptom relief. It must state in detail the scope and frequency of services needed to meet the consumer’s and family’s needs.

010.07(A)(iv) PHYSICIAN ORDER. Each licensee must have a written process by which orders from a physician or medical practitioner must be obtained, incorporated into the plan of care, and carried out.

010.07(B) HOSPICE CORE SERVICES. Core services include nursing services, social services, physician services, and counseling services. A licensee must ensure that substantially all the core services are routinely provided directly by employees of the licensee with the exception of the physician who can be contracted. A licensee may use contracted staff if necessary to supplement employees to meet the needs of consumers during periods of peak consumer loads or under extraordinary circumstances. If contracting is used, the licensee must maintain professional, financial, and administrative responsibility for the services and must assure that the qualifications of staff and services provided meet the requirements specified in this chapter.

010.07(B)(i) NURSING SERVICES. Nursing care and services must be provided by or under the supervision of a registered nurse. Nursing services must be directed and staffed to assure that the nursing needs of consumers are met. The direction and delegation of nursing care must be done in accordance with 172 NAC 99. Consumer care responsibilities of nursing personnel must be specified in writing.

010.07(B)(ii) SOCIAL SERVICES. Social services must be provided by a certified social worker, under the direction of a physician. All social work services must be provided in accordance with the plan of care and recognized standards of practice. A social worker must participate in the development, implementation, and revision of the consumer’s plan of care.

010.07(B)(iii) PHYSICIAN SERVICES. In addition to palliation and management of terminal illness and related conditions, physician employees of the licensee, including the physician members of the interdisciplinary group, must also meet the general medical needs of the consumers to the extent that these needs are not met by the attending physician.

010.07(B)(iv) COUNSELING SERVICES. Counseling services must be available to both the consumer and the family. Counseling includes bereavement counseling, provided before and after the consumer’s death, as well as dietary, spiritual, and any other counseling services for the consumer and family provided while the consumer is enrolled in the hospice.

010.07(B)(iv)(1) DIETARY COUNSELING. Dietary counseling, when required, must be provided by a licensed medical nutrition therapist or others whose scope of practice as defined by the Uniform Credentialing Act permits dietary counseling. Such individuals include, but are not limited to, a physician, a registered nurse, or a dietitian registered by the American Dietetic Association or an equivalent entity.

010.07(B)(iv)(2) SPIRITUAL COUNSELING. Spiritual counseling must include notice to consumers as to the availability of clergy.

010.07(B)(iv)(3) ADDITIONAL COUNSELING. Counseling may be provided by other members of the interdisciplinary group as well as by other qualified professionals.

010.07(B)(iv)(4) BEREAVEMENT COUNSELING. There must be an organized program for the provision of bereavement services under the supervision of a qualified professional. The plan of care for these services should reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery up to 1 year following the death of the consumer.

010.07(B)(v) HOME HEALTH AIDE AND MEDICATION AIDE. Each licensee that employs or contracts home health aides or medication aides must meet the following requirements for training and testing prior to providing care and services to consumers.

010.07(B)(v)(1) EMPLOY QUALIFIED AIDES. Each licensee must employ only home health aides qualified to provide home health care pursuant to Neb. Rev. Stat. §§ 71-6601 to 71-6615. Any home health aide not acting as such for a period of 3 years must repeat the 75-hour training course.

010.07(B)(v)(2) DIRECTION AND SUPERVISION. Each licensee must provide direction by using an aide care plan and assignment sheet written by a registered nurse and through registered nurse supervision of home health aides. The licensee must ensure a registered nurse is available or on call to the staff during all hours that home health aide services are provided. Any other task the licensee chooses to have a home health aide perform must not include a task which requires a credential under the Uniform Credentialing Act.

010.07(B)(v)(3) IN-SERVICE PROGRAM. Each licensee must provide in-service training as required at Neb. Rev. Stat. § 71-6606.

010.07(B)(v)(4) PERMITTED ACTS. Home health aides may only perform acts as allowed by Neb. Rev. Stat. § 71-6605.

010.07(B)(v)(5) REQUIREMENTS. To act as a home health aide, a person must meet the requirements at Neb. Rev. Stat. § 71-6603. To act as a medication aide, a person must be a registered Medication Aide.

010.07(B)(v)(6) HOME HEALTH AIDE TRAINING COURSE. A home health aide training course must meet the requirements at Neb. Rev. Stat. § 71-6608.01.

010.07(B)(v)(7) VERIFY COMPETENCY. Each licensee must verify and document the competency of all home health aides prior to the aide providing services in a consumer’s home or in the inpatient hospice service. The competency evaluation items are set out at Neb. Rev. Stat. § 71-6608.01 in subdivisions (1)(b) through (1)(m). All competency evaluations must be performed by a registered nurse and must be evaluated by observation and a written or oral examination as set out below:

(a) Observations must be made with a live consumer or person when performing the competency evaluation for requirements at Neb. Rev. Stat. § 71-6608.01 in subdivisions (1)(c), 1(i), 1(i)(i) through 1(i)(vi), (1)(j) and (1)(k); and (b) A written or oral examination must be used when performing the competency evaluation for requirements at Neb. Rev. Stat. § 71-6608.01 in subdivisions (1)(a), (1)(b), (1)(d) through (1)(h), (1)(l) and (1)(m).

010.07(B)(v)(8) HOME HEALTH AIDE CARE PLAN AND SUPERVISION. The home health aide care plan and supervision requirements must meet the requirements in Neb. Rev. Stat. § 71-6607 and the following:

(a) A registered nurse must make an initial evaluation visit to each consumer prior to home health aide services being provided and must devise a written plan of care for the physician’s approval. When aide services are provided the registered nurse must visit the home site at least every two weeks with or without the aide being present. The visit must include an assessment of the aide services and review of the aide care plan; and (b) The home health aide must provide services in accordance with the physician-approved written plan of care and the home health aide care plan. The home health aide care plan must include consumer-specific written instructions for each consumer. Visits made by home health aides must be documented in accordance with the plan of care and the home health aide care plan.

010.07(B)(v)(9) REPEAT HOME HEALTH AIDE TRAINING AND COMPETENCY VERIFICATION. Any home health aide not acting as such for a period of three years must repeat the training course as required in this chapter and the licensee must determine and verify competency of the home health aide as required in this chapter.

010.07(C) OTHER SERVICES. A hospice must ensure that the other services shown in this section are provided directly by hospice employees or under arrangements.

010.07(C)(i) VOLUNTEERS. The hospice uses volunteers, in defined roles, under the supervision of a designated hospice employee and in accordance with the following requirements:

010.07(C)(i)(1) TRAINING. The hospice must provide appropriate orientation and training that is consistent with acceptable standards of hospice practice.

010.07(C)(i)(2) ROLES. Volunteers must be used in administrative or direct consumer care roles.

010.07(C)(i)(3) RECRUITMENT AND RETENTION. The hospice must document active and ongoing efforts to recruit and retain volunteers.

010.07(C)(i)(4) COST SAVINGS. The hospice must document the cost savings achieved through the use of volunteers. Documentation must include:

(a) The identification of necessary positions which are occupied by volunteers; (b) The work time spent by volunteers occupying those positions; and (c) Estimates of the dollar costs which the hospice would have incurred if paid employees occupied the positions.

010.07(C)(i)(5) LEVEL OF ACTIVITY. The hospice must document and maintain a volunteer staff sufficient to provide day-to-day administrative or direct consumer care in an amount that, at a minimum, equals 5% of the total consumer care hours of all paid hospice employees and contract staff. The hospice must document a continuing level of volunteer activity. The hospice must record expansion of care, treatment and services achieved through the use of volunteers, including the type of services and time worked.

010.07(C)(ii) LABORATORY SERVICES. If the licensee engages in laboratory testing outside of the context of assisting a consumer in self-administering a test with an appliance that has been cleared for that testing by the Food And Drug Administration, the testing must be in compliance with all applicable requirements of the Clinical Laboratory Improvement Amendments of 1988, as amended. If the licensee chooses to refer specimens for laboratory testing to a reference laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of services in accordance with the applicable requirements of the Clinical Laboratory Improvement Amendments of 1988, as amended.

010.07(C)(iii) PHYSICIAL THERAPY, OCCUPATIONAL THERAPY, SPEECH LANGUAGE PATHOLOGY SERVICES. Physical therapy services, occupational therapy services, and speech-language pathology services must be available, and when provided, the services must be provided within the scope of practice as defined by the Uniform Credentialing Act.

010.07(C)(iv) CLERGY. The licensee must make reasonable efforts to arrange for visits of clergy and other members of religious organizations in the community to consumers who request the visits and must advise consumers of this opportunity.

010.07(C)(v) MEDICAL SUPPLIES AND EQUIPMENT. Medical supplies, equipment, and appliances, including drugs and biologicals, must be provided as needed for the palliation and management of the terminal illness and related conditions. The licensee must provide routine and preventative maintenance of equipment to ensure that it is safe and works as intended for the use in the consumer’s environment. The licensee must ensure that the consumer, family, and designee understand how to use the equipment and supplies.

010.07(C)(vi) HOMEMAKER QUALIFICATIONS, INSTRUCTIONS AND SUPERVISION. The licensee must have a written process for providing homemaker services. Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enable the consumer’s family to carry out the plan of care. A member of the interdisciplinary team must coordinate and supervise all homemaker services and must develop, and update every 2 weeks, written instructions for all homemaker duties. Homemakers must report all concerns about the consumer or the consumer’s family to the member of the interdisciplinary team who coordinates homemaker services.

010.07(D) PROFESSIONAL MANAGEMENT. Except for those core services described in 175 NAC 16, a licensee may arrange for another individual or entity to furnish services to the hospice’s consumers. If services are provided under arrangement, the licensee must:

(i) Assure the continuity of consumer and family care in home, outpatient, and inpatient settings; (ii) Have a written agreement for the provision of arranged services. The agreement must include:

(1) Identification of the services to be provided; (2) Have a stipulation that services may be provided only with the express authorization of the licensee; (3) Set out how the contracted services are coordinated, supervised, and evaluated by the licensee; (4) A delineation of the roles of the licensee and the contractor in the admission process, consumer and family assessment, and the interdisciplinary group care conferences; (5) Have requirements for documenting that services are furnished in accordance with the agreement; and (6) Set out the required qualifications of the personnel providing the services;

(iii) Retain professional management responsibility for those services and ensure that they are furnished in a safe and effective manner by qualified persons and in accordance with the consumer’s plan of care and other requirements of 175 NAC 16; and (iv) Ensure that inpatient care is furnished only in a facility which meets the requirements of a 24-hour registered nurse coverage in a skilled nursing facility and that:

(1) The licensee furnishes to the inpatient provider a copy of the consumer’s care plan and specifies the inpatient services to be furnished; (2) The inpatient provider has established policies consistent with those of the licensee and agrees to abide by the consumer care protocols established by the licensee for its consumers; (3) The medical record includes a record of all inpatient services and events and that a copy of the discharge summary and, if requested, a copy of the medical record is provided to the licensee; (4) Specifies the party responsible for the implementation of the provisions of the agreement; and (5) The licensee retains responsibility for appropriate hospice care training of the personnel who provide the care under the agreement.

010.07(E) INTERDISCIPLINARY TEAM. The licensee must designate an interdisciplinary team composed of individuals who provide or supervise the care, treatment, and services offered by the hospice.

010.07(E)(i) COMPOSITION OF THE TEAM. The interdisciplinary team must include at least the following individuals who are employees of the hospice, with the exception of the doctor of medicine or osteopathy who may be a contracted employee:

(1) A doctor of medicine or osteopathy; (2) A registered nurse; (3) A social worker; and (4) A pastoral or other counselor.

010.07(E)(ii) ROLE OF THE TEAM. The interdisciplinary team is responsible for:

(1) Participation in the establishment of the plan of care; (2) Provision or supervision of hospice care, treatment, and services; and (3) Periodic review and updating of the plan of care for each consumer receiving hospice care.

010.07(E)(iii) MULTIPLE INTERDISCIPLINARY TEAMS. If a licensee has more than 1 interdisciplinary team, the licensee must designate in advance the team to execute these functions for the hospice.

010.07(E)(iv) DESIGNATED REGISTERED NURSE. The licensee must designate a registered nurse to coordinate the implementation of the plan of care for each consumer. The plan of care must be updated as often as necessary but at least every 62 days.

010.07(F) SHORT-TERM INPATIENT CARE. A hospice must have an established agreement with a participating Medicare or Medicaid facility to provide short term care for pain control, symptom management, or respite purposes. Such care must be provided in one of the following:

(i) An inpatient hospice facility; or (ii) A hospital, skilled nursing facility, nursing facility, or intermediate care facility.

010.07(G) SHORT-TERM INPATIENT RESPITE CARE. For inpatient respite, the registered nurse must be available when required by the consumer’s plan of care.

010.08 ADMISSION AND RETENTION REQUIREMENTS. A licensee must accept a consumer only when the licensee reasonably expects that it can adequately meet the consumer’s medical, therapeutic, and social needs in the consumer’s permanent or temporary place of residence. Each consumer receiving services from the hospice is entitled to receive the full range of services.

010.09 ADMINSTRATION OF MEDICATIONS. Consumers must receive medications only as legally prescribed by a medical practitioner in accordance with the physician-approved plan of care, the 5 rights and prevailing professional standards.

010.09(A) METHODS OF ADMINISTRATION. When the licensee is responsible for the administration and provision of medication, it must be accomplished by the following methods:

010.09(A)(i) SELF-ADMINISTRATION. Consumers must be allowed to self-administer medication, with or without supervision, when the licensee determines that the consumer is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner. The licensee must implement written policies to address consumer self-administration of medication, including:

(1) Storage and handling of medications; (2) Inclusion of the determination that the consumer may self-administer medication in the consumer’s plan of care; and (3) Monitoring the plan of care to assure continued safe administration of medications by the consumer.

010.09(A)(iii) PROVISION OF MEDICATIONS BY A PERSON OTHER THAN A LICENSED HEALTH CARE PROFESSIONAL. When the licensee uses a person other than a licensed health care professional in the provision of medications, the licensee must use individuals who are registered medication aides and must comply with the Medication Aide Act, and 172 NAC 95 and 96.

010.09(A)(iv) MAINTAIN OVERALL SUPERVISION, SAFETY AND WELFARE OF CONSUMERS. When the licensee is not responsible for medication administration and provision the licensee retains responsibility for overall supervision, safety, and welfare of the consumer.

010.09(B) ADVERSE REACTIONS AND MEDICATION ERRORS. Each licensee must report any adverse reactions to a medication by the consumer and any medication errors in administration or provision of prescribed medications to the consumer’s licensed practitioner immediately upon discovery. A written report of the adverse reaction and medication error must be completed immediately upon discovery and kept in the consumer’s record. Errors include any variance from the 5 rights, the prescription, or professional standards.

010.09(C) VERBAL ORDERS. Each licensee must implement written policies and procedures for those staff authorized to receive telephone and verbal, diagnostic and therapeutic and medication orders.

010.10 CLINICAL RECORDKEEPING REQUIREMENTS. Each licensee must maintain records and reports in a manner that ensures accuracy and easy retrieval.

010.10(A) CLINICAL RECORDS. The licensee must have a clinical record for every consumer receiving care and services. The record must be complete, promptly, and accurately documented, readily accessible and systematically organized to facilitate retrieval. Entries must be made for all services provided and must be made and signed by the person providing the services. The record must include all services whether furnished directly or under arrangements made by the hospice. Each consumer’s record must contain:

(i) The initial and subsequent assessments; (ii) The plan of care; (iii) Identification data; (iv) Consent, authorization, and election forms; (v) Pertinent medical history; and (vi) Complete documentation of all services and events including evaluations, treatments, and progress notes.

010.10(B) INFORMED CONSENT. The licensee must have an informed consent form, signed, and dated by the consumer or designee, which specifies the type of care, treatment and services that may be provided as hospice care during the course of the illness for every consumer.

010.10(C) ITEMIZED BILLING STATEMENT. The licensee must provide, upon written request of a consumer or a consumer’s representative and without charge, an itemized billing statement, including diagnostic codes. The billing statement must be provided within 14 days after the request.

010.11 INPATIENT HOSPICE FACILITY AND 24-HOUR NURSING SERVICES. A licensee that provides inpatient hospice care directly must provide 24-hour nursing services which are sufficient to meet total nursing needs and which are in accordance with the consumer plan of care. Each consumer must receive treatments, medications, and diet as prescribed, and be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection. Each shift must include a registered nurse who provides direct consumer care when there is a consumer in the facility receiving inpatient care for pain control or symptom management.

010.12 FOOD SERVICE. A licensee that provides inpatient care must meet the daily nutritional need of all consumers, including any diet ordered by the attending physician. Food service must include:

(A) Providing food service directly or through a written agreement; (B) A staff member who is trained or experienced in food management or nutrition with the responsibility of:

(C) Being able to meet the needs of the consumer’s plan of care; nutritional needs, and therapeutic diet; and (D) Procuring, storing, preparing, distributing, and serving all food under sanitary conditions and in accordance with the Food Code.

010.13 PHARMACEUTICAL SERVICES. Each licensee that provides inpatient hospice services is responsible for the drugs and biologicals provided to each consumer. Pharmaceutical services must be provided in compliance with state law.

010.13(A) LICENSED PHARMACIST. The licensee must employ a licensed pharmacist or have a formal agreement with a licensed pharmacist to advise the licensee on ordering, storage, administration, disposal, and record keeping of drugs and biologicals.

010.13(B) ORDERS FOR MEDICATIONS. A physician, or licensed practitioner within their scope of practice, must authorize the administration of all medications for the consumer. If the medication order is verbal:

(i) The physician, or licensed practitioner within their scope of practice, must give it only to a licensed nurse, pharmacist, physician assistant, or another physician; and (ii) The individual receiving the order must record and sign it immediately and have the prescribing physician, or licensed practitioner within their scope of practice, sign it in a manner consistent with state law.

010.13(C) CONTROL AND ACCOUNTABILITY. The licensee must have written procedures for control and accountability of all drugs and biologicals throughout the inpatient hospice facility. Drugs must be dispensed in compliance with state and federal law. Records of receipt and disposition of all controlled drugs must be maintained in sufficient detail to enable accurate reconciliation. A pharmacist must determine that drug records are in order and that an account of all controlled drugs is maintained and reconciled.

010.13(D) LABELING OF DRUGS AND BIOLOGICALS. The labeling of drugs and biologicals must comply with state and federal law and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

010.13(E) STORAGE. All drugs and biologicals must be stored in locked compartments under proper temperature controls and only authorized personnel have access to the drugs and biologicals. Separately locked compartments must be used for storage of controlled drugs listed in Schedule II of Neb. Rev. Stat. § 28-405 and other drugs subject to abuse, except under single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

010.13(F) DRUG DISPOSAL. The licensee must have written policies to ensure controlled drugs are disposed of in compliance with State law.

History

Effective 2024-06-02

Chapter 17 Intermediate Care Facilites for Individuals with Intellectual Disabilites (icf/Iid)

Neb. Admin. Code tit. 175, ch. 17 Intermediate Care Facilites for Individuals with Intellectual Disabilites (icf/Iid) {#sec-175-nac-17 omnilex-key=us-ne-regs-official--title-175--175 NAC 17}

001. SCOPE AND AUTHORITY. These regulations govern licensure of intermediate care facilities for Individuals with Intellectual Disabilities (ICFIID) under the Health Care Facility Licensure Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479.

002. DEFINITIONS. Definitions set out in the Health Care Facility Licensure Act, 175 Nebraska Administrative Code (NAC) 1, and the following apply to this chapter.

002.01 ACTIVE TREATMENT. Treatment that meets the requirements specified in 42 CFR 483.440(a).

002.02 DEMENTIA. The disorders characterized by the development of multiple cognitive deficits, including memory impairment, that are due to the direct physiological effects of a general medical condition (not including trauma), to the persisting effects of a substance, or to multiple etiologies such as the combined effects of cerebrovascular disease and Alzheimer’s disease.

002.03 DEVELOPMENTAL DISABILITY. A group of conditions resulting in an impairment in physical, learning, language or behavioral areas that usually begin during the developmental stages in life and may impact day to day functioning.

002.04 FOOD CODE. The Nebraska Food Code as defined in Neb. Rev. Stat. § 81-2,244.01 and as published by the Nebraska Department of Agriculture, except for compliance and enforcement provisions.

002.05 QUALIFIED INTELLECTUAL DISABILITY PROFESSIONAL (QIDP). A professional who is responsible for integrating, coordinating, and monitoring each client’s active treatment program.

002.06 SUPERVISION. The daily observation and monitoring of individuals by direct care staff or oversight of staff by the administrator or administrator’s designee.

002.07 SUPPORT SERVICES. Physical and social modifications or interventions which assist the client in functioning and in adapting to physical and social environments.

002.08 TERMINALLY ILL. A medical prognosis that an individual’s life expectancy is six months or less if the illness runs its normal course.

002.09 TRAINING. The implementation of a systematic program of formal and informal techniques continuously targeted toward assisting the client in achieving the measurable skill competency as identified in individual program plan objectives, which is conducted in all applicable settings, and conducted by all personnel involved with the individual.

003. LICENSING REQUIREMENTS AND PROCEDURES. To receive a license, an applicant must submit a complete application and meet the requirements for a license set out in statute, 175 NAC 1, and in this chapter.

004. GENERAL REQUIREMENTS. The following requirements are applicable to all licenses.

004.01 EFFECTIVE DATE AND TERM OF LICENSE. ICF/ID licenses expire on March 31st of each year.

004.02 LICENSE NOT TRANSFERABLE. Licenses of Intermediate Care Facilities for Individuals with Intellectual Disabilities expire on March 31st of each year.

004.03 FEES. The initial and renewal licensure fees for Intermediate Care Facilities for Individuals with Intellectual Disabilities are as follows:

(A) 1 to 50 Beds $1,550 (B) 51 to 100 Beds $1,750 (C) 101 or more Beds $1,950

005. INSPECTIONS. Intermediate Care Facilities for Individuals with Intellectual Disabilities must meet inspection requirements in 175 NAC 1.

006. STANDARDS OF OPERATION, CARE AND TREATMENT. Each Intermediate Care Facility for Individuals with Intellectual Disabilities must be organized, managed, and administered in a manner by the licensee consistent with the size, resources, and type of services provided to ensure each client receives appropriate care and treatment in a safe manner and in accordance with current standards of practice. Each Intermediate Care Facility for Individuals with Intellectual Disabilities must meet the regulations identified in 175 NAC 1, this chapter, and must satisfy all the elements of the Centers for Medicare and Medicaid (CMS) Conditions of Participation for an Intermediate Care Facility for Individuals with Intellectual Disabilities as set out in 42 Code of Federal Regulations (CFR) 483.150 – 483.480, the Conditions of Coverage for Emergency Preparedness Requirements for an Intermediate Care Facility for Individuals with Intellectual Disabilities, and the State Fire Code and Life Safety Code.

006.01 LICENSEE RESPONSIBILITIES. The licensee has the legal responsibility for the total operation of the facility. The responsibilities of the licensee include:

(A) Monitoring policies to assure the appropriate administration and management of the Intermediate Care Facility for Individuals with Intellectual Disabilities; (B) Ensuring the Intermediate Care Facility for Individuals with Intellectual Disabilities is in compliance with all applicable and state and federal statutes and rules and regulations; (C) Ensuring quality services are provided to all clients whether services are furnished directly by the facility or through contract with another entity; (D) Periodically reviewing reports and recommendations regarding the Quality Assurance Performance Improvement (QAPI) program and implementing programs and policies to maintain and improve the quality of services; (E) Designating an administrator who is responsible for the day-to-day management of the Intermediate Care Facility for Individuals with Intellectual Disabilities and defining the duties and responsibilities of the administrator in writing; (F) Notifying the Division of Public Health in writing within 5 working days when a vacancy in the administrator position occurs including who will be responsible for the position duties until another administrator is appointed; and (G) Notifying the Division of Public Health in writing within 5 working days when the vacancy of the administrator position is filled including the effective date and name of the person appointed.

006.02 ADMINISTRATION. The administrator is responsible for planning, organizing, and directing the operation of the Intermediate Care Facility for Individuals with Intellectual Disabilities. The administrator must report in all matters related to maintenance, operation, and management of the Intermediate Care Facility for Individuals with Intellectual Disabilities to the licensee and be responsible to the licensee. The administrator’s responsibilities include:

(1) Ensuring that the facility protect and promote the health, safety, and well-being of the individuals; (2) Maintaining staff appropriate to meet individuals’ needs; (3) Designating a substitute, who is responsible and accountable for management of the ICF/ID, to act in the absence of the administrator; (4) Developing procedures which require the reporting of any evidence of abuse, neglect, or exploitation of any individual served by the facility in accordance with Neb. Rev. Stat. § 28-372 of the Adult Protective Services Act or in the case of a child, in accordance with Neb. Rev. Stat. § 28-711.

006.02(A) REPORTING. Each licensee must ensure that any incident where staff has reason to believe that abuse, neglect, or exploitation of a client has occurred is reported to:

(i) The Adult and Child Abuse and Neglect Hotline via telephone immediately; and (ii) Local law enforcement as required by state and federal laws.

006.02(B) INVESTIGATION. Each must ensure any incident where staff has reason to believe that abuse, neglect, or exploitation of a client has occurred is thoroughly investigated and the investigation documented in a written report. Within 5 working days of the incident, the facility must submit the written investigative report to the Division of Public Health.

006.02(C) PROTECTION. Each licensee must ensure that clients are protected throughout the investigation. Actions must be taken as a result of the investigation to ensure client safety and to prevent the potential for recurrence.

006.03 STAFF REQUIREMENTS. The licensee must ensure all persons who provide a service to clients meet applicable state laws. The licensee must ensure that all persons for whom a license, certification or registration is required hold the license, certification, or registration in accordance with applicable state laws. Staff may not provide care or treatment that is outside of the scope of practice permitted by the credential held by the individual.

006.03(A) STAFF CREDENTIALS. Each licensee must verify and maintain evidence of the current, active licensure, registration, certification, or other credential for each staff member. This must include, but is not limited to, verification prior to staff assuming assigned job duties; and evidence that such status is checked and maintained throughout the entire time of employment.

006.03(B) CRIMINAL BACKGROUND AND REGISTRY CHECKS. Criminal background and registry checks must be completed prior to employment for each licensed and unlicensed direct care staff member. Documentation of such check must be retained in each staff member’s personnel file for the duration of employment.

006.03(B)(i) CRIMINAL BACKGROUND CHECKS. Criminal background checks must be completed through a governmental law enforcement agency or a private entity that maintains criminal background information.

006.03(B)(ii) REGISTRY CHECKS. A check for adverse findings on the following Nebraska registries:

(1) Nurse Aide Registry; (2) Adult Protective Services Central Registry; (3) Central Register of Child Protection Cases; and (4) Nebraska State Patrol Sex Offender Registry.

006.03(B)(iii) COMPLIANCE. The licensee must:

(1) Not employ staff with a conviction or prior employment history of child or vulnerable adult abuse, neglect, or mistreatment or with adverse findings on the Nurse Aide Registry regarding abuse or neglect of individuals served, or misappropriation of the property of individuals served; (2) Determine how to use the criminal background and registry information, except for the Nurse Aide Registry, in making hiring decisions; and (3) Document any decision to hire a person with a criminal background or adverse registry findings, except for the Nurse Aide Registry. The documentation must include the basis for the decision and how it will not pose a threat to individuals’ safety or property.

006.04 ADMINISTRATION OF MEDICATION. Individuals must receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and prevailing professional standards.

006.04(A) METHODS OF ADMINISTRATION OF MEDICATION. When the facility is responsible for the administration of medication, it must be accomplished by the following methods:

006.04(A)(i) SELF ADMINISTRATION. Individuals must be permitted to self-administer medications if desired, with or without supervision, when the interdisciplinary team has determined the individual is capable of doing so safely. When individuals self-administer medication, the licensee maintains responsibility for the overall supervision, safety, and welfare of the individual.

006.04(A)(ii) LICENSED HEALTH CARE PROFESSIONAL. When licensed health care professionals for whom medication administration is included in their scope of practice are used, the licensee must ensure the medications are properly administered in accordance with prevailing professional standards and state and federal law.

006.04(A)(iii) PERSONS OTHER THAN A LICENSED HEALTH CARE PROFESSIONAL. When persons other than a licensed health care professional are used in the provision of medications, the licensee must only use individuals who are registered medication aides and must comply with 172 NAC 95 and 172 NAC 96.

006.04(B) HANDLING OF MEDICATIONS. The licensee must ensure clients receive medications as prescribed by a medical practitioner. There must be a method for verifying the identity of each client and the following:

(i) Medications sent with a client for temporary absences from the premises are in containers identified for the client; (ii) Medications must be sent with a client upon discharge upon client request; (iii) Medications authorized for one client must not be used for another client or staff; (iv) Any errors in administration or provision of prescribed medications must be reported to the client’s licensed health care professional in a timely manner upon discovery and a written report of the error prepared; and (v) Any adverse reaction to a medication must be reported immediately upon discovery to the client’s licensed health care professional and recorded in the client’s record.

006.04(C) DISPOSAL OF MEDICATIONS. Medications that are discontinued by the medical practitioner, and those medications which are beyond their expiration date, must be destroyed. The facility must identify who will be responsible for disposal of medications and the method to dispose of medications in a timely and safe manner. Documentation of the destruction of medications must be retained for a minimum of 5 years.

006.05 ADMISSION AND RETENTION. Written policies and procedures must be implemented and revised, as necessary, for admission and retention to ensure admission only of clients who have developmental disabilities or related conditions who are in need of an active treatment program; and retention only of such clients unless the following exception applies to the client.

006.05(A) EXCEPTION. If the licensee chooses to participate in providing services to individuals who meet the exception to the retention requirements, the licensee must implement and revise, as necessary, written policies, and procedures to address the retention of individuals who have been receiving and benefiting from active treatment in the Intermediate Care Facility for Individuals with Intellectual Disabilities and who have developed conditions where they no longer can benefit from an active treatment program. These conditions are associated with aging, dementia, decline in health, and terminal illness. The facility must ensure the following:

(i) Documentation from the individual’s attending physician that the transfer or discharge of the individual would be harmful to the individual’s physical, emotional, or mental health; (ii) Current and accurate assessments relevant to the individual’s condition and needs; (iii) The individual program plan or plan of care must document:

(1) The continued stay is in the best interest of the individual, and that transfer, or discharge would be harmful to the individual; (2) The interdisciplinary team rationale for the decision for continued stay; (3) The specific current needs of the individual; and (4) The plan and treatment approach to address the individual’s current needs and conditions;

(iv) The licensee must provide services to meet the individual’s current needs and condition(s); and (v) The licensee must primarily serve individuals who are receiving and benefiting from an active treatment program.

007. PHYSICAL PLANT STANDARDS. The licensee must ensure that the facility is designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of services to be provided. Physical plant standards in 175 NAC 1 and the following apply.

007.01 FOOD SERVICE. If food preparation is provided on site, the facility must dedicate space and equipment for the preparation of meals. Facilities licensed for more than 16 individuals must comply with the Food Code.

007.01(A) SMALL FACILITIES. For licensees who serve 16 or fewer clients or for areas of the facility used only for training or activity purposes, the licensee may follow the Food Code, or the licensee meet the following requirements:

(i) An automatic dishwasher final rinse cycle temperature of not less than 150 degrees Fahrenheit must be used; (ii) Refrigerated foods must be stored between 35 and 45 degrees. Frozen foods must be stored below 32 degrees; (iii) Temperatures of potentially hazardous foods must be 45 degrees Fahrenheit or below or 140 degrees Fahrenheit or above at all times; (iv) Food preparation and eating areas must be sanitary; and (v) All equipment and utensils, including dishes, glassware, and silverware used in the serving or preparation of food or drink for individuals must be thoroughly cleaned after each use and stored in a manner to ensure they are kept free of dust, vermin, and contamination.

007.02 LAUNDRY. Written procedures must be implemented, and revised, as necessary, for the storage and handling of soiled and clean laundry and linens in accordance current, accepted standards of practice and in a manner to reduce any risk of cross-contamination and or infections. Laundry may be completed onsite or by contract with an outside entity.

007.02(A) CONTRACT. If contractual services are used, areas for soiled laundry awaiting pickup and separate areas for storage and distribution of clean laundry must be used.

007.02(B) ON-SITE. If on-site services are provided, areas dedicated to laundry must be provided and include the following:

(i) Laundry areas must be equipped with a washer and dryer; (ii) Laundry areas must be divided into separate soiled areas for sorting and washing and separate clean areas for drying, folding, and mending. In new construction, there must be a conveniently located sink for soaking and hand washing of laundry and a housekeeping room; and (iii) Water temperatures in the laundry must exceed 160 degrees Fahrenheit, or an acceptable sanitizer or disinfectant must be used in accordance with the manufacturer’s instructions.

007.03 WASTE PROCESSING. Areas to collect, contain, process, and dispose of waste produced within the facility in a manner to prevent the attraction of rodents, flies, and all other insects and vermin, and to minimize the transmission of infectious diseases.

007.04 COSMETOLOGY AND BARBER SERVICES. When provided, cosmetology and barber services must be in conformance with the Nebraska Cosmetology, Electrology, Esthetics, Nail Technology, and Body Art Practice Act, Neb. Rev. Stat. §§ 38-1001 to 38-10,171 and the Barber Act, Neb. Rev. Stat. §§ 71-201 to 71-255.

007.05 PHARMACEUTICAL. The services must be provided in compliance with statutes governing the practice of pharmacy.

007.06 FLOOR AREA. Floor area is the space with ceilings at least 7 feet in height and excludes enclosed storage, toilet and bathing rooms, corridors, and halls. The space beyond the first 2 feet of vestibules and alcoves less than 5 feet in width is not included in the required floor area. In rooms with sloped ceilings, at least half of the ceiling must be at least 7 feet in height. Areas less than 5 feet in height are not included in the required floor area.

007.07 DINING AND ACTIVITY AREAS. Adequate space for dining, socialization, and leisure activities must be provided. A minimum of 15 square feet per individual in existing facilities and 20 square feet per individual in new construction is required. Dining and activity areas cannot be used for sleeping, offices, or corridors.

007.08 BATHING ROOMS. The facility must provide a bathing room consisting of a tub or shower equipped with hand grips or other assistive devices as needed or desired by the individual. The facility must have one bathing fixture per 20 licensed beds in existing facilities, and one fixture per eight licensed beds in new facilities and new construction.

007.09 TOILET ROOMS. The facility must provide a room with a sink and toilet for individuals’ use with one fixture per eight licensed beds in existing facilities, and one fixture per four licensed beds in new facilities and new construction.

007.10 BEDROOMS. The facility must provide bedrooms that provide for sleeping, afford privacy, provide reasonable access to furniture and belongings, and accommodate the needs of the individual. All bedrooms must:

(A) Not be accessed through a bathroom, food preparation area, laundry, office, or another bedroom; (B) Be located on an outside wall with an operable window with a minimum glass size of 6 square feet per individual in new construction and new facilities; (C) Contain at least 35 cubic feet of storage volume per individual in dressers, closets, wardrobes, or other similar types of storage; (D) Have 80 square feet of floor area for a single bedroom and 60 square feet of floor area per individual in a multiple bedroom; and (E) Not exceed 4 beds per room in existing facilities and 2 beds per room in new construction and new facilities.

007.11 CORRIDORS. The facility’s corridors must be wide enough to allow passage and be equipped as needed by the individuals with safety and assistive devices. All stairways and ramps must have handrails.

007.12 DOORS. The facility’s doors must be wide enough to allow passage and be equipped as needed by the individuals for privacy and safety.

007.13 OUTDOOR AREAS. The facility must provide an outdoor area for individuals’ use. It must be equipped and situated to provide for safety and the abilities of the individuals.

007.14 EMERGENCY TELEPHONE. The facility must provide non-coin operated telephone(s) in working order, accessible to individuals based on their needs, located on the premises for local calls and emergencies. Emergency numbers must be easily accessible near the telephone.

007.15 PRIVACY. Window coverings to ensure visual privacy of the individuals.

007.16 BUILDING SYSTEMS. The facility must have building systems that are designed, installed, and that operate in a manner to provide for the safety, comfort, and wellbeing of the clients.

007.17 WATER AND SEWER SYSTEMS. The facility must have and maintain an accessible, adequate, safe, and potable supply of water.

(A) Where an authorized public water supply of satisfactory quantity, quality, and pressure is available, the facility must be connected to it and its supply used exclusively. (B) If the facility does not utilize an authorized public water supply, the facility must construct, maintain, and operate the water supply as if it were a public water system in accordance with the regulations governing Public Water Systems, 179 NAC 2-002, 3 and 4. The facility must construct all water wells in accordance with 178 NAC 12.

007.18 HOT WATER SYSTEM. All buildings must have hot and cold water to all handwashing and bathing locations with water temperatures for the comfort and safety of each individual. Hot water temperatures must not exceed 120 degrees Fahrenheit.

007.19 HEATING AND COOLING SYSTEMS. The facility must provide a heating and air conditioning system for the comfort of the individuals and capable of maintaining temperatures of at least 70 degrees Fahrenheit during heating conditions and that does not exceed 85 degrees Fahrenheit during cooling conditions.

007.20 VENTILATION SYSTEM. The facility must provide exhaust and clean air to prevent the concentrations of contaminants which impair health or cause discomfort to clients and staff.

007.21 ELECTRICAL SYSTEM. The facility must have an electrical system that has sufficient capacity to maintain the services that are provided and that provides proper grounds.

007.22 ILLUMINATION. Minimum illumination levels which are measured at 30 inches above the floor in multiple areas in the room must provide as follows:

(A) General purpose areas – 5-foot candles; (B) General corridors and individuals’ living areas – 10-foot candles; (C) Personal care and food preparation areas – 20-foot candles; and (D) Activity areas – 30-foot candles.

007.23 EMERGENCY POWER SYSTEM. If the licensee provides services to individuals who need electrical life support equipment, the facility must maintain an emergency power system for that equipment.

History

Effective 2024-05-05

Chapter 18 Mental Health Substance Use Facilities

Neb. Admin. Code tit. 175, ch. 18 Mental Health Substance Use Facilities {#sec-175-nac-18 omnilex-key=us-ne-regs-official--title-175--175 NAC 18}

001. SCOPE AND AUTHORITY . These regulations govern licensing of Mental Health Substance Use Treatment Centers under Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 71-401 to 71-479 of the Health Care Facility Licensure Act.

002. DEFINITIONS . Definitions are set out in the Health Care Facility Licensure Act, 175 Nebraska Administrative Code (NAC) 1, and this chapter.

002.01 CIVIL PROTECTIVE CUSTODY. Civil protective custody allows the police to take a person into custody to receive medical supervision when alcohol or drug abuse makes them a danger to themselves or others.

002.02 COUNSELING. A professional relationship in which a practitioner assists the client with understanding, coping with, solving, and preventing problems, including areas of education, vocation, and interpersonal relationships in the social environment.

002.03 CRISIS MANAGEMENT. Treatment provided to immediately resolve an acute physical, social, or psychological emergency. It may include temporary housing, food, care, treatment, or referral to an emergency medical service or to a facility appropriate to meet the needs of the client. It is frequently the entry point into the continuum of care and provides an initial screening and evaluation.

002.04 EMERGENCY DETOXIFICATION PROGRAM. A medically supervised treatment program for clients with alcohol or drug intoxication, designed to rid the body of toxic substances and manage withdrawal symptom.

002.05 INDIVIDUALIZED SERVICE PLAN (ISP). A written action plan based on assessment data that identifies the client’s needs and the strategy for providing care and treatment to meet those needs.

002.06 MAINTENANCE ACTIVITIES. A provision of services intended to support a client who is a substance user to reduce or eliminate the use of substances.

002.07 MENTAL DISEASE, DISORDER, OR DISABILITY. A primary diagnosis of mental illness which is characterized by one or more functional impairments in the following areas: vocational, educational, emotional, social, or activities of daily living.

002.08 RELATED SERVICES. Activities that assist the client in carrying out their therapeutic activities as outlined in their individualized service plan (ISP).

002.09 SELF-HELP PROGRAM. A program for clients who are substance users which provides mutual support and encouragement to encourage them to avoid substance use. If a substance use professional is involved in a self-help program, it is only in an advisory or informational capacity rather than a supervisory or administrative capacity.

002.10 SELF-RUN PROGRAM. A program, which may be residential, operated by persons who are substance users for their own benefit. If a substance use professional is involved in a self-run program, it is only in an advisory or informational capacity rather than a supervisory or administrative capacity.

002.11 SOCIAL SETTING EMERGENCY DETOXIFICATION. A program for the treatment of clients who are experiencing acute intoxication and whose condition necessitates observation by a qualified person but does not necessitate medical treatment.

002.12 SUBSTANCE USE. The use of substances which have significant mood-changing or perception-changing capacities, which are likely to be physiologically or psychologically addictive, and the continued use of which may result in negative social consequences.

002.13 SUPPORTIVE SERVICES. Services which support personal care, provision of medications, activities of daily living and health maintenance activities.

002.14 THERAPEUTIC ACTIVITY. A professionally directed set of actions designed to lessen the effects of the disease, whether physical or mental, and designed to facilitate a behavior change in a client.

002.15 TIME OUT. Removal of a client from a setting in which he or she is exhibiting inappropriate behavior until the client exhibits appropriate behavior. The client is generally required to remain in an unlocked room or area where there are no other individuals except for staff monitoring the client.

003. LICENSING REQUIREMENTS . An applicant intending to establish, operate, or maintain a mental health substance use treatment center must first obtain a license from the Department by meeting the requirements in the Health Care Facility Licensure Act, 175 NAC 1, and this chapter.

004. GENERAL REQUIREMENTS . The following are the general terms and conditions regarding licensing for mental health substance use treatment centers.

004.01 EFFECTIVE DATE AND TERM OF LICENSE. A mental health substance use treatment center license expires annually on September 30.

004.02 FEES. The initial and renewal fees for mental health substance use treatment center facilities are based on the number of beds for which the facility is licensed:

(A) 1 to 16 Beds $250 (B) 17 to 50 Beds $275 (C) 51 or more Beds $300

005. INSPECTIONS . See 175 NAC 1 for inspections regarding mental health substance use treatment centers.

006. STANDARDS OF OPERATION, CARE, AND TREATMENT . Each mental health substance use treatment center must be organized, managed, and administered in a manner consistent with the size, resources, and type of services provided to ensure each client receives necessary care and treatment in a safe manner and in accordance with current standards of practice, and in accordance with the Healthcare Facility Licensure Act, 175 NAC 1, and this chapter.

006.01 LICENSEE. The licensee must establish, implement, and revise as necessary written policies and procedures to assure that the mental health substance use treatment center is administered and managed appropriately. The licensee’s responsibilities include:

(A) Monitoring policies to assure appropriate administration and management of the facility; (B) Ensuring the facility’s compliance with all applicable state statutes and relevant rules and regulations; (C) Ensuring the quality of all services, care, and treatment provided to clients whether those services, care, or treatment are furnished by facility staff or through contract with the facility; (D) Designating an administrator who is responsible for the day-to-day management of the facility; (E) Defining the duties and responsibilities of the administrator in writing; (F) Notifying the Department in writing within 5 working days when a vacancy in the administrator position occurs, including who will be responsible for the position until another administrator is appointed; (G) Notifying the Department in writing within 5 working days when the administrator vacancy is filled indicating effective date and name of person appointed administrator; (H) Ensuring clients are provided with a stable and supportive environment, through respect for the rights of clients and responsiveness to client needs; (I) Receiving periodic reports and recommendations regarding the quality assurance performance improvement program; (J) Implementing programs and policies to maintain and improve the quality of client care and treatment based on quality assurance performance improvement reports; and (K) Ensuring that staff levels are sufficient to meet the client’s needs.

006.02 ADMINISTRATION. The administrator is responsible for planning, organizing, and directing the day-to-day operation of the mental health substance use treatment center. The administrator must report and be directly responsible to the licensee in all matters related to the maintenance, operation, and management of the facility. The administrator’s responsibilities include:

(A) Being on the premises a sufficient number of hours to permit adequate attention to the management of the facility, ensuring the facility’s compliance with applicable rules and regulations; (B) Ensuring that the facility protects and promotes the client’s health, safety, and well-being; (C) Maintaining staff appropriate to meet clients’ needs; (D) Designating a substitute administrator, who is responsible and accountable for management of the facility, to act in the absence of the administrator; (E) Developing and implementing procedures which require the reporting of any evidence of abuse, neglect, or exploitation of any client served by the facility in accordance with Neb. Rev. Stat. § 28-372 of the Adult Protective Services Act, or in the case of a child, in accordance with Neb. Rev. Stat. § 28-711; and (F) Ensuring the facility conducts a thorough investigation on suspected abuse, neglect, or exploitation and that steps are taken to prevent abuse and neglect and protect clients.

006.03 STAFFING. The mental health substance use treatment center must maintain a sufficient number of staff with the required training and skills necessary to meet the client population’s requirements for care and treatment, including needs for therapeutic activities, supervision, support, health, and safety needs. The facility must provide care and treatment to clients in a safe and timely manner.

006.03(A) STAFF CREDENTIALS. Each mental health substance use treatment center must establish, implement, and revise as necessary written policies and procedures to verify and maintain evidence of the current, active licensure, registration, certification, or other credential for each staff member in accordance with applicable state law. This must include, but is not limited to, verification prior to staff assuming assigned job duties, and evidence that such status is checked and maintained throughout the entire time of employment.

006.03(B) HEALTH STATUS. The mental health substance use treatment center must establish, implement, and revise as necessary, policies and procedures regarding the health status of staff who provide direct care or treatment to clients to prevent the transmission of infectious disease. The facility:

(i) Must complete a health screening for each staff person prior to assuming job responsibilities; and (ii) May, in its discretion, based on the health screening require a staff person to have a physical examination.

006.03(C) STAFF TRAINING. The mental health substance use treatment center must provide staff with sufficient initial and ongoing training to meet client needs. Training must be provided by a person qualified by education, experience, and knowledge in the area of the service being provided. A record must be kept of all training including orientation, in-service, or other training programs including names of staff attending, subject matter of the training, names and qualifications of the instructors, dates of the training, length of training sessions and any written materials provided.

006.03(D) INITIAL ORIENTATION. The mental health substance use treatment center must provide staff with orientation prior to the staff person having direct responsibility for care and treatment of clients. The training must include:

(i) Client rights; (ii) Job responsibilities relating to care and treatment programs and client interactions; (iii) Emergency procedures including information regarding availability and notification; (iv) Information on any physical and mental special needs of the clients of the facility; and (v) Information on abuse, neglect, and misappropriation of money or property of a client and the reporting procedures.

006.03(F) DOCUMENTATION. The mental health substance use treatment center must maintain written documentation in each employee’s file:

(i) To support facility decisions regarding staffing of the facility, staff credentials, and staff health status; and (ii) Regarding staff orientation and ongoing training.

006.03(G) CRIMINAL BACKGROUND AND REGISTRY CHECKS. Each mental health substance use treatment center must complete and maintain documentation of pre-employment criminal background and registry checks on each unlicensed direct care staff member.

006.03(G)(i) CRIMINAL BACKGROUND CHECKS. The mental health substance use treatment center must complete criminal background checks through a governmental law enforcement agency or a private entity that maintains criminal background information.

006.03(G)(ii) REGISTRY CHECKS. The mental health substance use treatment center must check for adverse findings on the following registries:

(1) Nurse Aide Registry; (2) Adult Protective Services Central Registry; (3) Central Register of Child Protection Cases; and (4) Nebraska State Patrol Sex Offender Registry.

006.03(G)(iii) ADVERSE FINDINGS. The mental health substance use treatment center must not employ staff with adverse findings on the Nurse Aide Registry regarding abuse or neglect of individuals served, or misappropriation of the property of clients served. The mental health substance use treatment center must:

006.04 CLIENT RIGHTS. A mental health substance use treatment center must protect and promote each client’s rights. This includes the establishment, implementation, and revision as necessary of written policies and procedures to ensure clients are afforded the opportunity to exercise their rights and documented evidence that all clients have been informed of their rights in a manner and format that they can easily understand. Each client must have the right to:

(A) Be informed in advance about care and treatment and of any changes in care and treatment that may affect the client’s well-being; (B) Self-direct activities and participate in decisions regarding care and treatment; (C) Confidentiality of all records, communications, and personal information; (D) Voice complaints and file grievances without discrimination or reprisal and to have those complaints and grievances addressed; (E) Examine the results of the most recent survey of the facility conducted by representatives of the Department; (F) Be free of restraints except when indicated in 175 NAC 18.006.05(A),(B),(C),(D), and (E); (G) Be free of seclusion in a locked room, except when indicated in 175 NAC 18-006.05(A),(B),(C),(D), and (E) and except in cases of civil protective custody; (H) Be free of physical punishment; (I) Exercise his or her rights as a client of the facility and as a citizen of the United States; (J) Be free from arbitrary transfer or discharge; (K) Be free from involuntary treatment, unless the client has been involuntarily committed by appropriate court order and except in cases of civil protective custody; (L) Be free from abuse and neglect and misappropriation of their money and personal property; (M) Be informed prior to or at the time of admission and during stay at the facility of charges for care, treatment, or related charges; (N) Privacy in written communication including sending and receiving mail consistent with individualized service plans (ISP); (O) Receive visitors as long as this does not infringe on the rights and safety of other clients and is consistent with individualized service plans (ISP); (P) Have access to a telephone where calls can be made without being overheard when consistent with individualized service plans (ISP); and (Q) Retain and use personal possessions, including furnishings and clothing as space permits, unless to do so would infringe upon the rights and safety of other clients.

006.05 RESTRAINTS AND SECLUSION. A mental health substance use treatment center must not use restraints or seclusion for clients except as set forth in this section.

006.05(A) CIVIL PROTECTIVE CUSTODY. When a client is placed at the mental health substance use treatment center under civil protective custody, in which case restraint may be used only to the extent necessary to protect the client and others from harm. The facility must comply with Building Code and Life Safety Code requirements for locked or secured environments.

006.05(B) RESTRAINT AND SECLUSION. Restraint and seclusion include the following interventions:

(i) Seclusion; (ii) Mechanical restraint; (iii) Chemical restraint; (iv) Manual restraint; and (v) Time-out.

006.05(C) SECURED ENVIRONMENT. A mental health substance use treatment center may provide a secured and protective environment by restricting a client’s exit from the facility or its grounds through the use of approved locking devices on exit doors or other closures that must be accredited by an approved qualifying organization. The approved qualifying organizations include:

(i) The Joint Commission; (ii) Commission on Accreditation of Rehabilitation Facilities; and (iii) Council on Accreditation for Children and Family Services.

006.05(D) USE OF RESTRAINTS AND SECLUSION IN ACCREDITED FACILITIES. A mental health substance use treatment center that is accredited by an approved qualifying organization may use restraint and seclusion methods as part of a client’s treatment plan. The facility must comply with the approved qualifying organization’s requirements for initiation and continued use of restraint and seclusion.

006.05(E) USE OF RESTRAINTS AND SECLUSION IN NON-ACCREDITED FACILITIES. Except in the case of civil protective custody, a non-accredited mental health substance use treatment center is prohibited from using mechanical and chemical restraints and seclusion. The facility must establish alternative and less restrictive methods for staff to use in the place of restraints and seclusion to deal with client behaviors. A non-accredited mental health substance use treatment center may use manual restraint and time out as therapeutic techniques only after it has:

(i) Written policies and procedures for the use of manual restraint and time-out; (ii) Documented physician approval of the methods used by the facility; (iii) Trained all staff who might have the occasion to use manual restraints and time-out in the appropriate methods to use in order to protect client safety and rights; and (iv) Developed a system to review each use of manual restraint or time-out. The facility must ensure the process includes the following:

(1) That each use of manual restraint or time-out has been reported to the administrator for review of compliance with facility procedures; (2) That documentation of each use of manual restraint or time-out include a description of the incident and identification of staff involved; (3) A situation where the safety of the client or others is threatened; (4) The implementation and failure of other less restrictive behavior interventions have not been effective; and (5) Use of manual restraints or time out only by staff who are trained.

006.06 FACILITY HOUSE RULES. Except for emergency detoxification programs, the facility must develop reasonable house rules outlining operating protocols. The facility must provide the clients an opportunity to review and provide input into any proposed changes to house rules before the revisions become effective. The house rules must be:

(A) Consistent with client rights; (B) Posted in an area readily accessible to clients; and (C) Reviewed and updated, as necessary.

006.07 CARE AND TREATMENT REQUIREMENTS. The facility must ensure that all clients receive care and treatment in accordance with the facility’s program and that the facility meets each client’s identified needs.

006.07(A) PROGRAM DESCRIPTION. The facility must have a written program description that is available to staff, clients, and members of the public that explains the range of care and treatment activities provided. The description must include the following:

(i) The mission statement, program philosophy, goals and objectives developed by the governing body; (ii) The levels of care and treatment provided, including inpatient and outpatient components, when applicable; (iii) The client population served, including age groups and other relevant characteristics; (iv) The hours and days the facility provides care and treatment; (v) Staff composition and staffing qualification requirements to sufficiently provide care and treatment to meet facility goals and objectives; (vi) Staff job responsibilities for meeting care and treatment facility goals and objectives; (vii) The admission and discharge processes, including criteria for admission and discharge; (viii) A system of referral for alternative services for those individuals who do not meet admission criteria; (ix) The client admission and ongoing assessment and evaluation procedures used by the program, including individualized service plan (ISP) process; (x) A plan for providing emergency care and treatment, including use of facility approved interventions to be used by staff in an emergency situation; (xi) Quality assurance and improvement processes, including who will be responsible for the program and how results will be utilized to improve care and treatment; (xii) A system governing the reporting, investigation, and resolution of allegations of abuse, neglect, and exploitation; and (xiii) Client rights and the system for ensuring client rights will be protected and promoted.

006.07(B) ANNUAL REVIEW. The facility must review all elements of the written program at least annually. The facility must document the results of the annual review. Relevant findings from facility’s quality assurance performance improvement program for the purpose of improving client treatment and resolving problems in client care and treatment must be included in the review process. The licensee must revise the program description, as necessary, to reflect accurately care and treatment the facility is providing.

006.08 CLIENT ADMISSION. The facility must ensure that its admission practices meet the client’s identified needs and conform with the facility’s program description.

006.08(A) ADMISSION CRITERIA. The facility must have written criteria for admission that includes each level of care and the components of care and treatment provided by the facility. The written criteria must include how eligibility for admission is determined based on:

(i) Identification of client need for care and treatment, including the severity of the presenting problem; (ii) Rationale for determining appropriate level of care and treatment; and (iii) Need for supervision and other issues related to providing care and treatment.

006.08(B) ADMISSION DECISIONS. The facility must ensure that the decision to admit a client is based upon the facility’s admission criteria and the facility’s capability to meet the identified needs of the client.

006.08(C) ADMISSION ASSESSMENT. The facility must develop an assessment of the client to identify the effects of substance use on the client’s life, except for a client in an emergency detoxification program. The facility must complete the assessment process for each client within the following timelines within 15 days of the client admission to the facility. The assessment must include:

(i) An evaluation of the client which satisfies the facility’s admission criteria; (ii) The type and extent of any clinical examinations that were determined necessary; and (iii) Information on associated medical and psychological issues.

006.08(D) EMERGENCY DETOXIFICATION PROGRAM. The facility must evaluate a client in an emergency detoxification program as to his or her immediate need and implement the facility’s procedures for its emergency detoxification program.

006.08(E) INDIVIDUALIZED SERVICE PLAN (ISP). Each client, except for a client admitted to an emergency detoxification program, must have an individualized service plan (ISP) based on the assessment of the client’s needs. The facility must assign overall responsibility for development and implementation of the individualized service plan (ISP) to a qualified staff person in accordance with facility’s program description. The facility must base the intensity of care and treatment provided on the client’s need. The facility must:

(i) Begin to develop the initial individualized service plan (ISP) of care upon admission; (ii) Implement the individualized service plan (ISP) as soon as it has been established; and (iii) Complete development of the individualized service plan (ISP) when the assessment process is finished. The individualized service plan (ISP) must:

(1) Specify the care and treatment necessary to meet the client’s assessed needs; (2) Include referrals for needed services that the facility does not provide; (3) Contain specific goals and the measurement the client will use to achieve reduction or elimination of substance use; (4) Specify the extent and frequency of care and treatment; (5) Specify criteria to be met for termination of care and treatment; (6) Define therapeutic activity; (7) Document client participation in the development of the individualized service plan (ISP) by client signature and dates of participation or justification for the lack of the client’s signature; and (8) Estimate the length of stay and the plan for discharge.

006.08(F) EVALUATION OF CARE AND TREATMENT. The facility must periodically evaluate the client’s individualized service plan (ISP) as indicated by the client’s need and response to care and treatment. The maximum intervals between evaluations of the individualized service plan (ISP) are:

(i) Every 30 days for intensive treatment which consists of any level of inpatient treatment or outpatient treatment involving ten or more hours of therapeutic activity per week. This does not include client participation in self-help groups; and (ii) Every 90 days for less intensive treatment which consists of less than ten hours of therapeutic activity per week either at an inpatient or outpatient facility. This does not include client participation in self-help groups.

006.08(G) CARE AND TREATMENT PROVIDED. Care and treatment must meet client needs on an ongoing basis in a manner that respects clients’ rights, promotes recovery, and affords personal dignity, it must also include a communication component which encompasses methods and interventions outlining how facility staff need to communicate with the client and their designee in a manner and method the patient and designee can comprehend.

006.08(G)(i) INPATIENT FACILITY. An inpatient facility must, at a minimum, provide the following:

(1) Therapeutic activities as described in the facility program description; (2) Adequate food and shelter; (3) Medical and clinical oversight of client needs as identified in the client assessment; (4) Assistance and support, as necessary, to enable the client to meet personal hygiene and clothing needs; (5) Assistance and support, as necessary, to enable the client to meet laundry needs, which may include access to washers and dryers so that clients can do their own personal laundry if included in the client’s individualized service plan (ISP); (6) Assistance and support, as necessary, to enable the client to meet his or her housekeeping needs including access to materials needed to perform his or her own housekeeping duties as determined by the client’s individualized service plan (ISP); and (7) Health-related care and treatment, as necessary.

006.08(G)(ii) EMERGENCY DETOXIFICATION PROGRAM. An inpatient facility must provide an emergency detoxification program. Beds in an emergency detoxification program must be considered inpatient beds for calculation of licensure fees. Types of emergency detoxification include:

(1) Civil protective custody which:

(a) Is involuntary; (b) Is initiated by a law enforcement office; and (c) Has a maximum duration of 24 hours; and

(2) Social setting emergency detoxification which:

(a) Is voluntary; (b) Is initiated by the client or designee; and (c) Has a maximum duration of 5 calendar days.

006.08(G)(iii) POLICIES AND PROCEDURES. A mental health substance use treatment center providing one or both types of emergency detoxification programs must have policies and procedures for the assessment, observation, and routine monitoring of clients. A licensed physician must document the appropriateness of the facility’s policies and procedures. The policies and procedures must include:

(1) Recording the client’s identifying information, if available; (2) Determining the client’s level of consciousness; (3) Monitoring vital signs including temperature, respirations, pulse, and blood pressure; (4) Observing and monitoring at specific time intervals; (5) Determining the onset of acute withdrawal or psychiatric emergency according to methods established by the facility; (6) Assessing the need for medical treatment and initiating appropriate, established procedures for referral to a medical facility; and (7) Managing observation and monitoring according to methods established by the facility when the client is not cooperative.

006.09 DISCHARGE AND TRANSFER REQUIREMENTS. The facility must establish discharge criteria and use those criteria in developing an appropriate plan for discharge jointly with the client. A discharge plan is not required for clients in an emergency detoxification program. The discharge plan must include:

(1) A relapse prevention plan, which includes triggers and interventions for client to activate; (2) The client’s plan for follow up, continuing care, or other post-care and treatment services; (3) Documentation of referrals made for the client by the facility; (4) The client’s plan to further his or her recovery; (5) The client’s signature and the date; and (6) A treatment summary that will be completed no later than 30 days after the client’s discharge. The summary must include a description of the client’s progress under his or her individualized service plan (ISP), the reason for discharge, and any recommendations to the client.

006.09(A) DISCHARGE AND TRANSFER CRITERIA. A facility must establish written discharge criteria which is used by the facility administrator or designee to determine appropriate discharge or transfer for each client. The criteria establishing the basis for discharge must include:

(i) Client no longer is needing or desiring services provided at the facility; (ii) Client is requiring services or treatment not available at the facility; (iii) Client behavior is posing a threat to the health or safety of him or herself or to others and cannot be addressed with care and treatment available at the facility; (iv) Non-payment of fees in accordance with fee policy; and (v) Client is violating house rules resulting in significant disturbance to other clients or members of the community.

006.09(B) DISCHARGE PLAN. Within the first 30 days of admission a discharge plan must be developed including:

(i) Plan for follow up or continuing care; and (ii) Documentation of referrals made for the client.

006.10 MENTAL AND HEALTH MANAGEMENT. The facility must offer the client medical attention when needed. Arrangements for health services must be made with the consent of the client or designee.

006.10(A) PROFESSIONAL SERVICES. The facility must arrange for licensed mental health professional services consistent to meet client population served and individual client needs on an ongoing basis.

006.10(B) EMERGENCY MEDICAL SERVICES. The facility must have a plan delineating the manner in which medical emergency services is accessed to ensure timely response to emergency situations.

006.10(C) HEALTH SCREENINGS. The facility must ensure that each client has access to a qualified health care professional who is responsible for monitoring the client’s health care. Health screenings must be done in accordance with the recommendations of a qualified health care professional.

006.10(D) SUPERVISION OF NUTRITION. The facility must:

(i) Monitor clients whose assessment indicates potential nutritional problems; and (ii) Provide care and treatment to meet the identified nutritional needs.

006.10(E) ADMINISTRATION OR PROVISION OF MEDICATIONS. Each facility must establish and implement policies and procedures to ensure that clients receive medications only as legally prescribed by a medical practitioner in accordance with the five rights and with prevailing professional standards.

006.10(E)(i) METHODS OF ADMINISTRATION OF MEDICATION. When the facility is responsible for the administration of medication, it must be accomplished as set out in this section.

006.10(E)(i)(1) SELF-ADMINISTRATION OF MEDICATIONS. Clients may be allowed to self-administer medications, with or without visual supervision, when the facility determines that the client is competent and capable of doing so and has the capacity to make an informed decision about taking medications in a safe manner. The facility must develop and implement policies to address client self-administration of medication, including:

(a) Storage and handling of medications; (b) Inclusion of the determination that the client may self-administer medication in the client’s individualized service plan (ISP); and (c) Monitoring the plan to assure continued safe administration of medications by the client.

006.10(E)(i)(2) LICENSED HEALTH CARE PROFESSIONAL. When the facility uses a licensed health care professional for whom medication administration is included in the scope of practice, the facility must ensure the medications are properly administered in accordance with prevailing professional standards.

006.10(E)(i)(3) PROVISION OF MEDICATION BY A PERSON OTHER THAN A LICENSED HEALTH CARE PROFESSIONAL. When the facility uses a person other than a licensed health care professional in the provision of medications, the facility must follow 172 NAC 95, Regulations Governing the Provision of Medications by Medication Aides and Other Unlicensed Persons and 172 NAC 96, Regulations Governing the Medication Aide Registry.

006.10(E)(ii) SUPERVISION. When the facility is not responsible for medication administration or provision, the facility must maintain responsibility for overall supervision, safety, and welfare of the client.

006.10(F) REPORTING OF MEDICATION ERRORS. The facility must establish, implement, and revise as necessary policies and procedures for reporting errors in administration or provision of prescribed medication and adverse reactions to medication. Any variance from the five rights must be reported as an error. Reporting must be in writing to the client’s medical practitioner in a timely manner upon discovery.

006.10(G) STORAGE OF MEDICATION. All medications must be stored in locked areas and stored in accordance with the manufacturer’s instructions for temperature, light, humidity, or other storage instructions.

006.10(H) ACCESS TO MEDICATION. The facility must ensure that only authorized staff who are designated by the facility to be responsible for administration or provision of medications have access to medications.

006.10(I) AS PRESCRIBED. The facility must ensure that clients receive medications as prescribed by a medical practitioner.

006.10(J) MEDICATION RECORD. The facility must maintain records in sufficient detail to assure clients receive medications prescribed by a medical practitioner and maintain records to protect medications against theft or loss. Each client must have an individual medication administration record which includes:

(i) Identification of the client; (ii) Name of the medication given; (iii) Date, time, dosage, and method of administration for each medication administered or provided, and the identification of the person who administered or provided the medication and any refusal by the client; and (iv) Client’s medication allergies and sensitivities, if any.

006.10(K) DISPOSAL OF MEDICATIONS. Medications that are discontinued and medications which are beyond their expiration date, must be destroyed. The facility must develop and implement policies and procedures to identify who will be responsible for disposal of medications and how disposal will occur.

006.10(L) MEDICATION PROVISION DURING TEMPORARY ABSENCES. When a client is temporarily absent from the facility, the facility must put medication scheduled to be taken by the client in a container identified for the client.

006.11 FOOD SERVICE. When the facility provides food service, it must ensure the food is of good quality, properly prepared, and served in sufficient quantities and frequency to meet the daily nutritional needs of each client. The facility must ensure that clients receive special diets when ordered by a licensed health care professional. Food must be prepared in a safe and sanitary manner.

006.11(A) FOOD PREPARATION. If food preparation is provided on site, the facility must have dedicated space and equipment for the preparation of meals. Facilities licensed for more than 16 individuals must comply with the Nebraska Food Code.

006.11(B) MENUS. The facility must ensure that menus as served are maintained for at least 14 days, and must ensure that:

(i) Meals and snacks are appropriate to the client’s needs and preferences; (ii) A sufficient variety of foods must be planned and served in adequate amounts for each client at each meal. Menus must be adjusted for seasonal changes; and (iii) Written menus are based on the Food Guide Pyramid or equivalent and modified to accommodate special diets as needed by the client.

006.12 RECORD KEEPING REQUIREMENTS. The facility must maintain complete and accurate records to document the operation of the facility and care and treatment of the clients.

006.13 CLIENT RECORDS. A record must be established for each client upon admission. Each record must contain sufficient information to clearly identify the client, to justify the care and treatment provided and to document the results of care and treatment accurately. Each record must contain the following information:

(1) Dates of admission and discharge; (2) Name of client; (3) Gender and date of birth; (4) Demographic information, including address and telephone number; (5) Physical description or client photo identification; (6) Admission assessment information and determination of eligibility for admission; (7) Health screening information; (8) Individualized service plans (ISP); (9) Physician orders; (10) Medications and any special diet; (11) Significant medical conditions; (12) Allergies; (13) Person to contact in an emergency, including telephone number; (14) Fee agreement; (15) Documentation of care and treatment provided, client’s response to care and treatment, change in condition and changes in care and treatment; (16) Discharge and transfer information; (17) Client rights; and (18) Referral information.

006.13(A) DISCHARGE SUMMARY. The facility must document a summary in the client record which includes description of client’s progress under the individualized service plan (ISP) and reason or reasons for discharge or transfer from the facility.

006.13(B) TIMELY TRANSFER. The facility must ensure the timely transfer of a client and must provide appropriate client record information as authorized by the client or designee by a signed release of information.

006.14 CLIENT RECORD ORGANIZATION. The facility must ensure that records are systematically organized to ensure permanency and completeness.

006.15 RECORD ENTRIES. All record entries must be dated, legible and indelibly verified. In the case of electronic records, signatures may be replaced by an approved, uniquely identifiable electronic equivalent.

006.16 CONFIDENTIALITY. The facility must keep records confidential unless medically contraindicated. Records are subject to inspection by authorized representative of the Department.

006.17 RETENTION. Client records must be retained for a minimum of two years.

006.18 DESTRUCTION. Client records may be destroyed only when they are in excess of the retention requirement. In order to ensure the right of confidentiality, records must be destroyed or deposed of by shredding, incineration, electronic deletion, or another equally effective protective measure.

006.19 ACCESS. Client information or records may be released only with the consent of the client or client’s designee or as required by law. When a client is transferred to another facility or service, appropriate information must be sent to the receiving facility or service.

006.20 ADMINISTRATIVE CHANGES. If a facility changes ownership or Administrator, all client records must remain in the facility. Prior to the dissolution of any facility, the administrator must notify the Department in writing as to the location and storage of client records.

007. PHYSICAL PLANT STANDARDS . The licensee must ensure that the facility is designed, constructed, and maintained in a manner that is safe, clean, and functional for the type of services to be provided. The physical plant standards are set forth below.

007.01 SHARING SPACE. A mental health substance use treatment center may share physical space with another licensed or unlicensed entity when:

(A) The spaces are clearly identified in a manner so that a client or their designee is fully aware of the specific licensed facility where they are receiving care and treatment; (B) Medical records, staffing, and administration are clearly separated and not shared by the two entities; and (C) The two facilities are not providing care and treatment in the same space at the same time.

007.02 DIETARY. For facilities licensed for 16 or fewer clients or for areas of the facility used only for training or activity purposes, the facility may follow the Food Code or must develop policies and procedures to ensure the following:

(A) Automatic dishwasher final rinse cycle temperature of not less than 150 degrees Fahrenheit; (B) Foods are stored, prepared, transported, and served at proper temperatures; (C) Temperatures of potentially hazardous foods must be 45 degrees Fahrenheit or below or 140 degrees Fahrenheit or above at all times; (D) Food preparation and eating areas are maintained in a sanitary manner; and (E) All equipment and utensils, including dishes, glassware, and silverware used in the serving or preparation of food or drink for individuals is thoroughly cleaned after each use and stored in a manner to ensure they are kept free of dust, vermin, and contamination.

007.03 LAUNDRY. Each mental health substance use treatment center must establish, implement, and revise as necessary, written procedures for the storage and handling of soiled and clean laundry and linens in accordance current, accepted standards of practice and in a manner to reduce any risk of cross-contamination and or infections. Laundry may be completed onsite or by contract with an outside entity.

007.03(A) CONTRACT. If contractual services are used, the facility must have areas for soiled laundry awaiting pickup and separate areas for storage and distribution of clean laundry.

007.03(B) ON-SITE. If on-site services are provided, the facility must have areas dedicated to laundry and must include the following:

(i) A washer and dryer; (ii) Be divided into separate soiled areas for sorting and washing and separate clean areas for drying, folding, and mending. In new construction, the facility must provide a conveniently located sink for soaking and hand washing of laundry and a housekeeping room; and (iii) Water temperatures in the laundry must exceed 160 degrees Fahrenheit, or the facility must use an acceptable sanitizer or disinfectant in accordance with the manufacturer’s instructions.

007.04 WASTE PROCESSING. The facility must provide areas to collect, contain, process, and dispose of waste produced within the facility in a manner to prevent the attraction of vermin and to minimize the transmission of infectious diseases.

007.05 COSMETOLOGY AND BARBER SERVICES. When provided, cosmetology and barber services must be in conformance with the Nebraska Cosmetology Act, Neb. Rev. Stat. §§ 38-1001 to 38-10,172 and the Barber Act, Neb. Rev. Stat. §§ 71-201 to 71-248.

007.06 PHARMACEUTICAL. If the facility provides pharmacy services, the services must be provided in conformance with Neb. Rev. Stat. §§ 71-1,142 to 71-1,147.61.

007.07 FLOOR AREA. Floor area is the space with ceilings at least 7 feet in height and excludes enclosed storage, toilet and bathing rooms, corridors, and halls. The space beyond the first 2 feet of vestibules and alcoves less than 5 feet in width is included in the required floor area. In rooms with sloped ceilings, at least half of the ceiling must be at least 7 feet in height. Less than 5 feet in height are not included in the required floor area.

007.08 DINING AND ACTIVITY AREAS. The facility must provide adequate space for dining, socialization, and leisure activities as follows:

(A) The space must provide a minimum of 15 square feet per individual in existing facilities, and 20 square feet per individual in new construction; and (B) Dining and activity areas must not be used for sleeping, offices, or corridors.

007.09 BATHING ROOMS. The facility must provide a bathing room consisting of a tub or shower equipped with hand grips or other assistive devices as needed or desired by the client. The facility must have 1 bathing fixture per 20 licensed beds in existing facilities, and 1 fixture per 8 licensed beds in new facilities and new construction.

007.10 TOILET ROOMS. The facility must provide a room with a sink and toilet for individuals’ use with 1 fixture per 8 licensed beds in existing facilities, and 1 fixture per 4 licensed beds in new facilities and new construction.

007.11 BEDROOMS. The facility must provide bedrooms that provide for sleeping, afford privacy, provide reasonable access to furniture and belongings, and accommodate the needs of the individual. All bedrooms must:

(A) Not be accessed through a bathroom, food preparation area, laundry, office, or another bedroom; (B) Be located on an outside wall with an operable window with a minimum glass size of 6 square feet per individual in new construction and new facilities; (C) Contain at least 35 cubic feet of storage volume per individual in dressers, closets, wardrobes, or other similar types of storage; (D) Have 80 square feet of floor area for a single bedroom, and 60 square feet of floor area per individual in a multiple bedroom; and (E) Not exceed 4 beds per room in existing facilities, and 2 beds per room in new construction and new facilities.

007.12 CORRIDORS. The facility’s corridors must be wide enough to allow passage and be equipped as needed by the individuals with safety and assistive devices to. All stairways and ramps must have handrails.

007.13 DOORS. The facility doors must be wide enough to allow passage and be equipped as needed by the individuals for privacy and safety.

007.14 OUTDOOR AREAS. The facility must provide an outdoor area for individual use. It must be equipped and situated to provide for safety and the abilities of the individuals.

007.15 EMERGENCY TELEPHONE. The facility must provide non-coin operated telephones in working order, accessible to clients based on their needs, located on the premises for local calls and emergencies. Emergency numbers must be easily accessible near the telephone.

007.16 PRIVACY. The facility must provide window coverings to ensure visual privacy for the individuals.

007.17 BUILDING SYSTEMS. The facility must have building systems that are designed, installed, and that operate in a manner to provide for the safety, comfort, and well-being of the individuals.

007.18 WATER AND SEWER SYSTEMS. The facility must have and maintain an accessible, adequate, safe, and potable supply of water. Where an authorized public water supply of satisfactory quantity, quality, and pressure is available, the facility must be connected to it and its supply used exclusively. If the facility does not utilize an authorized public water supply, the facility must construct, maintain, and operate the water supply as if it were a public water system in accordance with the regulations governing Public Water Systems, 179 NAC 2. The facility must construct all water wells in accordance with 178 NAC 12, Water Well Construction, Pump Installation, and Water Well Decommissioning Standards.

007.19 HOT WATER SYSTEM. The facility must maintain hot and cold water to all hand washing and bathing locations with water temperatures for the comfort and safety of each individual. Hot water temperatures must not exceed 120 degrees Fahrenheit.

007.20 HEATING AND COOLING SYSTEM. The facility must provide a heating and air conditioning system for the comfort of the individuals which is capable of maintaining temperatures of at least 70 degrees Fahrenheit during heating conditions and which does not exceed 85 degrees Fahrenheit during cooling conditions.

007.21 VENTILATION SYSTEM. The facility must provide exhaust and clean air to prevent the concentrations of contaminants which impair health or cause discomfort to individuals and staff.

007.22 ELECTRICAL SYSTEM. The facility must have an electrical system that has sufficient capacity to maintain the services that are provided and that provides proper grounds.

007.23 ILLUMINATION. Light levels are measured at 30 inches above the floor in multiple areas in the room being evaluated and the readings are averaged. All facilities must provide minimum illumination levels as follows:

007.24 EMERGENCY POWER SYSTEM. If the facility provides services to clients who need electrical life support equipment, the facility must maintain an emergency power system.

007.25 EMERGENCY DETOXIFICATION PROGRAMS. Beds used in an emergency detoxification program must be in a room which has:

(A) A minimum of 50 square feet per bed; (B) A minimum of 3 feet between beds; (C) Appropriate temperature control, ventilation, and lighting; (D) No unsafe wall or ceiling fixtures and sharp edges; (E) A way to observe the client, such as, an observation window or, if necessary, flat wall mirrors so that all areas of the room are observable by staff from the outside of the room; and (F) A way to assure that the client cannot hold the door closed so as to deny staff immediate access to the room.

007.26 OBSERVATION ROOMS FOR SECLUSION AND DETOXIFICATION. If the facility provides behavior intervention methods such as seclusion or time-out, the facility must provide an area which has:

(A) Appropriate temperature control, ventilation, and lighting; (B) No unsafe wall or ceiling fixtures and sharp edges; (C) A way to observe the client, such as, an observation window or, if necessary, flat wall mirrors so that all areas of the room are observable by staff from outside of the room; and (D) A way to assure that the client cannot hold the door closed so as to deny staff immediate access to the room.

History

Effective 2024-03-20

Neb. Admin. Code tit. 175 — Health Care Facilities and Services Licensure

Chapter 1 General Facility and Services Regulations

Neb. Admin. Code tit. 175, ch. 1 General Facility and Services Regulations {#sec-175-nac-1 omnilex-key=us-ne-regs-official--title-175--175 NAC 1}

Chapter 3 Regulations Governing Centers for the Developmentally Disabled

Neb. Admin. Code tit. 175, ch. 3 Regulations Governing Centers for the Developmentally Disabled {#sec-175-nac-3 omnilex-key=us-ne-regs-official--title-175--175 NAC 3}

Chapter 4 Assisted-Living Facilities

Neb. Admin. Code tit. 175, ch. 4 Assisted-Living Facilities {#sec-175-nac-4 omnilex-key=us-ne-regs-official--title-175--175 NAC 4}

Chapter 5 Adult Day Service

Neb. Admin. Code tit. 175, ch. 5 Adult Day Service {#sec-175-nac-5 omnilex-key=us-ne-regs-official--title-175--175 NAC 5}

Chapter 6 Children’s Day Health Service

Neb. Admin. Code tit. 175, ch. 6 Children’s Day Health Service {#sec-175-nac-6 omnilex-key=us-ne-regs-official--title-175--175 NAC 6}

Chapter 7 Health Clinics

Neb. Admin. Code tit. 175, ch. 7 Health Clinics {#sec-175-nac-7 omnilex-key=us-ne-regs-official--title-175--175 NAC 7}

Chapter 8 Pharmacies

Neb. Admin. Code tit. 175, ch. 8 Pharmacies {#sec-175-nac-8 omnilex-key=us-ne-regs-official--title-175--175 NAC 8}

Chapter 9 Hospitals

Neb. Admin. Code tit. 175, ch. 9 Hospitals {#sec-175-nac-9 omnilex-key=us-ne-regs-official--title-175--175 NAC 9}

Chapter 12 Skilled Nursing Facilities, Nursing Facilities, and Intermediate Care Facilities

Neb. Admin. Code tit. 175, ch. 12 Skilled Nursing Facilities, Nursing Facilities, and Intermediate Care Facilities {#sec-175-nac-12 omnilex-key=us-ne-regs-official--title-175--175 NAC 12}

Chapter 14 Home Health Agencies

Neb. Admin. Code tit. 175, ch. 14 Home Health Agencies {#sec-175-nac-14 omnilex-key=us-ne-regs-official--title-175--175 NAC 14}

Chapter 15 Respite Care Service

Neb. Admin. Code tit. 175, ch. 15 Respite Care Service {#sec-175-nac-15 omnilex-key=us-ne-regs-official--title-175--175 NAC 15}

Chapter 16 Hospice Services

Neb. Admin. Code tit. 175, ch. 16 Hospice Services {#sec-175-nac-16 omnilex-key=us-ne-regs-official--title-175--175 NAC 16}

Chapter 17 Intermediate Care Facilites for Individuals with Intellectual Disabilites (icf/Iid)

Neb. Admin. Code tit. 175, ch. 17 Intermediate Care Facilites for Individuals with Intellectual Disabilites (icf/Iid) {#sec-175-nac-17 omnilex-key=us-ne-regs-official--title-175--175 NAC 17}

Chapter 18 Mental Health Substance Use Facilities

Neb. Admin. Code tit. 175, ch. 18 Mental Health Substance Use Facilities {#sec-175-nac-18 omnilex-key=us-ne-regs-official--title-175--175 NAC 18}

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