The Critical Element Pathways were developed by CMS (Centers for Medicare & Medicaid) for conducting surveys for Skilled Nursing Facilities using the QIS Survey Process. LDH does not develop CE pathways for licensing surveys.
Yes, The RN is required to do a monthly medication review for Staff Administration of Medications for all levels of ARCPs providing staff administration of medications. Please refer to the NOI Potpourri published on 03/20/15 section §6843.C.3(e)viii.
§6833. D. 4. a. It is the ARCP's responsibility to assure that needed services are provided, even if those services are provided by the resident’s family or by a third party or contracted provider. A copy of such third party contract shall be verifiable, in writing, and retained in the resident’s record. The ARCP retains responsibility for notifying the resident or the resident's representative, if applicable, if services are not delivered or if the resident’s condition changes. The facility is required by regulation to maintain a copy of the third party contract and documentation of notifications provided to the resident or resident’s representative if the services are not delivered or for a resident’s change of condition. Any additional information maintained to assure third party services are provided would be based on facility policy/procedure.
A copy of the third party contract is required when: 1. (§6833.D.4.a.) The 3rd party provides services to meet resident’s time limited needs for a prohibited condition; 2. (§6843.C.4.b.) The 3rd party provides assistance with medication administration. If the 3rd party is not providing assistance with the above two requirements, then a copy of the contract is not required by regulation.
A copy of the third party contract is required when:
1. (§6833.D.4.a.) The 3rd party provides services to meet resident’s time limited needs for a prohibited condition;
2. (§6843.C.4.b.) The 3rd party provides assistance with medication administration.
If the 3rd party is not providing assistance with the above two requirements, then a copy of the contract is not required by regulation.
LDH intent is for the resident to be informed of their rights and the grievance process when signing a residency agreement.
For self-administration, third party administration, and\or family administration of resident’s medications, a pharmacist review is not required. The pharmacist review is required for all levels of ARCPs for staff administration of medications. The ARCP shall maintain documentation in the record from the Pharmacist who completes the monthly medication review and shall maintain documentation of any notifications to the physician regarding the review.
LDH does not specify a specific tool for determining competency. LDH intent is that the ARCP shall formulate its own policy & procedures ensuring competency of its employees to perform their duties. However, a competency checklist, return demonstration techniques and\or other teaching & evaluation tools related to the employee’s job duties and position may be used.
Examples may include but are not limited to a copy of third party contract, PCSP documentation requirements for 3rd party services provided, and documentation of notes regarding communication/notifications with 3rd party provider and, the resident, or the resident’s representative, if applicable.
§6835. A. 2. If the resident’s person-centered service plan includes staff administration of medication or intermittent nursing services, the assessment for those services shall be completed by a registered nurse.
§6835. E. All plans, reviews and updates shall be signed by the resident, ARCP staff, and the resident’s representative, if applicable. If the resident’s PCSP includes staff administration of medication or intermittent nursing services, a registered nurse shall also sign the plans, reviews and updates.
The regulations do not require the RN who is an employee of the third party to sign the PCSP for third party administration of medications.
ADA complaints may be filed with the United States Department of Justice Civil Rights Division. Complaints may be filed via:
Electronic form: www. ada.gov/filing_complaint.htm
Fax: (202) 307-1197
Mail: US Department of Justice
950 Pennsylvania Avenue, NW
Civil Rights Division
Disability Rights Section – 1425 NYAV
Washington, D.C. 20530
Standing orders are not regulatory and are not prohibited by the LDH licensing regulations for ARCPs. However, any medication orders received for a resident shall be included in the resident’s records, signed and dated by the prescribing practitioner and are subject to the monthly RN and pharmacist review. The ARCP’s policy shall indicate how routine or standing orders are signed and dated by the licensed practitioner and length of time for prescribed usage.
§6843. A. there shall also be policies regarding obtaining and refilling medications, storing and controlling medications, disposing of medications, and documentation of medication administration. Any resident may maintain possession of their medications if the ARCP determines that is safe for the resident to maintain possession, control and dispose of the resident’s own medications. This may include the resident storing their own insulin medication in their own apartment refrigerator. If the ARCP maintains control or custody of a resident’s medications, then the ARCP is required to be in compliance with part §6843. D. Storage of Medications.
Staff Administration of Medication- Yes, a licensed nurse may administer prescribed eye drops;
For Assistance with Administration – unlicensed staff may assist with over the counter eye drops, but not prescription;
For 3rd Party Administration - eye drop administration is based on 3rd party policy and the ARCP policy on this level of administration.
The intent of this regulation is not to require the ARCP to provide an on-site general orientation to third party providers, although this may be done if the ARCP chooses to provide orientation in this manner. LDH intent is that third party providers have the information needed to ensure that the contracted care of the resident is provided in a manner consistent with the ARCP’s policies and procedures. The ARCP may provide brochures or applicable policies/procedures to third party providers providing services to the residents. Policy and procedures may include but are not limited to information on the ARCP resident privacy policies, communication procedures, facility dress code, evacuation routes, floor plans, security and/or sign in procedures (if applicable), or other general policy/procedures the facility deems appropriate. The ARCP may determine its own method for distributing this information to the third party provider in accordance with the ARCP’s orientation policy.
Part §6843. D. Storage of Medications, is applicable if the ARCP maintains possession or control of a resident’s medications. The method the third party company uses for medication storage may be based on the third party provider procedure in accordance with the ARCP policy for third party providers, for storage of resident medications.
Example: If the third party company stores the resident’s medications in the resident’s living area, then the third party provider shall ensure that the ARCP policy for safe storage in a resident’s living area is followed.
No, §6843. D.4. applies to controlled substances that are maintained under the control of the ARCP.
LDH interpretation is that this section applies to any medications administered by self-administration, assistance with administration, or staff administration. Third party disposal of medications would be according to the third party company procedures.
Yes, the 3rd party medication company may be owned or affiliated with the ARCP. Residents shall have the right to select the 3rd party medication company of their choice.
§6833. D. 5. is applicable to 3rd party providers providing services to meet the time limited needs of residents with a prohibited condition.
Staff administration of medications is an optional service. If the ARCP only provides for 3rd party administration, then a policy regarding 3rd party administration is required. §6843. A. indicates the ARCP “shall have” policies/procedures for medication administration including self-administration, gratuitous, 3rd party, and staff administration of medications. It is acceptable for the ARCP to have a policy stating that staff administration medication is not provided because that service is optional.
Part §6843. D. Storage of Medications, is applicable if medications are kept under control or custody of the ARCP. The method the third party company uses for medication storage may be based on the third party provider procedure in accordance with the ARCP policy for third party providers, for storage of resident medications.
If the ARCP is reducing or increasing the number of licensed apartments or units, then LDH approval is required. If no changes are made to the number of approved apartments, then no approval is required (for example, the census is reduced from 10 to 6 residents, but 10 apartments remain licensed). The ARCP shall not exceed its approved licensed capacity.
§6835. A. 2. A registered nurse is required to conduct an assessment for staff administration of medications or intermittent nursing services within 7 calendar days of the date the resident moves into the ARCP, if those services are provided. Within 30 days, the ARCP designated staff (determined by the ARCP) in conjunction with the resident or resident’s representative (if applicable) will develop the PCSP using information from the assessments.
§6835.E. requires RN approval of the PCSP for staff administration of medications or intermittent nursing services.
§6865. B. requires ARCPs that offer staff administration of medications to provide sufficient numbers of RNs and LPNs to provide services to all residents in accordance with the PCSP, 24 hours a day. The ARCP regulation does not specifically prohibit the ARCP from using a nurse that is employed by the nursing home. However, please review the nursing home licensing regulations to ensure there is not a conflict with LDH Nursing Home minimum licensing regulations or Nursing Home Federal regulations.
If the resident’s condition deteriorates to a point where services cannot be provided in accordance with the regulations or the services required exceed those agreed to be provided in the residency agreement, then the resident may be physically discharged to a higher level of care. The resident retains the right to appeal termination of the Residency Agreement to the DAL and termination of the residency agreement is suspended with such appeals.
Injectable medications that are prescribed for the resident by a licensed medical practitioner may be administered by the ARCP staff to the resident in accordance with the ARCP’s medication administration policy and in accordance with the licensed professional’s scope of practice.
The intent for this regulation is if the ARCP provides its own transportation to the ARCP’s residents, that the ARCP has the ability to meet the needs of the residents being transported, including meeting the needs for any of the ARCP’s residents who have disabilities during transportation in an ARCP vehicle.
The ARCP may assist a resident with the application of the resident’s prescribed CPAP mask if the resident is cognitively intact and if the resident is aware of what the CPAP is for.
Medically prescribed diets shall be available if necessary; however nothing shall prohibit the ARCP from offering liberalized diets. If the resident requests a liberalized diet and the dietician approves, then it is ok for the resident to have a liberalized diet. There may be circumstances where a resident wants to adhere to a medically prescribed diet, in that case the facility is required to provide the prescribed diet.
Incident reports shall be submitted by fax or email. Please submit to:
Fax: 225-342-5073 or
No, not all incidents are reportable. §6871. B. Only the following types of incidents are reportable:
1. Incidents involving suspected abuse;
2. Incidents involving suspected neglect;
3. Incidents involving suspected misappropriation of personal property regardless of monetary value;
4. Injuries of unknown origin.
§6829. A. 8. requires the ARCP to develop a policy and procedure for abuse and neglect. The ARCP abuse and neglect policy shall determine the procedure for determining whether or not an allegation rises to the level of suspected abuse, neglect, or misappropriation of property. LDH interpretation of suspected abuse/neglect/misappropriation of property is that based on the allegations received, the ARCP has reason to believe that abuse/neglect/misappropriation of property may have occurred.
It is important for the ARCP to consider the resident and any health or behavioral issues they have when making a determination for suspected abuse/neglect/misappropriation of property. Some residents may get injured easily due to health reasons or aging. For example, some medications and health problems may cause bruising not caused by abuse. Is the injury suspicious because of location? For example, protected body parts and soft tissue areas, such as the back, thighs, genital area, buttocks, back of legs, or face, are less likely to accidentally come into contact with objects that can cause injury. A resident may be forgetful and have a history of losing items, but their missing item may not be due to misappropriation of property. Examples of suspected misappropriation of property may include, but not limited to, a sudden decrease in bank account balances, sudden unexplained large withdrawals from a bank account or ATM, sudden problems paying bills or buying other necessities, etc. If the incident includes allegations of abuse/neglect/misappropriation of property and the ARCP has reason to believe that abuse/neglect/misappropriation of property may have occurred, the incident shall be reported.
Injuries of unknown origin are defined as:
a. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident;
b. the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma)
Injury meets criteria:
· Resident has injury
· The Injury was not observed by any person
· The source of injury cannot be explained by resident
· The injury is suspicious due to severity or location of injury
The examples provided do not cover every possible injury. The injury may be suspicious because it affects protected body parts and soft tissue areas, such as the back, thighs, genital area, buttocks, back of legs, or face, are less likely to accidentally come into contact with objects that can cause injury. Other examples may include fractures in the absence of a known disease process or without explanation. Spiral fractures that result from twisting limbs may be related to abuse, what does the x-ray indicate? Unexplained pattern burns, shaped like a cigarette butt or electrical appliance are suspicious for abuse. There are numerous suspicious injuries which can be classified as an injury of unknown origin, the ARCP abuse policy and procedure shall guide staff with the decision making process.
The regulations do not mandate that a policy and procedure be developed for cessation of business. The ARCP is required to be in compliance with section §6825.Cessation of Business, when closing.
Yes, if the ARCP, resident & resident representative (if applicable), and physician are in agreement.
For CPR, Health Standards does not accept online CPR certification courses, because those courses do not allow for hands on demonstration. Other government agencies, such as OSHA and other states, have also determined that online CPR certification is not acceptable. Proper technique for CPR should be evaluated by an instructor through in-person demonstration of skills. CPR certification that includes an online knowledge component, yet still requires an in-person demonstration and skills assessment to obtain certification, is acceptable.
LDH has noted provider concerns regarding the 7 day period for completing orientation for new hires in part §6867.A.(3). For Part §6867.C.(1)., the intent for the staff training requirements is to ensure new hires receive the required orientation and training to competently perform duties prior to being assigned to resident care. LDH has determined that it will be acceptable for the five days of direct observation of the performance of ADLs and IADLs to be completed in a timeframe that may exceed the 7 day period as long as the intent of the requirement is met.
§6865.B.1. requires ARCPs that offer staff administration of medication to provide a sufficient number of RNs and LPNs to provide services to all residents in accordance with each resident’s person centered service plan 24 hours per day. The regulation does not require the licensed nurse to be on-site 24 hours a day. The ARCP may schedule a licensed nurse on-call to meet the needs of the resident in accordance with the person centered service plan based on the ARCP policy and procedure.
The resident representative may be any person the resident authorizes in writing to act on their behalf. A Power of Attorney is an acceptable form for a resident to designate a legal representative.
The regulation is clear, in part, §6803. Resident’s Representative- “No member of the governing body, administration or staff or an ARCP or any member of their family shall serve as the resident’s representative unless they are related to the resident by blood or marriage.” The residency agreement should be executed according to ARCP policy & procedure and staff shall not sign the residency agreement for the resident.
A settlement agreement is a contractual agreement entered into by the provider with LDH to avoid adverse action taken by LDH against the ARCP’s license due to the ARCP’s regulatory non-compliance. In a settlement agreement or education letter, the ARCP would be required and has agreed to meet specific terms specified by LDH to demonstrate regulatory compliance.
Please reference the Public Health Sanitary Code Title 51, Part §503. Mandatory Tuberculosis Testing & Part §505. Required Medical Examinations of All Persons Admitted to Nursing Homes and Residential Facilities. ARCPs may consult the LDH Office of Public Health as a further resource.
§6849. C. 4. Dietary employees engaged in the handling, preparation and serving of food shall use effective hair restraints to prevent the contamination of food or food contact surfaces.
Hair restraints are required in the food preparation areas (kitchen) or food service line where foods are being handled, prepared, and plated. Hair restraints are not required to be worn by dietary employees when serving residents in the dining room(s).
§6849.D. If a licensed dietitian is not employed full-time, the ARCP shall designate a full-time person to serve as the dietary manager.
1. The dietary manager who oversees food preparation may also fulfill other staff roles in the ARCP.
2. The dietary manager shall have Servsafe® certification.
The ARCP may contract or directly employ the Licensed Dietician or Dietary Manager.
§6863. A. The ARCP shall have qualified staff sufficient in number to meet the scheduled and unscheduled needs of residents and to respond in emergency situations.
B. Sufficient direct care staff shall be employed or contracted to ensure provision of personal assistance as required by the resident’s PCSP.
Sufficient staffing is determined by the resident assessment and the amount of assistance required to meet each resident’s individual needs, according to the person centered service plan.
An oral request is sufficient to produce the current record for inspection or review by the resident or resident’s legal representative. For copies, the ARCP policy & procedure for releasing records shall be followed. The ARCP policy & procedure releasing records may require the request to be in writing, verify identities, and charge appropriate fees for photocopies.
The ARCP may create an affidavit of its choice to verify assets.
The ARCP will be required to verify assets via an affidavit, this will also apply to initial licensing;
The ARCP is licensed to have a capacity of at least 17 residents, which means the ARCP has the square footage approved for a minimum of 17 residents. If the ARCP census falls below 17, this will not affect the ARCP license because the capacity is determined by the square footage of the ARCP.
If an ARCP has plan review approval and initiated construction prior to August 15, 2015, then the physical environment regulations the ARCP was reviewed for in architectural plan review would apply. The ARCP must submit evidence to verify that construction began prior to August 15, 2015.