Revision 17-1

 

§19.901 Quality of Care


Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as defined by and in accordance with the comprehensive assessment and plan of care. If children are admitted to the facility, care and services must be provided to meet their unique medical and developmental needs.

(1) Activities of daily living. Based on the comprehensive assessment of the resident, the facility must ensure that:

(A) a resident's abilities in activities of daily living do not diminish unless the circumstances of the individual's clinical condition demonstrate that diminution is unavoidable. This includes the resident's abilities to:
(i) bathe, dress, and groom;
(ii) transfer and ambulate;
(iii) toilet;
(iv) eat; and
(v) use speech, language, or other functional communication systems.
(B) the resident is given the appropriate treatment and services to maintain or improve his abilities specified in paragraph (1) of this section. (C) a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

(2) Vision and hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident:

(A) in making appointments; and
(B) by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

(3) Pressure sores. Based on the comprehensive assessment of the resident, the facility must ensure that:

(A) a resident who enters the facility without pressure sores does not develop pressure sores unless his clinical condition demonstrates that they are unavoidable; and
(B) a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

(4) Urinary incontinence. Based on the comprehensive assessment of the resident, the facility must ensure that:

(A) a resident who enters the facility without an indwelling catheter is not catheterized unless his clinical condition demonstrates that catheterization is necessary; and
(B) a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

(5) Range of motion. Based on the comprehensive assessment of the resident, the facility must ensure that:

(A) a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and
(B) a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

(6) Mental and psychosocial functioning. Based on the comprehensive assessment of the resident, the facility must ensure that:

(A) a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem; and
(B) a resident whose assessment does not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless his clinical condition demonstrates that such a pattern is unavoidable.

(7) Naso-gastric tube. Based on the comprehensive assessment of the resident, the facility must ensure that:

(A) a resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless his clinical condition demonstrates that use of a naso-gastric tube is unavoidable; and
(B) a resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers, and to restore, if possible, normal eating skills.

(8) Accidents. The facility must ensure that:

(A) the resident environment remains as free of accident hazards as possible; and(B) each resident receives adequate supervision and assistive devices to prevent accidents.

(9) Nutrition. Based on the comprehensive assessment of the resident, the facility must ensure that a resident:

(A) maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless his clinical condition demonstrates that this is not possible; and
(B) receives a therapeutic diet when there is a nutritional problem.

(10) Hydration. The facility must ensure that the resident is provided with sufficient fluid intake to maintain proper hydration and health.
(11) Special needs. The facility must ensure that residents receive proper treatment and care for the following special services:

(A) injections;(B) parenteral or enteral fluids;(C) colostomy, ureterostomy, or ileostomy care;(D) tracheostomy care;(E) tracheal suctioning;(F) respiratory care;(G) foot care; and(H) prostheses.

(12) Unnecessary Drugs.

(A) General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
(i) in excessive dose (including duplicate drug therapy); or (ii) for excessive duration; or (iii) without adequate monitoring; or(iv) without adequate indications for its use; or(v) in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or(vi) any combination of the circumstances in clauses (i)-(v) of this subparagraph.
(B) Antipsychotic drugs. Based on the comprehensive assessment of the resident, the facility must ensure that:
(i) residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and
(ii) residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue use of these drugs.

(13) Medication errors. The facility must ensure that:

(A) it is free of medication error rates of five percent or greater, and(B) residents are free of significant medication errors.

(14) Pediatric care.

(A) Licensed nursing care of children. A facility caring for children must have twenty-four hour a day on-site licensed nursing staff in numbers sufficient to provide safe care. For any facility with five or more children under 26 pounds, at least one nurse must be assigned solely to the care of those children.
(B) Fewer than five pediatric residents. Facilities with fewer than five pediatric residents must assure that the children's rooms are in close proximity to the nurses' station.
(C) Respiratory care of children.
(i) To facilitate the care of ventilator-dependent children or children with tracheostomies, a facility must group those children in rooms contiguous or in close proximity to each other. An exception to this rule is children who are able to be schooled off-site.
(ii) Facilities must assure that alarms on ventilators, apnea monitors, and any other such equipment uniquely identify the child or the child's room.
(iii) A facility caring for children with tracheostomies requiring daily care (including ventilator-dependent children with tracheostomies) must have twenty-four hour a day on-site respiratory therapy staff in numbers sufficient to provide a safe ratio of respiratory therapist per these residents. For the purposes of this rule, respiratory therapy staff is defined as a registered respiratory therapist (RRT), a certified respiratory therapy technician (CRT), or a licensed nurse whose primary function is respiratory care.
(I) If the facility cares for nine or more children with tracheostomies requiring daily care (including ventilator-dependent children with tracheostomies), the facility must maintain a ratio of no less than one respiratory therapy staff per nine tracheostomy residents twenty-four hours a day.
(II) If the facility cares for six or more ventilator dependent children, the facility must:
(-a-) designate a respiratory therapy supervisor, either on staff or contracted who must be credentialed by the National Board for Respiratory Care (either CRT or RRT).
(-b-) provide and document that all respiratory therapy staff is trained in the care of children who are ventilator dependent. This training must be reviewed annually.
(-c-) assure that appropriate care, maintenance, and disinfection of all ventilator equipment and accessories occurs.

 

§19.910 Quality Assurance Early Warning System

 

The Health and Human Services Commission (HHSC) uses an early warning system to detect conditions that could be detrimental to the health, safety, and welfare of residents.

(1) Quality-of-care monitors conduct visits that may be announced or unannounced and may occur on any day and at any time, including nights, weekends, and holidays.
(2) Quality-of-care monitors may visit a facility:

(A) with a history of resident care deficiencies;
(B) that is identified as a medium risk through the early warning system; or
(C) that requests a visit.

(3) Quality-of-care monitors assess:

(A) the overall quality of life in the facility; and
(B) specific conditions in the facility directly related to resident care, including conditions identified through the facility's quality measure reports based on MDS assessments.

(4) A quality-of-care monitor assessment visit includes:

(A) observation of the care and services provided to a resident; and
(B) formal and informal interviews with residents, family members, facility staff, resident guests, volunteers, other regular staff, and resident representatives and advocates.

(5) HHSC does not disclose the identity of a resident or family member of a resident interviewed by a quality-of-care monitor unless required by law to do so.
(6) A quality-of-care monitor provides the findings of a monitoring visit, both positive and negative, orally and in writing to the facility administrator or, in the absence of the facility administrator, to the administrator on duty or the director of nursing.
(7) A quality-of-care monitor may recommend to the facility administrator procedural and policy changes and staff training to improve the care or quality of life of residents.
(8) A quality-of-care monitor conducts a follow-up visit within 45 days after the date of an initial visit.
(9) A quality-of-care monitor who observes conditions that may constitute an immediate threat to the health or safety of a resident immediately reports the conditions to the facility administrator, the monitor's regional office supervisor for appropriate action and, as appropriate, to law enforcement, adult protective services, other divisions of HHSC, and other agencies.

 

§19.911 Rapid Response Teams

 

(a) A rapid response team is comprised of one or more quality-of-care monitors and visits a facility that:

(1) is identified as high risk through the early warning system described in §19.910 of this subchapter (relating to Quality Assurance Early Warning System); or
(2) has committed three violations that constitute an immediate threat to health and safety relating to abuse or neglect of a resident as described in §19.2107 of this chapter (relating to Revocation of a License by the HHSC Executive Commissioner).

(b) A facility must cooperate with a rapid response team to improve the quality-of-care provided at the facility by:

(1) providing immediate access to all the parts of the building;
(2) providing immediate access to residents, staff, contractors and reasonable access to volunteers;
(3) providing access to all documents maintained by or on behalf of the facility upon request from the rapid response team;
(4) allowing the rapid response team to copy documents, photograph residents, and use any other available recording devices in accordance with §19.2002(h) of this chapter (relating to Procedural Requirements – Licensure Inspections and Surveys); and
(5) not interfering with the work of the rapid response team during a visit.

(c) In determining whether a facility has demonstrated improvement in quality of care, the rapid response team may consider factors such as implementation of the team’s recommendation or guidance.
(d) A rapid response team may visit a facility that requests assistance from HHSC. A visit under this subsection may not occur until at least 60 days after the date of an exit interview following an inspection.
(e) A rapid response team may not be deployed for the purpose of helping a facility prepare for an inspection or survey.