Header:
TEXAS ADMINISTRATIVE CODE
TITLE 40. SOCIAL SERVICES AND ASSISTANCE
PART 1. DEPARTMENT OF AGING AND DISABILITY SERVICES
CHAPTER 98. ADULT DAY CARE AND DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS
SUBCHAPTER D. LICENSURE AND PROGRAM REQUIREMENTS
Date:
08/31/2009
Document:
§ 98.62. Program Requirements
(a) Staff qualifications.
(1) Director.
(A) The director must:
(i) have graduated from an accredited four-year college or university and have no less than one year of experience in working with people in a human service or medically-related program, or have an associate degree or 60 semester hours from an accredited college or university with three years of experience in working with people in a human service or medically-related program; or
(ii) be a registered nurse with one year of experience in a human service or medically-related program; or
(iii) meet the training and experience requirements for a license as a nursing facility administrator under the rules of the Texas Board of Licensure for Nursing Facility Administrators; or
(iv) have met, on July 16, 1989, the qualifications for the position under the requirements in effect at that time and have served continuously in the capacity of director of a Texas Department of Human Services-certified facility since that date.
(B) The director must show evidence of 12 contact hours of annual continuing education in at least two of the following areas:
(i) individual and provider rights and responsibilities, abuse, neglect, and confidentiality;
(ii) basic principles of supervision;
(iii) skills for working with individuals, families, and other professional service providers;
(iv) individual characteristics and needs;
(v) community resources;
(vi) basic emergency first aid, such as CPR or choking; or
(vii) federal laws, such as Americans with Disabilities Act, Civil Rights Act of 1991, the Rehabilitation Act of 1993, and the Family and Medical Leave Act of 1993.
(C) The activities director may fulfill the function of facility director if he meets the qualifications for facility director.
(D) One person may not serve as facility nurse, activities director, and facility director, regardless of qualifications.
(E) The facility must have a policy regarding the delegation of responsibility in the administrator's absence, not to exceed 10 working days.
(F) The facility must request a waiver from Long Term Care-Regulatory (LTC-R) Regional Office for exceptional circumstances. Exceptional circumstances include, but are not limited to, hospitalization, death, etc.
(2) Nurse. The facility nurse must be a registered nurse (RN) or a licensed vocational nurse (LVN).
(A) The RN must have a current license from the Board of Nurse Examiners for the State of Texas and must practice in compliance with the Nurse Practice Act and rules and regulations of the Board of Nurse Examiners.
(B) The LVN must have a current license from the Board of Vocational Nurse Examiners of Texas and must practice in compliance with the Vocational Nurse Act and rules and regulations of the Board of Vocational Nurse Examiners.
(C) If a nurse serving as director leaves the facility to perform other duties related to the provisions of the day care program, an LVN or another RN must fulfill the duties of the facility nurse.
(D) Licensed facilities that do not have a Day Activity and Health Services (DAHS) contract, but have a Special Services to Persons with Disabilities contract, are not required to have a registered nurse on duty, as long as the client receiving services has no medical needs and is able to self medicate.
(3) Activities director.
(A) The activities director must be a high school graduate (or equivalent) and have:
(i) a bachelor's degree from an accredited college or university, plus one year of full-time experience in working with the elderly or people with disabilities in a human service or medically-related program; or
(ii) 60 semester hours from an accredited college or university, plus two years of full-time experience in working with the elderly or people with disabilities in a human service or medically-related program; or
(iii) completed a state-approved activities director's course, plus two years of full-time experience in working with the elderly or people with disabilities in a human service or medically-related program.
(B) Anyone hired prior to May 1, 1999, as an activities director with four years of full-time experience in working with elderly or people with disabilities in a human service or medically-related program, will be considered a qualified activities director.
(4) Attendants. Attendants must be 18 years old or older and may include, but are not limited to, bus drivers, aides, cooks, janitors, porters, maids, and laundry workers.
(A) If the facility employs a bus driver, the driver must have a current operator's license, issued by the Texas Department of Public Safety, which is appropriate for the class of vehicle used to transport clients.
(B) If an attendant handles food in the facility, he must meet the requirements described in the Texas Department of Health rules on food service sanitation as described under 25 TAC §§ 229.161-229.171 and §§ 229.173-175 (relating to Texas Food Establishments).
(5) Food service personnel. If the facility prepares meals on site, the facility must have sufficient food service personnel to prepare meals and snacks. Food service personnel must meet the requirements described in the Texas Department of Health rules on food service sanitation as described under 25 TAC §§ 229.161-229.171 and §§ 229.173-229.175 (relating to Texas Food Establishments).
(6) Additional requirements for Day Activity and Health Services (DAHS) employees.
(A) Housekeeper. A DAHS facility may employ a part-time or full-time housekeeper.
(B) Driver. If a DAHS facility employs a part-time or full-time driver, the driver must:
(i) operate the facility's vehicles in a safe manner; and
(ii) maintain adult cardiopulmonary resuscitation (CPR) certification.
(b) Staffing ratio. The facility must ensure that:
(1) the ratio of direct service staff to clients is at least one to eight, which must be maintained during provision of all covered services except during facility-provided transportation;
(2) at a minimum, one registered nurse or licensed vocational nurse must be working on site, eight hours per day. The facility may schedule nursing hours according to client needs. Sufficient licensed nursing staff must be on site to meet the nursing needs of the clients;
(3) the facility director works a minimum of 40 hours per week performing duties relating to the provision of adult day care services; and
(4) the activities director works 40 hours a week.
(5) clients whose needs cannot be met by the facility are not admitted or retained. Sufficient staff must be on duty at all times to meet the needs of the clients. The facility is responsible for all care provided at the facility.
(c) Staff health. All direct staff must be free of communicable diseases.
(1) The facility must screen all employees for tuberculosis within two weeks of employment and annually, according to Center for Disease Control screening guidelines. All persons providing services under an outside resource contract must also screen all employees for tuberculosis within two weeks of employment and annually according to Center for Disease Control screening guidelines. When requested to do so by the facility, persons providing services under an outside resource contract must provide evidence of compliance with this requirement.
(2) If employees contract a communicable disease that is transmissible to individuals through food handling or direct individual care, the employee must be excluded from providing these services as long as a period of communicability is present.
(d) Staff responsibilities.
(1) Facility director. The facility director is responsible for:
(A) managing the adult day care program and/or the facility;
(B) training and supervising facility staff;
(C) monitoring the facility building and grounds to ensure compliance;
(D) maintaining all financial and client records;
(E) developing relationships with community groups and agencies for identification and referral of clients;
(F) maintaining communication with the client's family members or responsible parties;
(G) assuring the development and maintenance of the individual plan of care; and
(H) ensuring that, if he serves as the nurse consultant during the same eight- hours-per-day period, he is fulfilling his responsibility as director.
(2) Facility nurse. The facility nurse is responsible for:
(A) assessing the client's nursing and medical needs;
(B) developing a client's individual plan of care;
(C) obtaining physician's orders for medication and treatments to be administered;
(D) determining whether self-administered medications have been appropriately taken, applied, or used;
(E) entering, dating, and signing monthly progress notes on medical care provided;
(F) administering medication and treatments;
(G) providing health education; and
(H) maintaining medical records.
(3) Activities director. The activities director is responsible for:
(A) planning and directing the daily program of activities, including physical fitness exercises or other recreational activities;
(B) recording the client's social history;
(C) assisting the client's related support needs;
(D) assuring that the identified related support services are included in the client's individual plan of care; and
(E) signing and dating monthly progress notes about social and related support services activities provided.
(4) Attendant. The attendant is responsible for:
(A) providing personal care services (assistance with activities of daily living);
(B) assisting the activities director with recreational activities; and
(C) providing protective supervision (observation and monitoring).
(5) Food service personnel. Food service personnel are responsible for:
(A) preparing meals and snacks; and
(B) maintaining the kitchen area and utensils in a safe and sanitary condition.
(6) Dietitian consultant.
(A) The facility must receive consultation at least four hours each month from a dietitian. The dietitian consultant plans and/or reviews menus and must:
(i) prior approve and sign each snack and luncheon menu;
(ii) review menus monthly to ensure that substitutions were appropriate; and
(iii) develop any special diets ordered by physicians for individual clients.
(B) The dietitian consultant is required for all facilities, even those that have their meals delivered from another facility with its own dietitian consultant. A consultant may provide consultation to several facilities as long as each facility receives at least four hours a month. The four hours cannot be "shared" by several facilities.
(C) Facilities that contract for the preparation and delivery of meals with management companies employing their own registered dietitians are required to have the four hours of consultation from a dietitian consultant.
(7) Registered nurse consultant. In facilities where the nurse is a licensed vocational nurse, a registered nurse consultant must provide on- site consultation four hours per week. The RN consultant must document the consultation provided. The RN consultant must provide the consultation during the time when clients are present in the facility. The RN consultant may provide the following types of assistance:
(A) reviewing plans of care and suggesting changes, if appropriate;
(B) assessing clients' health conditions;
(C) consulting with the LVN in solving problems involving client care and service planning;
(D) counseling clients on their health needs;
(E) training, consulting, and assisting the LVN in maintaining proper medical records; and
(F) providing in-service training for direct service staff.
(e) Training.
(1) Initial training.
(A) The facility must:
(i) provide all staff with training in the fire, disaster, and evacuation procedures within three workdays of employment. The training must be documented in the facility records.
(ii) provide direct delivery staff a minimum of 18 hours of training during the first three months of employment. Training must be documented in the facility records. Training must include:
(I) any nationally or locally recognized adult cardiopulmonary resuscitation (CPR) course/certification;
(II) first aid; or
(III) orientation to health care delivery including the following components:
(-a-) safe body function and mechanics;
(-b-) personal care techniques and procedures; and
(-c-) overview of client population served at the facility; and
(IV) identification and reporting of abuse, neglect, or exploitation.
(B) Staff employed as substitutes on an infrequent and irregular basis are not required to have 18 hours of initial training. Substitute and consultant staff must receive a minimum of three hours of orientation. Substitutes for direct service staff used by a facility on a regular basis must meet all training requirements as specified under this subsection.
(2) Ongoing training.
(A) The facility must provide a minimum of three hours of ongoing training to direct service staff quarterly. The facility must ensure that direct delivery staff maintain current certification in CPR.
(B) The facility must practice evacuation procedures with staff and clients not less than once a month. The evacuation results must be documented in the facility records.
(f) Medications.
(1) Administration.
(A) Clients who choose not to or cannot self-administer their medications must have their medications administered by a person who holds a current license under state law which authorizes the licensee to administer medications.
(B) All medication prescribed to clients must be dispensed through a pharmacy or by the client's treating physician or dentist.
(C) Physician sample medications may be given to a client by the facility provided the medication has specific dosage instructions for the individual client.
(D) Each client's medications must be listed on an individual client's medication profile record. The recorded information obtained from the prescription label must include, but is not limited to, the medication name, strength, dosage, amount received, directions for use, route of administration, prescription number, pharmacy name, and the date each medication was issued by the pharmacy.
(2) Assistance with self administration. Assistance with self adminis- tration of client's medication regimen by licensed nursing staff may be provided to clients who are incapable of self-administering without assistance. Assistance with self-medication includes, and is limited to:
(A) reminders to take their medications at the prescribed time;
(B) opening containers or packages and replacing lids;
(C) pouring prescribed dosage according to medication profile record;
(D) returning medications to the proper locked areas;
(E) obtaining medications from a pharmacy; and
(F) listing on an individual client's medication profile record the medication name, strength, dosage, amount received, directions for use, route of administration, prescription number, pharmacy name, and the date each medication was issued by the pharmacy.
(3) Self-administration.
(A) Clients who self-administer their own medications must be counseled at least once a month by licensed nursing staff to ascertain if the clients continue to be capable of self-administering their medications and/or treatments. A written record of counseling must be kept by the facility.
(B) Clients who choose to keep their medications locked in the central medication storage area may be permitted entrance or access to the area for the purpose of self-administering their own medication and/or treatment regimen. A facility staff member must remain in or at the storage area the entire time any client is present.
(4) General.
(A) The facility director, the activities director, or a facility nurse must immediately report to the client's physician and responsible party any unusual reactions to medications or treatments.
(B) When the facility supervises or administers the medications, a written record must be kept when the client does not receive or take his medications and/or treatments as prescribed. The documentation must include the date and time the dose should have been taken, and the name and strength of medication missed.
(5) Storage.
(A) The facility must provide a locked area for all medications. Examples of areas include, but are not limited to:
(i) central storage area; and
(ii) medication cart.
(B) Each client's medication must be stored separately from other clients' medications within the storage area.
(C) A refrigerator must have a designated and locked storage for medications requiring refrigeration. Medications requiring refrigeration must be stored in a refrigerator used only for medicine storage or in a separate, permanently attached, and locked medication storage box in a refrigerator.
(D) Poisonous substances and medications labeled for "external use only" must be stored separately within the locked medical area.
(E) The medication room or cabinet medication storage area must have a separate, permanently attached cabinet, box, or drawer with a lock to store drugs covered by Schedule II of the Controlled Substances Act of 1970.
(6) Disposal.
(A) Medications no longer being used by the client for the following reasons must be kept separate from current medications and are to be disposed of by a registered pharmacist licensed in the State of Texas:
(i) medications discontinued by order of the physician;
(ii) medications which remain after a client is deceased; or
(iii) medications which have passed the expiration date.
(B) Needles and hypodermic syringes with needles attached must be disposed as required by 25 TAC 1, Subchapter K (relating to the Definition, Treatment, and Disposal of Special Waste from Health Care Related Facilities).
(C) Medications kept in a central storage area are released to discharged clients when a receipt has been signed by the client or responsible party.
(g) Accident, injury, or acute illness.
(1) The facility must stock and maintain in a single location first aid supplies to treat burns, cuts, and poisoning.
(2) In the event of accident or injury requiring emergency medical, dental, or nursing care, or in the event of apparent death, the adult day care facility must:
(A) make arrangements for emergency care and/or transfer to an appropriate place for treatment (including, but not limited to, physician's office, clinic, or hospital);
(B) immediately notify the client's physician and next of kin, responsible party, or agency who placed the client in the facility; and
(C) describe and document the accident, injury, or illness on a separate report. The report must contain a statement of final disposition and be maintained on file.
(h) Menus.
(1) Menus must be planned at least two weeks in advance, dated, maintained on file, and posted in the facility. Meals must be served according to approved menus.
(2) Special diet meals ordered by the client's physician and developed by the dietician must be labeled with the client's name and type of diet.
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