The purpose of the proposed rule amendments is to incorporate changes in the authorizing statute, revise technical errors and update references.

Health Facility and Agency Licensing

RULE NOS.:RULE TITLES:

59A-4.103Licensure, Administration and Fiscal Management

59A-4.106Facility Policies

59A-4.107Physician Services

59A-4.1075Medical Director

59A-4.108Nursing Services

59A-4.109Resident Assessment and Care Plan

59A-4.110Dietary Services

59A-4.112Pharmacy Services

59A-4.118Medical Records

59A-4.122Physical Environment

59A-4.123Risk Management and Quality Assurance

59A-4.126Disaster Preparedness

59A-4.128Evaluation of Nursing Homes and Licensure Status

59A-4.1288Exception

59A-4.130Fire Prevention, Fire Protection, and Life Safety

59A-4.133Plans Submission and Review and Construction Standards

59A-4.134Plans Submission and Fee Requirements

59A-4.150Geriatric Outpatient Nurse Clinic

59A-4.165Nursing Home Guide

59A-4.202Quality of Care

59A-4.204Turnover Ratio

59A-4.206Termination and Frequency of Review

PURPOSE AND EFFECT: The purpose of the proposed rule amendments is to incorporate changes in the authorizing statute, revise technical errors and update references.

SUMMARY: Rule 59A-4.103, F.A.C., is amended to include provisions for initial and change of ownership applications or the suspension of a current license when licensure fees are returned to the Agency due to insufficient funds. This section also includes specifications regarding the issuance of partial inactive licenses for alternative uses pursuant to Section 400.0712, Florida Statutes (F.S.). Other changes to this section include modifications to the licensure application. This rule amendment also eliminates the requirement to report monthly vacant beds and provide quarterly nursing home staffing reports to the Agency. Rule 59A-4.106, F.A.C., is amended to include the provision of a web address for obtaining transfer and discharge forms and deletes a reference to services provided by the Department of Children and Families. This rule amendment includes the requirement for each facility to adopt, implement and maintain policies and procedures for therapeutic services (if offered), updates a reference to the Code of Federal Regulations 483, and provides a specific address to obtain copies of “Health Care Advance Directives.” Rule 59A-4.107, F.A.C., is amended to allow physician orders to be transmitted by email or electronic records and minor technical changes as needed. Rule 59A-4.1075, F.A.C., is amended to address minor technical changes as needed. Rule 59A-4.108 is amended to establish requirements for requesting the use of licensed nurses to perform licensed nursing and certified nursing assistant duties. The rule is further amended to eliminate the minimum staffing requirements which are cited in Section 400.23(3)(a)1, F.S. Rule 59A-4.109, F.A.C., is amended to address minor technical changes. Rule 59A-4.110, F.A.C., is amended to include a requirement for the director of food services to be a certified dietary manager and replaces the outdated references to the Dietary Managers training and certification process. Rule 59A-4.112, F.A.C., is amended to update statutory references and requires nursing homes to only allow licensed staff access to the locked medication room in accordance with state and federal laws. Further, the rule is amended to address the statutory requirement regarding the emergency drug medication kit contents and to address minor technical changes as needed. Rule 59A-4.118, F.A.C., relating to standards for medical records is amended to eliminate the requirement for nursing homes to employ or contract with a person who is eligible for certification as a Registered Record Administrator or an Accredited Record Technician by the American Health Information Management Association of a graduate of a School of Medical Record Science that is accredited jointly by the Council on Medical Education of the American Medical Association and the American Health Information Management Association. The amendment will align this requirement with federal requirements that states a nursing home must maintain clinical records on each resident in accordance with acceptable professional standards and practices that are: complete, accurately documented, readily accessible and systematically organized. Rule 59A-4.122, F.A.C., is amended to define the requirement for comfortable and safe room temperatures and establishes written policies and procedures to maintain the physical plant and overall nursing home environment. Rule 59A-4.123, F.A.C., is amended to remove the requirement to complete the 1-day Adverse Incident Reporting Form and revise the 15-day Adverse Incident Reporting Form and provide for electronic submission of this form. Rule 59A-4.126, F.A.C., is amended to provide language regarding the submission of the emergency management plan, testing of this plan, and procedures and notifications for evacuation, overcapacity and re-occupancy of the nursing home structure during a disaster. Rule 59A-4.128, F.A.C., is amended to remove the statement that noncompliance will be stated as deficiencies measured in terms of scope and severity. Rule 59A-4.1288, F.A.C., is amended to update the references to federal regulations. Rule 59A-4.130, F.A.C., is amended to revise language to conform to code edition changes in the Florida Building Code and retain language not included in the Florida Building Code. Rule 59A-4.133, F.A.C., is amended to provide language to reference the Florida Building Code to conform to statutory changes, and deletes all other requirements. This rule is also amended to change the rule title to “Physical Plant Codes and Standards for Nursing Homes.” Rule 59A-4.134, F.A.C., is amended to update the requirements for construction plan submissions to conform to codes and statutory changes. Rule 59A-4.150, F.A.C., is amended to delete or correct recurring or obsolete definitions and references throughout this section and allows physician assistant and advanced registered nurse practitioner to render services to nursing home residents. Rule 59A-4.165, F.A.C., is amended to replace the reference to a 45-month reporting period in the Nursing Home Guide with language that cites the time period defined in Section 400.191, F.S. The amendment includes the new website address for the Nursing Home Guide Methodology. This rule is also amended to include a methodology to obtain a Quality of Care score for current non-federally certified nursing homes that becomes federally certified. Rule 59A-4.202, F.A.C., is amended to include the web address Nursing Home Guide Methodology. Rule 59A-4.204, F.A.C., is amended to remove references to repealed statutory language and includes the methodology used to compute the nursing home turnover and stability rates for Gold Seal Award criteria purposes. Rule 59A-4.206, F.A.C., is amended to include language on termination of the Gold Seal Award designation to a facility or applicant if they no longer meet Gold Seal Award criteria.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION: The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A checklist was prepared by the Agency to determine the need for SERC. Based on this information at the time of the analysis and pursuant to Section 120.541, Florida Statutes, the rule will not require legislative ratification.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 400.23 FS.

LAW IMPLEMENTED: 400.011, 400.022, 400.141, 400.142, 400.23 FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: January 20, 2015, 9:30 a.m. ‒ 11:30 a.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room B

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Terrosa Buie, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #33, Tallahassee, FL 32308 or [e-mail]. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Jacqueline Williams, 2727 Mahan Drive, Mail Stop #33, Tallahassee, FL 32308 or via e-mail at [e-mail] or by phone at [phone]

COMMENTS WILL BE RECEIVED UNTIL 5:00 P.M. ON WEDNESDAY, JANUARY 21, 2015.

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59A-4.103 Licensure, Administration and Fiscal Management.

(1) The licensee or applicant prospective licensee shall make application for an initial, renewal or change of ownership license to operate a nursing home facility and shall provide:

(a) All all of the information required by this rule, and Chapter 400, Part II, F.S., and Chapter 408, Part II, on the Health Care Licensing Application, Nursing Homes, AHCA Form 3110-6001, July 2014, which is incorporated by reference. These forms may be obtained at http://www.flrules.org/Gateway/reference.asp?No=Ref-XXXX and are available from the Agency for Health Care Administration, Long-Term Care Unit, 2727 Mahan Drive, Mail Stop #33, Tallahassee, FL 32308 or at the web address: http://ahca.myflorida.com/HQAlicensureforms January, 2002, “Application for Nursing Home Licensure”, and AHCA Form 3001-6001, January, 2002, Instructions for Completing Application for Nursing Home Licensure, which is incorporated by reference and AHCA Forms 3110-0011, 3110-0011A, 3110-0011B, 3110-0011C, and 3110-0011D, August, 2001, “Controlling Interest Affidavit for Nursing Homes”, which is incorporated by reference and

(b) Proof of Financial Ability to Operate, AHCA Form 3100-0009, July 2009, 1332-0001, January, 2002, “Proof of Financial Ability Schedule” which is incorporated by reference, available at http://www.flrules.org/Gateway/reference. asp?No=Ref-XXXXXX and from the Agency for Health Care Administration, Long Term Care Unit, 2727 Mahan Drive, Mail Stop #33, Tallahassee, Florida 32308 or online at http://ahca.myflorida.com/HQAlicensureforms.

(2) The licensure fees must fee shall be included with the application. The licensure fees are: a biennial fee of $100.00 An annual fee is $50 per bed and a resident protection fee of $. 50 per bed as required by section as described in Section 400.062(3), F.S., plus the resident protection fee of $.25per bed and the Data Collection and Analysis Assessment of $12.00 $6.00 per bed as required by Section authorized by Section 408.20(1)(b), F.S., Assessments: Health Care Trust Fund Costs of Nursing Home Statistical Unit, March 9, 1994. The assessment required by Section 408.20(1)(b), F.S. Data Collection and Analysis Assessment is waived for facilities having a certificate of authority under Chapter 651, F.S.

(3) Single copies of AHCA forms incorporated by reference within this chapter may be obtained from the AHCA, Long Term Care Section, 2727 Mahan Drive, MS 33, Tallahassee, Florida 32308.

(3) A nursing home licensee may request an inactive license for part of a facility to use an occupied contiguous portion of the facility for an alternative use as authorized by Section 400.0712, F.S. Prior to providing alternative services, the facility must submit a written request to the Agency. A request may be submitted at any time during the licensure period and must provide: the intended use of the inactive portion, a floor plan of the building identifying the inactive area, the total number of inactive beds and the prospective date the beds will become inactive.

(a) Upon receipt of written approval by the Agency to continue with the plan for the partial inactive license, the licensee must submit a completed Health Care Licensing Application, Nursing Homes, AHCA Form 3110-6001, July 2014, to the Agency within 60 days of the approval and a bed change request form for beds certified through the Centers for Medicare and Medicaid Services. The appropriate facility licensure application for the alternative use must accompany this application, unless the space will be utilized for services authorized under the existing nursing home licensure.

(b) If the alternative service license is approved, a partial inactive license will be issued concurrently with the issuance of the license for the alternative use. The expiration date of the partial inactive license will be the same date that the licensee’s nursing home must file for renewal of their nursing home license. The licensee must indicate the intent to continue the partial inactive license at each nursing home licensure renewal. Licensure fees will remain at the standard rate for nursing home beds, whether active or inactive, at the time of renewal and will not be assessed for another Agency license  for the alternative use of the inactive beds.

(c) Notification to reactivate the inactive portion of the building and the appropriate change request form for beds certified through the Center for Medicare and Medicaid Services, must be submitted to the Agency at least 30 days prior to the planned date to admit residents to the previously inactive beds. The inactive portion of the license will be reactivated upon Agency approval.

(4) Administration.

(a) The licensee of each nursing home must shall have full legal authority and responsibility for the operation of the facility.

(b) The licensee of each facility must shall designate one person, who is licensed by the Florida Department of Health, Agency for Health Care Administration, Board of Nursing Home Administrators under Chapter 468, Part II, F.S., as the Administrator who oversees the day to day administration and operation of the facility.

(c) Each nursing home must shall be organized according to a written table of organization Organization.

(d) The licensee shall submit a monthly vacant bed report which is incorporated by reference by using AHCA Form 3110-0013, October 2008, “Nursing Home Monthly Bed Vacancy Report”, as authorized by Section 400.141, F.S., this form is available from the Agency for Health Care Administration, Long Term Care Unit, 2727 Mahan Drive MS 33, Tallahassee, FL 32308 or online at: http://ahca.myflorida.com/.

(e) Submit Nursing Home Staffing Report which is incorporated by reference by using AHCA Form 3110-0012, October 2008, “Nursing Home Staffing Report”, as authorized by Section 400.141, F.S., this form is available from the Agency for Health Care Administration, Long Term Care Unit, 2727 Mahan Drive MS 33, Tallahassee, FL 32308 or online at: http://ahca.myflorida.com/.

(5) Fiscal Management.

(a) The licensee, for each nursing home it operates, must shall maintain fiscal records in accordance with the requirements of Chapter 400, Part II, F.S., and this rule these rules.

(b) An accrual or cash system of accounting must shall be used to reflect transactions of the business. Records and accounts of transactions, such as, general ledgers and disbursement journals, must shall be brought current no less than quarterly and shall be available for review by authorized representatives of appropriate state and federal Federal agencies.

(c) A licensee must shall obtain a surety bond as required by Chapter 400, Part II, F.S.; it must shall be based on twice the average monthly balance in the resident trust fund during the prior fiscal year or $5,000, whichever is greater. A licensee who owns more than one nursing home may purchase a single surety bond to cover the residents’ funds held in nursing homes located within the state same AHCA service district. A surety bond must shall contain substantially the same language as is found in the Nursing Home Patient Trust Surety Bond, AHCA Form 3110-6002, May 2008, July, 2001 Surety Bond, which is incorporated by reference and may be obtained at http://www.flrules.org/Gateway/reference.asp?No+Ref-XXXXX and from the Agency online at http://ahca.myflorida.com reference. The surety bond must AHCA 3110-6002, July, 2001, may be obtained from, and shall be filed with the Agency for Health Care Administration, AHCA 2727 Mahan Drive, Mail Stop #33, Tallahassee, Florida 32308.

(d) A self-insurance pool, which may be an interest bearing account, may be established for non-certified facilities only to provide compensation to any resident suffering financial loss in accordance with the provisions of Section 400.162(5)(c), F.S., as the result of one or more of the member licensees violating any of the provisions of Section 400.162, F.S.

1. Such self-insurance pool must shall be administered under the direction of an elected board of trustees. The membership of the board of trustees must shall be composed of one representative from each participating licensee.

2. An application for establishing a self-insurance pool must shall be made by the trustees to the Agency ahca. Such application shall contain the following information: the names, complete addresses, and affiliation of the trustees:, the name and complete address of each licensee participating in the pool;, the total dollar amount of the pool; and the name and complete address of the bank in which the account is maintained and the account number. The application must shall be accompanied by:

a. An individual application from each licensee applying for membership in the self-insurance pool. Such application must shall contain the following information: the name, telephone number, and complete address of the facility; the name, telephone number, and complete address of and the licensee;, the name of the facility’s administrator, manager or supervisor, and his or her license and renewal number; the names of all employees involved in the administration of the resident trust fund account; the average monthly balance in the resident trust fund account during the prior year; the total dollar amount the licensee has deposited in the self-insurance pool; and the name and complete address of the bank in which the account is maintained and the account number.

b. Prima facie evidence showing that each individual member of the pool has deposited an amount equal to twice the average monthly balance of the trust fund account or $5,000.00 dollars, whichever is greater, in a separate account maintained by the board of trustees in the name of the self-insurance pool in a chartered commercial bank authorized under Chapter 658, F.S., in the State of Florida that is a member of the Federal Reserve System to secure performance of payment of all lawful awards made against any member or members of the self-insurance pool, as required by Section 400.162(5), F.S., and this rule these rules.

3. After the inception date of the pool, prospective new members of the pool must shall submit an application for membership to the board of trustees. Such application must shall contain the information specified in subparagraph (5)(d)2. of this rule. (5)(b)2. The trustees may approve the application for membership in accordance with these rules. If so approved, the application for membership in accordance with these rules must shall be filed with the Agency ahca at the Agency for Health Care Administration, Long-Term Care Unit, 2727 Mahan Drive, Mail Stop #33, Tallahassee, FL 32308. Participation in a pool by a particular licensee shall be approved by the ahca if the licensee indicates in its application that it does meet the requirements of Section 400.162(5), F.S., and these rules and verification is provided to document the financial status indicated on the application.

4. The amount deposited in such an account must shall be maintained at all times.

(e) If, at any time during the period for which a license is issued, a licensee who has not purchased a surety bond or entered into a self-insurance agreement is requested to hold funds in trust as provided in Section 400.162(5), F.S., the licensee must shall notify the Agency ahca, in writing, of the request at the Agency for Health Care Administration, Long-Term Care Unit, 2727 Mahan Drive, Mail Stop #33, Tallahassee, FL 32308, and make application for a surety bond or for participation in a self-insurance agreement within seven business days of the request, exclusive of weekends and holidays. Copies of the application, along with written documentation of related correspondence with an insurance agency or group, must shall be maintained and must shall be available for review. All notices required by this rule provision must shall be sent to the Agency for Health Care Administration AHCA, 2727 Mahan Drive, Mail Stop #33, Tallahassee, Florida 32308.

Rulemaking Authority 400.062, 400.23, 408.810(8) FS. Law Implemented 400.022, 400.0712, 400.0225, 400.071, 400.102, 400.111, 400.1183, 400.121, 400.141, 400.147, 400.151, 400.162, 400.179, 400.20, 408.033, 400.18, 400.232 408.20, 408.810(8) FS. History–New 4-1-82, Amended 4-1-84, 8-1-85, 1-1-86, 11-12-89, 12-25-90, 10-6-91, Formerly 10d-29.103, Amended 4-18-94, 2-6-97, 5-5-02,_________.

 

59A-4.106 Facility Policies.

(1) Admission, retention, transfer, and discharge policies:

(a) Each resident must will receive the following, at the time of admission, and as changes are being made and upon request, in a language the resident or his representative understands:

1. A copy of the residents’ bill of rights as required by conforming to the requirements in Section 400.022, F.S.;

2. A copy of the facility’s admission and discharge policies; and

3. Information regarding advance directives.

(b) Each resident admitted to the facility must shall have a contract as required by in accordance with Section 400.151, F.S., which includes the following covers:

1. A list of services and supplies, complete with a list of standard charges for those services and supplies, available to the resident, but not covered by the facility’s per diem or by Title XVIII and Title XIX of the Social Security Act and a copy of the bed reservation and refund policies of the facility.

2. When a resident is in a facility offering continuing care, and is transferred from independent living or assisted living to the nursing home section, a new contract need not be executed; an addendum must shall be attached to describe any additional services, supplies or costs not included in the most recent contract that is in effect.

(c) No resident who is suffering from a communicable disease shall be admitted or retained unless the medical director or attending physician certifies that adequate or appropriate isolation measures are available to control transmission of the disease.

(d) Residents may not be retained in the facility who require services beyond those for which the facility is licensed or has the functional ability to provide as determined by the Medical Director and the Director of Nursing in consultation with the facility Administrator administrator.

(e) Residents must shall be assigned to a bedroom area and must shall not be assigned bedroom space in common areas except in an emergency. Emergencies must shall be documented and must shall be for a limited, specified period of time.

(f) All resident transfers and discharges must shall be in accordance with the facility’s policies and procedures , provisions of Sections 400.022 and 400.0255, F.S., this rule, and Title 42 Code of Federal Regulations section 483.12(a), revision date January 7, 2011, other applicable state and federal laws and will include notices provided to residents which are incorporated by reference by using the Nursing Home Transfer and Discharge Notice, AHCA Form 3120-0002, April 2014 3120-0002A, Revised May, 2001, “Nursing Home Transfer and Discharge Notice,” and, herein incorporated by reference and available at http://www.flrules.org/Gateway/reference. asp?No=Ref-XXXXXX, the Fair Hearing Request for Transfer or Discharge From a Nursing Home, AHCA Form 3120-0003, April 2014, herein incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-XXXXXX, Revised May, 2001, “Fair Hearing Request for Transfer or Discharge From a Nursing Home,” the Long-Term Care Ombudsman Program Request for Review of Nursing Home Discharge and Transfer, AHCA Form 3120-0004, April 2014, herein incorporated by reference and available at http:// www.flrules.org/Gateway/reference.asp?No=Ref-XXXXXX, Revised, May, 2001, “Long-Term Care Ombudsman Council Request for Review of Nursing Home Discharge and Transfer.” or the Spanish language version, Solicitud de Revisión de Long-Term Care Ombudsman de la Dada de Alta o El Traslado de un Hogar de Ancianos, AHCA Form 3120-0004A, April 2014, herein incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-XXXXXX. These forms may also be obtained from the Agency for Health Care Administration, Long Term Care Unit, 2727 Mahan Drive, Mail Stop# MS33, Tallahassee, FL 32308 or at the web address: http://ahca.myflorida.com/. The Department of Children and Family Services will assist in the arrangement for appropriate continued care, when requested.

(2) Each nursing home licensee must facility shall adopt, implement, and maintain written policies and procedures governing all services provided in the facility.

(3) All policies and procedures must shall be reviewed at least annually and revised as needed with input from, at minimum, the facility Administrator, Medical Director, and Director of Nursing.

(4) Each facility shall maintain policies and procedures in the following areas:

(a) Activities;

(b) Advance directives;

(c) Consultant services;

(d) Death of residents in the facility;

(e) Dental services;

(f) Staff education, including HIV/AIDS hiv/aids Training as required by section 381.0035, F.S.;

(g) Diagnostic services;

(h) Dietary services;

(i) Disaster preparedness;

(j) Fire prevention and control;

(k) Housekeeping;

(l) Infection control;

(m) Laundry service;

(n) Loss of power, water, air conditioning or heating;

(o) Medical director/consultant services;

(p) Medical records;

(q) Mental health;

(r) Nursing services;

(s) Pastoral services;

(t) Pharmacy services;

(u) Podiatry services;

(v) Resident care planning;

(w) Resident identification;

(x) Resident’s rights;

(y) Safety awareness;

(z) Social services;

(aa) Specialized rehabilitative and restorative services;

(bb) Therapeutic spa services, if offered;

(cc) (bb) Volunteer services; and

(dd) (cc) The reporting of accidents or unusual incidents involving any resident, staff member, volunteer or visitor. This policy shall include reporting within the facility and to the Agency as required by Section 400.147, F.S ahca.

(5) Staff Education.

(a) Each nursing home licensee must shall develop, implement, and maintain a written staff education plan which ensures a coordinated program for staff education for all facility employees. The staff education plan must shall be reviewed at least annually by the risk management and quality assurance committee and revised as needed.

(b) The staff education plan must shall include both pre-service and in-service programs.

(c) The staff education plan must shall ensure that education is conducted annually for all facility employees, at a minimum, in the following areas:

1. Prevention and control of infection;

2. Fire prevention, life safety, and disaster preparedness;

3. Accident prevention and safety awareness program;

4. Resident’s rights’;

5. Federal law, 42 CFR 483, Requirements for State and Long Term Care Facilities, October 1, 2011, which is incorporated by reference and available at http://ecfr. gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl, September 26, 1991, which is incorporated by reference, and state rules and regulations Chapter 400, Part II, F.S., and subsection 59A-4.106(5), F.A.C. this rule;

6. The Florida “Right to Know” Hazardous Materials, Chapter 442, F.S.;

(d) The staff education plan must shall ensure that all nonlicensed employees of the nursing home complete an initial educational course on HIV/AIDS as required by Section 381.0035, F.S. hiv/aids. If the employee does not have a certificate of completion at the time they are hired, they must complete the course have two hours within six months of employment or before the employee staff  provides care for an HIV/AIDS hiv/aids diagnosed resident. All employees shall have a minimum of one hour biennially.

(6) Advance directives.

(a) Each nursing home licensee must shall have written policies and procedures, which delineate the nursing home’s position with respect to the state law and rules relative to advance directives. The policies must shall not condition treatment or admission upon whether or not the individual has executed or waived an advance directive. In the event of conflict between the facility’s policies and procedures and the individual’s advance directive, provision should be made in accordance with Section 765.1105 Section 765.308, F.S.

(b)( 7) The facility’s policy must shall include:

1.(a) Providing each adult individual, at the time of the admission as a resident, with a copy of “Health Care Advance Directives – The Patient’s Right to Decide,” as prepared by the Agency for Health Care Administration, revised 2006 2727 Mahan Drive, Tallahassee, FL 32308, effective 1-11-93, which is hereby incorporated by reference and available at http//www.flrules.org/Gateway/reference.asp?No=Ref-XXXXX, from the Agency for Health Care Administration at http://www.floridahealthfinder.gov/reports-guides/advance-directives.aspx, from the Agency for Health Care Administration at 2727 Mahan Drive, Mail Stop #16, Tallahassee, FL 32308 or electronically at http://ahca.myflorida.com/MCHQ/Health_Facility Regulation/ HC_Advance_Directives/., or with a copy of some other substantially similar document which is a written description of Florida’s state law regarding advance directives;:

2.(b) Providing each adult individual, at the time of the admission as a resident, with written information concerning the nursing home’s policies respecting advance directives; and

3.(c) The requirement that documentation of the existence of an advance directive be contained in the medical record. A nursing home licensee that which is provided with the individual’s advance directive must shall make the advance directive, or a copy thereof, a part of the individual’s medical record.

Rulemaking Authority 400.141, 400.141(7),400.142(3), 400.23, 765.110 FS. Law Implemented 400.022, 400.0255, 400.102, 400.141, 400.141(7), 400.142(3), 400.151, 400.23, 765.110 FS. History–New 4-1-82, Amended 4-1-84, Formerly 10d-29.106, Amended 4-18-94, 1-10-95, 2-6-97, 5-5-02,__________.

 

59A-4.107 Physician Services.

(1) Each nursing home licensee must facility shall retain, pursuant to a written agreement, a physician licensed under Chapter 458 or 459, F.S., to serve as Medical Director. In facilities with a licensed capacity of 60 beds or less, pursuant to written agreement, a physician licensed under Chapter 458 or 459, F.S., may serve as a medical consultant Medical Consultant in lieu of a Medical Director.

(2) Each resident or legal representative must shall be allowed to select his or her own private physician.

(3) Verbal orders, including telephone orders, must shall be immediately recorded, dated, and signed by the person receiving the order. All verbal treatment orders must shall be countersigned by the physician or other health care professional on the next visit to the facility.

(4) Physician orders may be transmitted by facsimile machine, email or electronic medical record as required by state health information security and privacy laws and federal HIPAA laws. It is not necessary for a physician to re-sign a facsimile order when he or she visits a facility.

(5) All physician orders must shall be followed as prescribed, and if not followed, the reason must shall be recorded on the resident’s medical record during that shift.

(6) Each resident must shall be seen by a physician or another licensed health professional acting within their scope of practice at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. If a physician documents that a resident does not need to be seen on this schedule and there is no other requirement for physician’s services that must be met due to Title XVIII or XIX of the Social Security Act title xviii or xix, the resident’s physician may document an alternate visitation schedule.

(7) If the physician chooses to designate another health care professional to fulfill the physician’s component of resident care, they may do so after the required visit. All responsibilities of a physician, except for the position of medical director, may be carried out by other health care professionals acting within their scope of practice.

(8) Each nursing home licensee must facility shall have a list of physicians designated to provide emergency services to residents when the resident’s attending physician, or designated alternate is not available.

Rulemaking Authority 400.23 FS. Law Implemented 400.022, 400.102, 400.141, 400.23, 464.012 FS. History–New 4-1-82, Amended 4-1-84, Formerly 10D-29.107, Amended 10-5-92, 4-18-94, 1-10-95,__________.

 

59A-4.1075 Medical Director.

(1) Each nursing home licensee must facility will have only one physician who is designated as Medical Director.

(2)(a) The Medical Director must be a physician licensed under Chapter 458 or 459, F.S., the nursing home administrator may require that the Medical Director be certified or credentialed through a recognized certifying or credentialing organization.

(b) A Medical Director who does not have hospital privileges must shall be certified or credentialed through a recognized certifying or credentialing body, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the American Medical Directors Association, the Healthcare Facilities Accreditation Program of the American Osteopathic Association, the Bureau of Osteopathic Specialists of the American Osteopathic Association, the Florida Medical Directors Association or a health Health maintenance organization licensed in Florida.

(c) A physician must have his/ or her principal office within 60 miles of all facilities for which he/ or she serves as Medical Director. The principal Principal office is the office maintained by a physician as required by Section 458.348 or 459.025(3)(c)(1), F.S., pursuant to Section 458.351 or 459.026 F.S., and where the physician delivers the majority of medical services. The physician must specify the address of his/ or her principal office at the time of becoming Medical Director. The agency may approve a request to waive this requirement for rural facilities that exceed this distance requirement. A rural facility is a facility located in a county with a population density of no greater than 100 persons per square mile, which is at least 30 minutes of travel time, on normally traveled roads under normal traffic conditions, from any other nursing home facility within the same county.

(d) The nursing home licensee must facility shall appoint a Medical Director who must shall visit the facility at least once a month. The Medical Director must shall review all new policies and procedures; review all new incident and new accident reports from the facility to identify clinical risk and safety hazards. The Medical Director must shall review the most recent grievance logs for any complaints or concerns related to clinical issues. Each visit must be documented in writing by the Medical Director.

(3) A physician may be Medical Director of a maximum of 10 nursing homes at any one time. The Medical Director, in an emergency where the health of a resident is in jeopardy and the attending physician or covering physician cannot be located, may assume temporary responsibility of the care of the resident and provide the care deemed necessary.

(4) The Medical Director must appointed by the facility shall meet at least quarterly with the risk management and quality assessment and assurance committee of the facility.

(5) The Medical Director must appointed by the facility shall participate in the development of the comprehensive care plan for the resident when he/ or she is also the attending physician of the resident.

Rulemaking Authority 400.141 FS. Law Implemented 400.141(1)(b), (2) FS. History–New 8-2-01, Amended___________.

 

59A-4.108 Nursing Services.

(1) The Administrator of each nursing home must will designate one full time registered nurse as a Director of Nursing (DON) who shall be responsible and accountable for the supervision and administration of the total nursing services program. When a director of nursing is delegated institutional responsibilities, a full time qualified registered nurse (RN), as defined in Chapter 464, F.S., must shall be designated to serve as Assistant Director of Nursing. In a facility with a census of 121 or more residents, an RN must be designated as an Assistant Director of Nursing.

(2) Persons designated as Director of Nursing or Assistant Director of Nursing must shall serve only one nursing home facility in this capacity, and shall not serve as the administrator of the nursing home facility.

(3) The Director of Nursing must shall designate one licensed nurse on each shift to be responsible for the delivery of nursing services during that shift.

(4) In addition to the requirements outlined in subsection 400.23(3)(a), F.S., the The nursing home licensee must facility shall have sufficient nursing staff, on a 24-hour basis, to provide nursing and related services to residents in order to maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility will staff, at a minimum, an average of 1.7 hours of certified nursing assistant and .6 hours of licensed nursing staff time for each resident during a 24 hour period.

(5) In multi-story, multi-wing, or multi-station nursing home facilities, there must shall be a minimum of one nursing services staff person who is capable of providing direct care on duty at all times on each floor, wing, or station.

(6) No nursing services staff person shall be scheduled for more than 16 hours within a 24 hour period, for three consecutive days, except in an emergency. Emergencies must shall be documented and must shall be for a limited, specified period of time.

(7) Upon approval by the Agency, a nursing home licensee may allow a licensed nurse that performs both licensed nursing and certified nursing assistant duties during the same shift to divide the hours of patient care provided between the licensed nurse and certified nursing assistant staffing ratio requirements consistent with services provided, as referenced in Section 400.23(3)(a)4., F.S. Approval to utilize licensed nurses to perform certified nursing assistant duties must be requested in writing.  This request may be submitted upon license renewal on the Health Care Licensing Application, Nursing Homes, AHCA Form 3110-6001, July 2014, incorporated by reference in paragraph 59A-4.103(1)(a), F.A.C. or by letter from the facility administrator. The licensee must document daily the time the licensed nurse performed personal care services to comply with minimum staffing requirements.  The hours of a licensed nurse with dual job responsibilities may not be counted twice.

Rulemaking Authority 400.022, 400.23 FS. Law Implemented 400.011, 400.022, 400.141, 400.23 FS. History–New 4-1-82, Amended 4-1-84, 8-1-85, 7-1-88, 7-10-91, Formerly 10D-29.108, Amended 4-18-94,___________.

 

59A-4.109 Resident Assessment and Care Plan.

(1) Each resident admitted to the nursing home facility must shall have a plan of care. The plan of care must shall consist of:

(a) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential.

(b) A preliminary nursing evaluation with physician’s orders for immediate care, completed upon on admission.

(c) A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter. The assessment must shall be:

1. Reviewed no less than once every 3 months;,

2. Reviewed promptly after a significant change in the resident’s physical or mental condition;,

3. Revised as appropriate to assure the continued accuracy of the assessment.

(2) The nursing home licensee must facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment.

(3) At the resident’s option, every effort must shall be made to include the resident and family or responsible party, including private duty nurse or nursing assistant, in the development, implementation, maintenance and evaluation of the resident’s plan of care.

(4) All staff personnel who provide care, and at the resident’s option, private duty nurses or personnel who are not non employees of the facility, must shall be knowledgeable of, and have access to, the resident’s plan of care.

(5) A summary of the resident’s plan of care and a copy of any advanced directives must shall accompany each resident discharged or transferred to another health care facility, licensed under Chapters 395 or Chapter 400, Part II, F.S., or must shall be forwarded to the receiving facility as soon as possible consistent with good medical practice.

Rulemaking Authority 400.23 FS. Law Implemented 400.022, 400.102, 400.141, 400.23 FS. History–New 4-1-82, Amended 4-1-84, Formerly 10D-29.109, Amended 4-18-94, 1-10-95,__________.

 

59A-4.110 Dietary Services.

(1)  The Administrator must designate one full-time person as a Director of Food Services Dietary Services Supervisor. In a facility with a census of 61 or more residents, the duties of the Director of Food Services must Dietary Services Supervisor shall not include food preparation or service on a regular basis.

(2) The Director of Food Services must Dietary Services Supervisor shall either be a qualified dietitian or the facility shall obtain consultation from a qualified dietitian. A qualified dietitian is one who:

(a) Is a registered dietitian/ or nutritionist as defined by the Commission on Dietetic Registration of the Academy of Nutrition and Dietetics, March 1, 1994, which is incorporated by reference, the credentialing agency for the American Dietetic Association and is currently registered with the American Dietetic Association; or

(b) Has a baccalaureate degree with major studies in food and nutrition, dietetics, or food service management, as defined by the Commission on Dietetic Registration of the Academy of Nutrition and Dietetics American Dietetic Association, March 1, 1994, which is incorporated by reference, has one year of supervisory experience in the dietetic service of a health care facility, and participates annually in continuing dietetic education.

(3) A Director of Food Services Dietary Services Supervisor shall be a person who:

(a) Is a qualified dietitian as defined in paragraphs 59A-4.110(2)(a), (b), F.A.C.; or

(b) Has successfully completed a college or university an associate degree program which meets the education standard established by the Academy of Nutrition and Dietetics for a Dietetic Technician, Registered American Dietetic Association; or

(c) Has successfully completed a Dietetic Assistant correspondence or class room training program, approved by the Academy of Nutrition and Dietetics American Dietetic Association; or

(d) Has successfully completed a course offered by an accredited college or university that provided 90 or more hours of correspondence or classroom instruction in food service supervision, and has prior work experience as a Dietary Supervisor in a health care institution with consultation from a qualified dietitian; or

(e) Has training and experience in food service supervision and management in the military service equivalent in content to the program in paragraph (3)(b), (c) or (d) of this rule; or

(f) Is a Certified Dietary Manager certified dietary manager who has successfully completed the Dietary Manager’s Course and is certified through the Certifying Board for Dietary Managers the Association of Nutrition and Food Service Professionals and is maintaining their certification with continuing clock hours at 45 CEU’s per three year period.

(4) A one-week supply of a variety of non-perishable food and supplies, that represents a good diet, shall be maintained by the facility.

Rulemaking Authority 400.022(1)(a), (f), (g), 400.141(5), 400.23 FS. Law Implemented 400.022, 400.102, 400.141, 400.23 FS. History–New 4-1-82, Amended 4-1-84, 7-1-88, 7-10-91, Formerly 10D-29.110, Amended 4-18-94, 2-6-97,__________.

 

59A-4.112 Pharmacy Services.

(1) The nursing home licensee must facility shall adopt procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident.

(2) The facility must shall employ, or obtain, the services of a state licensed consultant pharmacist. A consultant pharmacist is a pharmacist who is licensed by the Department of Health, Board of Pharmacy, Business and Professional Regulation and registered as a consultant pharmacist by the Board of Pharmacy in accordance with Rules 64B16-26.300 and 64B16-28.501, F.A.C., and who provides consultation on all aspects of the provision of pharmacy services in the facility.

(3) The consultant pharmacist must shall establish a system to accurately record the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation.

(4) The consultant pharmacist must shall determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

(5) Drugs and biologicals used in the facility must shall be labeled in accordance with currently accepted professional principles, as required by Chapter 499, F.S., and Rules Chapter 64B16-28.108 and 64B16-28.502, F.A.C.

(6) Prescription drugs Drugs and non-prescription medications requiring refrigeration must shall be stored in a refrigerator. The refrigerator must be locked or located within a locked medication room and accessible only to licensed staff as required by state and federal laws. When stored in a general-use refrigerator, they shall be stored in a separate, covered, waterproof, and labeled receptacle.

(7) All controlled substances must shall be disposed of as required by in accordance with state and federal laws. All non-controlled substances may be destroyed in accordance with the facility’s policies and procedures. Records of the disposition of all substances must shall be maintained in sufficient detail to enable an accurate reconciliation and a copy of the disposition must be filed in the resident’s record or maintained electronically in a readily accessible format.

(8) Non-controlled substances, in unit dose containers, may be returned to the dispensing pharmacy for credit.

(9) If ordered by the resident’s physician, the resident or his or her representative may, upon discharge, take all current prescription drugs with him or her. An inventory list of the drugs released must shall be completed, shall be dated, and signed by both the person releasing the drugs and the person receiving the drugs, and must shall be placed in the resident’s record.

(10) The facility shall maintain an Emergency Medication Kit., The kit must contain a limited supply of medications in the facility for use during emergency or after-hours situations.  The the contents must of which shall be determined by the residents’ needs in consultation with the Medical Director, Director of Nursing and Pharmacist, and it must shall be in accordance with facility policies and procedures. The kit must shall be readily available and shall be kept sealed. All items in the kit must shall be properly labeled. The licensee must facility shall maintain an accurate log of receipt and disposition of each item in the Emergency Medication Kit. An inventory of the contents of the Emergency Medication Kit must shall be attached to the outside of the kit, which must include the earliest expiration date of the kit drugs. If the seal is broken, the kit must be restocked and resealed the next business day after use.

Rulemaking Authority 400.23, 400.142 FS. Law Implemented 400.022, 400.102, 400.141, 400.142, 400.23 FS. History–New 4-1-82, Amended 4-1-84, 7-10-91, Formerly 10D-29.112, Amended 4-18-94,__________.

 

59A-4.118 Medical Records.

(1) The licensee must facility shall designate a full-time employee as being responsible and accountable for the facility’s medical records. If this employee is not a qualified Medical Record Practitioner, then the facility shall have the services of a qualified Medical Record Practitioner on a consultant basis. A qualified Medical Record Practitioner is one who is eligible for a certification as a Registered Record Administrator or an Accredited Record Technician by the American Health Information Management Association or a graduate of a School of Medical Record Science that is accredited jointly by the Council on Medical Education of the American Medical Association and the American Health Information Management Association.

(2) Each medical record must shall contain sufficient information to clearly identify the resident, his or her diagnosis and treatment, and results. Medical records shall be complete, accurate, accessible and systematically organized.

(3) Medical records must shall be retained for a period of five years from the date of discharge. In the case of a minor, the record must shall be retained for 3 years after a resident reaches legal age under state law.

Rulemaking Authority 400.23 FS. Law Implemented 400.022, 400.102, 400.141, 400.145, 400.23 FS. History–New 4-1-82, Amended 4-1-84, 3-2-88, Formerly 10D-29.118, Amended 4-18-94,__________.

 

59A-4.122 Physical Environment and Physical Plant Maintenance.

(1) The licensee must facility shall provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible.

(2) The licensee must facility shall provide:

(a) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

(b) Clean bed and bath linens that are in good condition;

(c) Private closet space for each resident;

(d) Furniture, such as a bed-side cabinet, drawer space;

(e) Adequate and comfortable lighting levels in all areas;

(c)(f) Comfortable and safe room temperature levels in accordance with 42 CFR, Section 483.15(h)(6), which is incorporated by reference; and

(d)(g)The maintenance of comfortable sound levels. Individual radios, TVs and other such transmitters belonging to the resident will be tuned to stations of the resident’s choice.

(3) Each nursing home licensee must establish written policies designed to maintain the physical plant and overall nursing home environment to assure the safety and well-being of residents.

(4) The building and mechanical maintenance programs must be supervised by a person who is knowledgeable in the areas of building and mechanical maintenance as determined by the facility.

(5) All mechanical and electrical equipment must be maintained in working order and must be accessible for cleaning and inspection.

(6) All heating, ventilation and air conditioning (HVAC) systems must be maintained to ensure they are operating within specified parameters to meet manufacturers’ specifications.  Permanent records must be maintained for equipment installed after December 31, 2014.

Rulemaking Authority 400.23 FS. Law Implemented 400.102, 400.141, 400.232 FS. History–New 4-1-82, Amended 4-1-84, Formerly 10D-29.122, Amended 4-18-94,_________.

 

59A-4.123 Risk Management and Quality Assurance.

(1) The nursing home licensee must facility shall maintain a risk management and quality assurance committee as required in Section 400.147, F.S.

(2) Each licensee must submit a full report of each adverse incident to the Agency within 15 calendar days after the incident occurs as required in Section 400.147(7), F.S. through the Agency’s internet site at http://www.ahca.myflorida.com/reporting/index.shtml as required in subsection 59A-35.110(2), F.A.C. The facility shall use AHCA Form 3110-0009, Revised, January, 2002, October, 2001, “Confidential Nursing Home Initial Adverse Incident Report – 1 Day,” and AHCA Form 3110-0010, 3110-0010A, and 3110-0010B, Revised, January, 2002, “Confidential Nursing Home Complete Adverse Incident Report – 15 Day,” which are incorporated by reference when reporting events as stated in Section 400.147, F.S. These forms may be obtained from the Agency for Health Care Administration, Long Term Care Unit, 2727 Mahan Drive, MS 33, Tallahassee, FL 32308.

(3) Each facility shall use AHCA Form 3110-0008, Revised, October 2008, “Nursing Home Monthly Liability Claim Information”, which are incorporated by reference when reporting liability claims filed against it as required by Section 400.147(9), F.S. These forms may be obtained from the Agency for Health Care Administration, Long Term Care Unit, 2727 Mahan Drive, MS 33, Tallahassee, FL 32308.

Rulemaking Authority 400.147, 400.23 FS. Law Implemented 400.022, 400.102, 400.141, 400.147, 400.23 FS. History–New 4-1-82, Amended 9-5-82, 4-1-84, 8-1-85, 7-10-91, Formerly 10D-29.123, Amended 4-18-94, 5-5-02,________.

 

59A-4.126 Disaster Preparedness.

(1) Each nursing home licensee must facility shall have a written plan with procedures to be followed in the event of an internal or externally caused disaster. The initiation, development, and maintenance of this plan is shall be the responsibility of the facility administrator, and must shall be accomplished in consultation with the Division of Emergency Management, Department of Community Affairs, County Emergency Management Agency.

(2) The plan must shall include, at a minimum, the following:

(a) Criteria, as shown, in Section 400.23(2)(g), F.S.; and

(b) The Emergency Management Planning Criteria for Nursing Home Facilities, AHCA 3110-6006, March, 1994, which is incorporated herein by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-XXXXXX and from the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #24, Tallahassee, Florida 32308 or on the website at htttp://ahca.myflorida.com/MCHQ/Plans/index.shtml#forms.

(3) The plan, including the “Emergency Management Planning Criteria for Nursing Homes,” must be submitted annually, at the time of a change of ownership of the facility and after significant modification of the plan, to the county emergency management agency for review and approval.

(4) If the licensee is advised by the county emergency management agency of necessary revisions to the plan, then those revisions must be made and the plan resubmitted to the county emergency management agency within 30 days of notification.

(5) The county emergency management agency shall be the final administrative authority for emergency plans developed by the nursing home licensee.

(6) The nursing home licensee must test the implementation of the emergency management plan annually, either in response to a disaster, an emergency, or in a planned drill.  The outcome must be evaluated and documented and appropriate modifications to the plan to address deficiencies must be made within 30 days.

(7) The emergency management plan must be located in a designated area of the facility for immediate access by nursing home staff.

(8) If residents must be evacuated from the premises due to emergency conditions or a disaster, then the licensee must report the location and number of residents evacuated to the Agency’s Long Term Care Unit in Tallahassee by phone [phone], by fax at [phone] or through an online database approved by the Agency to report information regarding the provider’s emergency status, planning or operations within 24 hours after the evacuation is complete.  If the Long-Term Care Unit or the online database is unavailable to receive such information, then the licensee must contact the appropriate Agency field office or designated Agency mutual aid office.  The administrator or designee is responsible for knowing the location of each resident until the resident has been discharged from the facility. The licensee must inform the appropriate Agency field office of a contact person(s) who will be available 24 hours a day, seven days a week, until the facility is reoccupied.

(9) A licensee may exceed its licensed capacity to act as a receiving facility in accordance with an emergency operations plan for residents of evacuating providers from geographic area where an evacuation order has been issued by a local authority having jurisdiction. While in an overcapacity status, each licensee must furnish or arrange for appropriate care and services including Fire/Life Safety Safeguards for all residents.

(10) The Agency must authorize requests for overcapacity which last in excess of 15 days.  Approvals shall be based upon approved jurisdiction, need, and resident safety as provided by the receiving and sending facilities.

(11) If residents are evacuated from a nursing home during or after an emergency situation or disaster and there is no damage to the facility and all utilities and services are operating within normal parameters,  the facility may be reoccupied and notice provided to the Agency within 24 hours of return to the facility. This notification may be sent to the agency by telephone or fax, or by electronic transmission if receipt is confirmed.  However, if there has been water intrusion, interior damage, structural damage or if the facility is unable to operate under normal electrical power then a determination of whether or not the facility can be reoccupied must be made by the Agency. A determination may also require the review and approval from the local authority having jurisdiction.  In those cases, the facility may not be occupied until all approvals are obtained.

(12) A facility with significant structural or systems damage must relocate residents out of the damaged facility until approval is received from the Agency’s Office of Plans and Construction to reoccupy the facility.

Rulemaking Authority 400.23 FS. Law Implemented 400.102, 400.141, 400.23 FS. History–New 4-1-82, Amended 4-1-84, Formerly 10D-29.126, Amended 8-15-94,_________.

 

59A-4.128 Evaluation of Nursing Homes and Licensure Status.

(1) The Agency agency shall, at least every 15 months, evaluate and assign a licensure status to every nursing home facility. The evaluation and licensure status shall be based on the facility’s compliance with the requirements of contained in this rule and, Chapter 400, Part II, F.S.

(2) The evaluation shall be based on the most recent licensure survey report and, investigations conducted by the Agency .AHCA and those persons authorized to inspect nursing homes under Chapter 400, Part II, F.S.

(3) The licensure status assigned to the nursing home facility will be either conditional or standard. The licensure status is based on the compliance with the standards contained in this rule and Chapter 400, Part II, Chapter 408, Part II, F.S. and this rule. Non-compliance will be stated as deficiencies measured in terms of scope and severity.

Rulemaking Authority 400.23 FS. Law Implemented 400.102, 400.19, 400.23 FS. History–New 4-1-82, Amended 4-1-84, 9-26-85, 7-21-87, Formerly 10D-29.128, Amended 8-15-94, 2-28-95, 10-13-96, 5-5-02,_________.

 

59A-4.1288 Exception.

Nursing homes licensees that participate in Title XVIII or XIX must follow certification rules and regulations as required by found in 42 C.F.R., Part 483.1-483.75, Requirements for State and Long Term Care Facilities, September 26, 1991which is incorporated by reference and state rules and regulations, Chapter 400, Part II, F.S. and this rule. Non-certified facility licensees facilities must follow the contents of this rule and the standards contained in the Conditions of Participation as required by found in 42 C.F.R. 483, Requirements for States and Long Term Care Facilities, September 26, 1991 which is incorporated by reference with respect to social services, dental services, infection control, dietary and the therapies.

Rulemaking Authority 400.23 FS. Law Implemented 400.102, 400.141, 400.23 FS. History–New 4-18-94, Amended_________.

 

(Substantial rewording of Rule 59A-4.130 follows.  See Florida Administrative Code for present text.)

 

59A-4.130 Fire Protection, Fire Prevention, and Life Safety, Systems Failure and External Emergency Communications.

(1) Each nursing home licensee must provide fire protection through the elimination of fire hazards.  All portions of the existing facility must comply with the requirements of the Existing Health Care Occupancy chapter of the National Fire Protection Association (NFPA) Life Safety Code 101, as adopted by the State Fire Marshall and described in Chapter 69A-53, Florida Administrative Code.

(2) All fires or explosions shall be reported to the Agency’s Office of Plans and Construction by telephone at [phone] or by fax at [phone] by the next working day after the occurrence. The nursing home licensee shall complete and submit a Fire Incident Report, AHCA form 3500-0031, July 2014, incorporated by reference and available at http://www. flrules.org/Gateway/reference.asp?No=Ref-XXXXX, to the Office of Plans and Construction and a copy to the appropriate Agency field office within 15 calendar days of the incident. All reports shall be complete and thorough and shall record the cause of the fire or explosion, the date and time of day it occurred, the location within the facility, how it was extinguished, any injuries which may have occurred and a description of the local fire department participation. The Fire Incident Report is available from the Agency for Health Care Administration, Office of Plans and Construction, 2727 Mahan Drive, Mail Stop 24, Tallahassee, Florida 32308 or at the web address: http://ahca.myflorida.com/plansandconstruction.

(3) If a system failure of the fire alarm system, smoke detection system, or sprinkler system occurs, the following actions shall be taken by the licensee:

(a) Immediately notify the local fire department and document the response and any instructions given by the local fire department.

(b) Notify the Agency’s Office of Plans and Construction and the appropriate Agency field office within one business day after the occurrence.

(c) Assess the extent of the condition, effect corrective action and document the estimated length of time for the corrective action.  If the corrective action will take more than four hours, the following must be completed:

1. Implement a contingency plan to the facility fire plan containing a description of the problem, a specific description of the system failure, and the projected correction period. All staff on the shifts involved must have documented in-service training for the emergency contingency.

2. Begin a documented fire watch until the system is restored.  Staff performing the fire watch must be trained in appropriate observations and actions, as well as be able to expeditiously contact the fire department.  To maintain a fire watch, the licensee must utilize only certified public fire safety personnel, a security guard service, or facility staff.  If facility staff are used for this function, they must meet the following criteria:

a. Be off duty from their regular facility position or assigned only to fire watch duty. The licensee must maintain compliance with direct care staffing requirements at all times;

b. Be trained and competent, as determined by the licensee, in the duties and responsibilities of a fire watch;

c. Have immediate access to two-way electronic communication.

3. If the projected correction period changes or the system is restored to normal operation, the licensee must notify the appropriate Agency’s field office and local fire authorities.

(4) External Emergency Communication.  Each newly constructed facility that has not received a Preliminary Stage II Plan Approval from the Office of Plans and Construction by January 1, 2015, shall provide for external electronic communication not dependent on terrestrial telephone lines, cellular, radio, or microwave towers, such as an on-site radio transmitter, satellite communication systems or a written agreement with an amateur radio operator volunteer group.  This agreement must provide for a volunteer operator and communication equipment to be relocated into the facility in the event of a disaster until communications are restored.  Other methods that can be shown to maintain uninterrupted electronic communications not dependent on a land-based transmission must be approved by the Agency’s Office of Plans and Construction.

Rulemaking Authority 381.031(1)(g)7., 400.23, 400.191(2) FS. Law Implemented 381.031, 400.102, 400.141, 400.23, 633.05(8), 633.051 FS. History–New 4-1-82, Amended 4-1-84, 8-1-85, Formerly 10D-29.119, 59A-4.119, Amended_________.

 

(Substantial rewording of Rule 59A-4.133 follows. See Florida Administrative Code for the present text.)

 

59A-4.133 Physical Plant Codes and Standards for Nursing Homes. Plans Submission and Review and Construction Standards.

(1) All construction of new nursing homes and all additions, alterations, refurbishing, renovations to and reconstruction of existing nursing homes shall be in compliance with the following codes and standards:

(a)  The Florida Building Code (FBC) as adopted by the Florida Building Commission and incorporated by reference and obtainable from the International Code Council at www.iccsafe.org.

(b) The fire codes as adopted by the State Fire Marshall and described in Chapter 69A-53 and 69A-60, Florida Administrative Codes and incorporated herein by reference and obtainable from the National Fire Protection Association, 1 Batterymarch Park, P.O. Box 9101, Quincy, Massachusetts 02269-9101.

(2)  No building shall be converted to a licensed nursing home unless it complies with the standards and codes set forth herein and with licensure requirements set forth in Chapter 400, Part II, F.S. and Chapter 59A-4, Florida Administrative Code.

(3) National Fire Protection Association (NFPA) 101A: Guide on Alternative approaches to Life Safety may only be used for a nursing home facility licensed before January 1, 2015.

(4) Where additions, modifications, alterations, refurbishing, renovations or reconstruction are undertaken within an existing facility, all such additions, modifications, alterations, refurbishing, renovations or reconstruction must comply with applicable sections of the codes for new facilities.  Only that portion of the total facility affected by the project must comply with applicable sections of the referenced codes for new construction.  Where existing major structural elements make total compliance impractical or impossible, the licensee or applicant for licensure may submit a request to the Office of Plans and Construction to utilize alternate materials, designs or methods which meet the intent of code provisions as permitted by the Florida Building Code.

(5) A licensed nursing home and any portion of a licensed nursing home that was reviewed and approved by the Agency for Health Care Administration prior to October 1, 2005, must be maintained in compliance with the requirements of this rule and the requirements of the NFPA 101 Life Safety code for Existing Health Care Occupancy, incorporated in rule 69A-3.012, F.A.C. and the requirements of Tables I, II and III, incorporated by reference and available at http://www. flrules.org/Gateway/reference.asp?No=Ref-XXXXXX or at the web address at http://ahca.myflorida.com/plansandconstruction. The requirements in Table I identified by an asterisk do not apply.

(6) A licensed nursing home, and any portion of a licensed nursing home, that was reviewed and approved by the Agency for Health Care Administration after October 1, 2005, must be maintained in compliance with the requirements of the NFPA 101 Life Safety code for Existing Health Care Occupancies and the design requirements for Nursing Homes of the Florida Building Code in effect at the date of initial licensure.

(7) When a building or portion of a building is converted to a new licensed nursing home, it shall be in compliance with the requirements for a new nursing home set forth in subsection 59A-4.133(1), F.A.C. A change of ownership shall not constitute a change of occupancy.

(8) Other facilities or providers not owned or operated by the licensee of a nursing home may be fully integrated with the nursing home’s physical plant only after it has been successfully demonstrated to the Agency that all areas of the facility’s physical plant are designed and maintained in a manner that will ensure continued licensure compliance of the nursing home.

(9) All hazards to life and safety and all areas of noncompliance with applicable codes and regulations must be corrected in accordance with a plan of correction approved in advance by the Agency’s Office of Plans and Construction.

(10) Projects that have not received at least a Stage II Preliminary Plan approval from the Office of Plans and Construction by December 31, 2014, must conform to the requirements set forth in these rules.

Rulemaking Authority 381.031(1)(g)7., 400.23 FS. Law Implemented 381.031, 400.011(2), 400.021(1)-(17), 400.022(1)-(4), 400.102, 400.141, 400.23, 400.232 FS. History–New 4-1-82, Amended 4-1-84, 4-29-92, Formerly 10D-29.120, 59A-4.120, Amended 2-6-97, 10-21-99,__________.

 

59A-4.134 Plans Submission and Fee Requirements.

(1) No construction work, including demolition, shall be started until prior written approval has been provided by the Agency’s Office of Plans and Construction. This includes all construction of new facilities and all additions, modifications, alterations, renovations, and refurbishing to the site, facility, equipment or systems of all existing facilities.

(2) Approval to start construction only for demolition, site work, foundation, and building structural frame may be obtained prior to construction document approval when the following is submitted for review and approval:

(a) Preliminary Stage II approval letter from the Agency’s Office of Plans and Construction.

(b) Construction documents and specifications for all work to be undertaken.

(c) A life safety plan indicating temporary egress and detailed phasing plans indicating how the areas to be demolished or constructed are to be separated from all occupied areas when demolition or construction is in and around occupied buildings.

(3) Projects that have been submitted to the Agency for review will be considered abandoned and will be terminated after any of the following has occurred;

(a) Construction has not begun within one year after written approval of the construction documents from the Agency’s Office of Plans and Construction;

(b) No further plans have been submitted for Agency review within one year after a project has been initiated with the Agency’s Office of Plans and Construction;

(c) Construction has been halted for more than one year. 

After termination, resubmission as a new project will be required.

(4) When construction is planned, either for new buildings, additions, alterations or renovations to existing buildings, the plans and specifications must be prepared and submitted to the Agency’s Office of Plans and Construction for approval by a Florida registered architect and a Florida registered professional engineer. An architecture or engineering firm, not practicing as a sole proprietor, must provide proof of registration as an architecture or engineering firm with the Florida Department of Business and Professional Regulation.

(5) The initial submission of plans to the Agency’s Office of Plans and Construction for any new project must include a completed Application for Plan Review, AHCA Form 3500-0011, June 2014, incorporated by reference and available  at http://www.flrules.org/Gateway/reference.asp?No=Ref-XXXXX and from the Agency for Health Care Administration, 2727 Mahan Drive, MS 24, Tallahassee, Florida 32308 or at the web address at http://ahca.myflorida.com/plansandconstruction, and a valid Certificate of Need or exemption as required by Sections 408.031 through 408.045, F.S. This information must accompany the initial submission. Approval will not be granted for any project without a Certificate of Need as required by Rule 59C-1.004, F.A.C.

(6) Plans and specifications submitted for review are subject to plan review fees as required in section 400.232, F.S.  Plan review fees must be included with the application.

(7) Plans and specifications shall be submitted in three stages. These stages are as follows:

(a) Stage I, schematic plans.

(b) Stage II, preliminary plans or design development drawings.

(c) Stage III, construction documents, including specifications, addenda and change orders.

(8) For each stage of submission, a program or scope of work must be submitted.  It must consist of a detailed word description of all contemplated work and any required phasing to be provided in the proposed construction.

(9) For projects involving only equipment changes or system renovations, only Stage III, construction documents need be submitted. These documents must include the following:

(a) Life safety plans showing the fire/smoke compartments in the area of renovation.

(b) Detailed phasing plans indicating how the new work will be separated from all occupied areas.

(c) Engineering plans and specifications for all of the required work.

(10) Stage I, Schematic Plans – The following must be incorporated into the schematic plans:

(a) Single-line drawings of each floor that must show the relationship of the various activities or services to each other and each room arrangement. The function of each room or space must be noted in or near the room or space. The proposed roads and walkways, service and entrance courts, parking, and orientation must be shown on either a small plot plan or on the first floor plan. Provide a simple cross-section diagram showing the anticipated construction.  Provide a schematic life safety plan showing smoke and fire compartments, exits, exit passageways and gross area of smoke and fire compartments. Provide information as to which areas have sprinklers, both new and existing.

(b) If the proposed construction is an addition or is otherwise related to existing buildings on the site, the schematic plans must show the facility and general arrangement of those other buildings.

(c) A schedule showing the total number of beds, types of bedrooms and types of ancillary spaces.

(11) Stage II, Preliminary Plans – To gain a Stage II approval, the following must be incorporated into the preliminary plans:

(a) A vicinity map showing the major local highway intersections for new nursing home construction.

(b) Site development plans that:

1. Show existing grades and proposed improvement as required by the schematic submission.

2. Provide building locating dimensions.

3. Provide site elevations for both the 100 year flood elevations and hurricane category 3 surge inundation elevations if the project involves the construction of a new facility or is a new addition of a wing or floor to an existing facility.

4. Provide the location of the fire protection services water source to the building.

(c) Architectural plan that include:

1. Floor plans, 1/8-inch scale minimum, showing door swings, windows, casework and millwork, fixed equipment and plumbing fixtures.  Indicate the function of each space.

2. A large-scale plan of typical new bedrooms with tabulation of gross and net square footage of each bedroom.  Tabulate the size of the bedroom window glass.

3. Typical large-scale interior and exterior wall sections to include typical rated fire and fire/smoke partitions and a typical corridor partition.

4. All exterior building elevations.

5. Equipment that is not included in the construction contract but that requires mechanical or electrical service connections or construction modifications must be identified to assure its coordination with the architectural, mechanical and electrical phases of construction.

6. If the project is located in an occupied facility, preliminary phasing plans indicating how the project is to be separated from all occupied areas.

(d) Life safety plans that include:

1. Single-sheet floor plans showing fire and smoke compartmentation, all means of egress and all exit signs.  Additionally, depict and provide the dimension for the longest path of travel in each smoke compartment to the door(s) to the adjoining compartment, calculate the total area of the smoke compartment in square feet, and tabulate exit inches.

2. All sprinklered areas, fire extinguishers, fire alarm devices and pull station locations.

3. Fully developed life safety plans, if the project is an addition or conversion of an existing building.

4. Life safety plans of the floor being renovated and required exit egress floor(s) if the project is a renovation in an existing building.

5. When demolition or construction is to be undertaken in and around occupied buildings, a life safety plan indicating temporary egress and detailed phasing plans indicating how the areas to be demolished or constructed are to be separated from all occupied areas.

(e) Mechanical engineering plans that include:

1. Single-sheet floor plans with a one-line diagram of the ventilating system with relative pressures of each space.  Provide a written description and drawings of the anticipated smoke control system, passive or active, and a sequence of operation correlated with the life safety plans.

2. The general location of all fire and smoke dampers, all duct smoke detectors and fire stats.

3. If the building is equipped with fire sprinklers, the location of the sprinkler system risers and the point of connection for the fire sprinkler system.  State the method of design for the existing and new fire sprinkler systems.

4. The locations of all plumbing fixtures and other items of equipment requiring plumbing services and/or gas service.

5. The locations of any fume, radiological or chemical hoods.

6. The locations of all medical gas outlets, piping distribution risers, terminals, alarm panels, low pressure emergency oxygen connection, isolation/zone valves, and gas source locations.

7. The locations and relative size of major items of mechanical equipment such as chillers, air handling units, fire pumps, medical gas storage, boilers, vacuum pumps, air compressors and fuel storage vessels.

8. The locations of hazardous areas and the volume of products to be contained therein.

9. The location of fire pump, stand pipes, and sprinkler risers.

(f) Electrical engineering drawings that include:

1. A one-line diagram of normal and essential electrical power systems showing service transformers and entrances, switchboards, transfer switches, distribution feeders and over-current devices, panel boards and step-down transformers. The diagram must include a preliminary listing and description of new and existing, normal and emergency loads, preliminary estimates of available short-circuit current at all new equipment and existing equipment serving any new equipment, short-circuit and withstand ratings of existing equipment serving new loads and any new or revised grounding requirements.

2. Fire alarm zones and correlate with the life safety plan.

(g) Outline specifications are to include a general description of the construction, including construction classification and ratings of components, interior finishes, general types and locations of acoustical material, floor coverings, electrical equipment, ventilating equipment and plumbing fixtures, fire protection equipment, and medical gas equipment.

(h) Whenever an existing building is to be converted to a health care facility, the general layout of spaces of the existing structure must be submitted with the preliminary plans for the proposed facility.

(i) Whenever additions, modifications, alterations, renovations, and refurbishing to an existing building are proposed, the general layout of spaces of the existing facility must be submitted with the preliminary plans.

(12) Stage III, Construction Documents – The Stage III construction documents shall be an extension of the Stage II preliminary plan submission and shall provide a complete description of the contemplated construction.  Construction documents shall be signed, sealed, dated and submitted for written approval to the Agency’s Office of Plans and Construction submitted by a Florida registered architect and Florida registered professional engineer. An architecture or engineering firm, not practicing as a sole proprietor, must provide proof of registration as an architecture or engineering firm with the Florida Department of Business and Professional Regulation. The documents must consist of work related to civil, structural, mechanical, and electrical engineering, fire protection, lightning protection, landscape architecture and all architectural work.  In addition to the requirements for Stage II submission, the following must be incorporated into the construction documents:

(a) Site and civil engineering plans that indicate building and site elevations, site utilities, paving plans, grading and drainage plans and details, locations of the two fire hydrants utilized to perform the water supply flow test, and landscaping plans.

(b) Life safety plans for the entire project.

(c) Architectural plans.

1. Typical large-scale details of all typical interior and exterior walls and smoke walls, horizontal exist and exit passageways.

2. Comprehensive ceiling plans that show all utilities, lighting fixtures, smoke detectors, ventilation devices, sprinkler head locations and fire-rated ceiling suspension member locations where applicable.

3. Floor/ceiling and roof/ceiling assembly descriptions for all conditions.

4. Details and other instructions to the contract on the construction documents describing the techniques to be used to seal floor construction penetrations to the extent necessary to prevent smoke migration from floor to floor during a fire.

(d) Structural engineering plans, schedules and details.

(e) Mechanical engineering plans to include fire and smoke control plans. Show all items of owner furnished equipment requiring mechanical services. Provide a clear and concise narrative control sequence of operations for each item of mechanical equipment including: air conditioning, heating, ventilation, medical gas, plumbing, and fire protection and any interconnection of the equipment of the systems. Mechanical engineering drawings must depict completely the systems to be utilized, whether new or existing, from the point of system origination to its termination.  Provide a tubular schedule giving the required air flow (as computed from the information contained on the ventilation rate table) in cubic feet per minute (cfm) for supply, return, exhaust, outdoor, and ventilation air for each space listed or referenced by note on the ventilation rate table as shown on the architectural documents.  The schedule must also contain the Heating Ventilation and Air Conditioning (HVAC) system design air flow rates and the resulting space relative pressures. The schedule or portion of the schedule, as applicable, must be placed in the specifications or in the drawing set containing the spaces depicted.

(f) Fire protection plans, where applicable, that must include the existing system as necessary to define the new work.

(g) Electrical engineering plans that must describe complete power, lighting, alarm, communications and lightning protection systems and power system study.

(h) A power study that must include a fault study complete with calculations to demonstrate that over-current devices, transfer switches, switchboards, panel boards, motor controls, transformers and feeders are adequately sized to safely withstand available phase-to-phase and phase-to-ground faults. The study must also include an analysis of generator performance under fault conditions and a coordination study resulting in the tabulation of settings for all over-current device adjustable trips, time delays, relays and ground fault coordination. This must be provided for all new equipment and existing equipment serving any new equipment. Power studies for renovations of existing distribution systems must include only new equipment and existing equipment upstream to the normal and emergency sources of the new equipment. Renovations involving only branch circuit panel boards without modifications to the feeder will not require a full power study; instead, the power study will be limited to the calculation of new and existing loads of the branch circuit panel.

(i) A complete set of specifications of all work to be undertaken.

1. All project required contractor supplied testing and/or certification reports must be submitted in type written format, on standard forms, reviewed and accepted by the Engineer of Record prior to presenting to the Agency for review. 

2. The specifications must require a performance verification test and balance air quality value report for two operating conditions for each air handling unit system. One operating condition must be with the specified air filters installed in the minimum pressure drop or clean state. The second operating condition must be at the maximum pressure drop and/or dirty state. The air quantities reported are acceptable if they are within ten percent of the design value and the space relative pressures are maintained. This requirement applies to any air-handling unit affected by the construction to be performed.

(j) Well-coordinated construction documents. In the case of additions to existing institutions, the mechanical and electrical, especially existing essential electrical systems and all other pertinent conditions must be a part of this submission.

(k) Signed, sealed and dated subsequent addenda, change orders, field orders and other documents altering the above must be submitted for advance written approval from the Agency’s Office of Plans and Construction.

(13) Initial submissions will be acted upon by the Agency within 60 days of the receipt of the initial payment of the plan review fee. The Agency will either approve or disapprove the submission and will provide a listing of deficiencies in writing.  Each subsequent resubmission of documents for review on the project will initiate another 60-day response period. All deficiencies noted by the Agency must be satisfactorily corrected before final construction approval can be obtained for the project from the Agency.

(14) Additions or revisions that substantially change the original scope of the project or are submitted by different design professionals will be required to be submitted as a new project.

(15) Within 60 days after final approval of the project has been obtained from the Agency, the licensee and the Agency’s Office of Plans and Construction must be provided with a complete set of record drawings electronically submitted as Portable Document Format (.pdf) files showing all of the construction, fixed equipment and the mechanical and electrical systems as installed. These electronically submitted .pdf files must include the life safety plans of the facility.

Rulemaking Authority 400.23 FS. Law Implemented 400.011(2), 400.141, 400.232 FS. History–New_________.

 

59A-4.150 Geriatric Outpatient Nurse Clinic.

(1) Definitions:

(a) Advanced Registered Nurse Practitioner – a person who holds a current active license to practice professional nursing and a current Advanced Registered Nurse Practitioner certificate issued by the Florida State Board of Nursing.

(a)(b) Appropriate Resources – those service providers who provide most effectively and efficiently the specific services needed by the geriatric patient.

(c) Agency for Health Care Administration – AHCA.

(b)(d) Geriatric Outpatient Nurse Clinic – a site in a nursing home treatment room for the provision of health care to geriatric patients on an outpatient basis which is staffed by a registered nurse or by a physician’s assistant or a licensed practical nurse under the direct supervision of a registered nurse, advanced registered nurse practitioner, physical assistant or a physician.

(c)(e) Geriatric Patient – any patient who is 60 years of age or older.

(f) Nursing Facility – a facility licensed under Part I of Chapter 400, F.S.

(g) Physician’s Assistant – a person who holds a current certificate issued by the Florida State Board of Medical Examiners of Florida State Board of Osteopathic Medical Examiners, to serve as a physician’s assistant to function in the dependent relationship with the supervising physician. (Sections 458.135(2)(d); 459.151(2)(d), F.S.)

(d)(h) Pre-established Protocols – a statement prepared by or with the responsible or attending physician and/or physician assistant and advanced registered nurse practitioner defining the extent and limits of the medical services provided by the nurse. Such protocols are to be reviewed at periods not to exceed one year, to be dated and signed by the physician, and to be kept readily available.

(i) Professional Standards of Practice – those measurements or guides for practice developed and/or endorsed by the respective professional disciplines.

(j) Registered Dietitian – one who meets the standards and qualifications established by the Committee on Professional Registration of the American Dietetic Association and is currently registered with the American Dietetic Association.

(k) Registered Nurse – a person who holds a current active license to practice professional nursing issued by the Florida State Board of Nursing. (Section 464.071, F.S.)

(e)(l) Responsible Physician – the licensed physician delegated by the supervising physician as responsible for the services rendered by the registered nurse, physician’s assistant, advanced registered nurse practitioner, or a licensed practical nurse under the direct supervision of a registered nurse, advanced registered nurse practitioner, physician assistant or a physician in the absence of the supervising physician.

(f)(m) Routine Health Care – the provision of preventive care, detection of health problems, referral for medical care, and management of chronic illness within medical prescriptions.

(g)(n) Substantive Change – a change in when the patient’s condition indicating the need for changes to such an extent that a change in treatment and/or medication orders is indicated or when pre-established protocols are not applicable.

(h)(o) Supervising Physician – the licensed physician assuming responsibility and legal liability for the services rendered by the registered nurse, physician’s assistant, advanced registered nurse practitioner or a licensed practical nurse under the direct supervision of a registered nurse, advanced registered nurse practitioner, physician assistant or a physician.

(i)(p) Treatment Room – the room or suite of rooms set aside for the examination and care of patients.

(2) Applications.

(a) The nursing home licensee must submit a letter A letter shall be sent through the local county Health unit to the Agency for Health Care Administration, Long Term Care Unit, 2727 Mahan Drive, MS 33, Tallahassee, FL 32303, AHCA by the operator of a currently licensed nursing home stating intent to establish a geriatric outpatient nurse clinic in compliance with Chapter 400, F.S., Chapter 77-401, Laws of Florida, and this rule the rules pertaining to these chapters. Such notice may also be provided at the time of initial licensure or licensure renewal.  A copy of said letter shall be sent to the Health Program Office of the Department of Health and Rehabilitative Services by the local county health unit. This letter must shall be sent at least sixty (60) days prior to the anticipated date of the establishment of the clinic. The Director, County Health Unit shall provide specific recommendations for operation of the clinic when transmitting the letter.

(b) The licensee must be compliant The AHCA shall ascertain compliance with all applicable laws, rules, regulations, Chapter 400, Part II and Chapter 408, Part II, F.S. and Florida Building Code during an inspection by the Agency and codes and by letter notify the operator of compliance or non-compliance.

(c) Receipt of the letter of notification stating compliance shall constitute authority to operate a geriatric outpatient nurse clinic within the facility.

(d) Application for renewal of authority to operate a geriatric outpatient nurse clinic must shall be submitted in the manner described above at the same time the application for the nursing home licensure renewal relicensure is submitted.

(e) Suspension or revocation of the nursing home license automatically suspends or revokes authority to operate the geriatric outpatient nurse clinic.

(f) A Certificate of Need issued by the AHCA required by Sections 381.493 through 381.497, F.S., is a pre-requisite to establish a geriatric outpatient nurse clinic.

(3) Treatment Rooms and Access Areas.

(a) Plant maintenance and housekeeping must shall be in accordance with Rule 59A-4.122 Rule 59A-4.049, F.A.C.

(b) Every nursing home licensee facility conducting a geriatric outpatient nurse clinic must shall:

1. Use an existing treatment room exclusively for the examination and treatment of patients.

2. Store supplies and equipment in such a manner that safeguards patients and staff from hazards.

3. Have a waiting area which does not interfere with regular in-patient functions.

4. Provide clinic patients with the most direct route to and from the treatment room.

(4) Administration.

(a) The business and administrative management of the geriatric outpatient nurse clinic must shall be under the management control of the nursing home facility administrator. This must shall include, but not be limited to maintenance of the following written records:.

1. Clinic financial records which identify all income by source and describe all expenditures by category in such a manner as to be suitable by community recognized procedure.

1.2. An accident and incident record, containing a clear description of each accident and any other incident hazardous or deviant behavior of a patient or staff member with names of individuals involved, description of medical and other services provided, by whom such services were provided and the steps taken to prevent recurrence.

2.3. Personnel records for each clinic employee and/or contractual provider. Employees of a geriatric outpatient clinic must have a Level 2 background screening as required in Section 408.809 and chapter 435, F.S. These records must will be kept updated and include current Florida license and certificate numbers. The original Original application for the position, references furnished and an annual performance evaluation must shall be included.

3.4. A record of personnel policies, including statement of policies affecting personnel, and a job description for each person providing clinic services.

4.5. Clinic Schedule.

5.6. Compliance with the requirements of Title VI of the Civil Rights Act of 1964, Section 2000, effective date July 2, 1964, is incorporated herein by reference at http://www.justice.gov/crt/cor/coord/titlevistat.php.

(b) The provision of health services through geriatric outpatient nurse clinics must shall be under the direct management control of the registered nurse, or physician’s assistant or a licensed practical nurse under the direct supervision of a registered nurse, advanced registered nurse practitioner, physician assistant or physician, providing those services. The licensee must oversee Management control of the provision of health services to assure all health services are provided to protect the health, safety and well-being of the patients. The licensee must also:

1. Assurance that all health services are provided according to legal, ethical and professional practice standards to protect the health, safety and well-being of the patients.

1.2. Maintain the Maintenance and confidentiality of clinical records for each patient as required in this  chapterrule, section 400.0222, F.S., Title 42 Code of Federal Regulation section 483.10, effective October 1, 2003, Title 45 Code of Federal Regulation chapters 160, 162 and 164 with an effective date of August 14, 2002, which is incorporated by reference and available at http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl.

2.3. Develop and periodically Responsibility for development and periodic review the of written policies and protocols governing patient care, including emergency procedures.

3.4. Develop and periodically Responsibility for development and periodic review the of patient referral system.

4.5. Administer and handle Responsibility for the administration and handling of drugs and biological as required in these rules this rule, Chapter 400 Part II, F.S., Title 42 C.F.R. 483.25(1), Title 42 C.F.R. 483.25(m), effective October 7, 2005 and 42 C.F.R. 483.60, effective September 23, 1992, which is incorporated by reference and available at http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%Findex.tpl.

5.6. Maintain Maintenance of an individual and cumulative clinic census record.

6.7. Coordinate Coordination of patient care with the attending physician and other community health and social agencies and/or facilities.

7.8. Maintain Maintenance of a safe, and sanitary clinic environment.

(5) Fiscal Management.

(a) There must shall be a recognized system of accounting used to accurately reflect business details of the clinic operation, documentation of all transactions, and services kept separate from the nursing home’s facility fiscal records.

(b) A reasonable fee, based on cost of operation and services, may be charged for clinic services rendered.

(c) Personnel involved in operating and/or providing clinic services must shall not:

1. Pay any commission, bonus, rebate or gratuity to any organization, agency, physician, employee or other person for referral of any patients to the clinic.

2. Request or accept any remuneration, rebate, gift, benefit, or advantage of any form from any vendor or other supplier because of the purchase, rental, or loan, of equipment, supplies or services for the resident client and/or patient.

(6) Personnel Policies.

(a) Staff in the geriatric outpatient nurse clinic must will be governed by the personnel standards in this rule, Section 400.141, F.S., Title 42 Code of Federal Regulation 483.75, effective May 5, 2002, 42 CFR 483.75, effective August 11, 2009, 42 CFR 483.30, effective October 28, 2005, which is incorporated by reference and available at http://ecfr.gpoaccess. gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl their Personnel Standards in rules and Regulations governing Nursing Homes and Related Health Care Facilities, Rule 59A-4.157, F.A.C.

(b) Staff in the geriatric outpatient nurse clinic must shall be qualified and sufficient in numbers to perform the necessary services.

(c) Services of this clinic must not will in no way reduce the minimum staffing standards for in-patient care.

(d) Staff in the geriatric outpatient clinic may be regularly employed or serve on a contractual basis.

(7) Personnel Functions and Responsibilities.

(a) Registered Nurse (Sections 464.021(2)(a)1., 2., F.S.) The registered nurse, advanced registered nurse practitioner (ARNP), physician assistant or a licensed practical nurse under the direct supervision of a registered nurse, ARNP, physician assistant or physician staffing the geriatric outpatient clinic must:

1. Be responsible The nurse shall have the responsibility for eliciting and recording a health history, observation and assessment nursing diagnosis, counseling and health teaching of patients and the maintenance of health and prevention of illness. The nurse shall provide treatment for the medical aspects of care according to pre-established protocols or physician’s orders.

2. Provide treatment for the medical aspects of care according to pre-established protocols or physician’s orders.

3.2. Note The nurse shall note findings and activities on the clinical record.

4.3. Provide The nurse shall provide progress reports to the attending physicians about patients under the physician’s care when there is a substantive change in the patient’s condition, there are deviations from the plan of care, or at least every sixty (60) days.

(b) The Advanced Registered Nurse Practitioner (Section 464.003(3)(c), F.S.)

1. The Advanced Registered Nurse Practitioner shall perform the functions outlined for the Registered Nurse, and in addition: Provide additional services dependent upon the certification authority of the Advanced Registered Nurse Practitioner by the Florida State Board of Nursing.

2. The Advanced Registered Nurse Practitioner shall note findings and activities on the clinical record.

(c) The Physician’s Assistant (Sections 458.347(3); 459.022, F.S.)

1. The Physician’s assistant shall perform health care tasks delegated by the supervising or responsible physician.

2. The Physician’s Assistant shall note findings and activities on the clinical record.

(8) Patient Eligibility Criteria.

(a) Acceptance of patients and discharge policies must shall include but not be limited to the following:

1.(b) Patients must shall be accepted for clinic services on self-referral for nursing care, or upon a plan of treatment established by the patient’s attending physician.

2.(c) Patients The patients with an attending physician will be held responsible for providing the clinic with a written medical plan of treatment reviewed and signed by their physician at least sixty (60) days.

3.(d) When services are to be terminated, the patient must is to be notified of the date of termination and the reason for termination which shall be documented in the patient’s clinical record. A plan shall be developed for a referral made for any continuing care required indicated.

(9) Patient’s Rights.

(a) The nursing home licensee must facility shall adopt, implement and make public a statement of the rights and responsibilities of the clinic patients and must shall treat such patients in accordance with the provisions of the said statement. This statement must shall be conspicuously posted and available to clinic patients in pamphlet form. The statement must ensure shall insure each patient the following:

1.(b)The right to have private communication with any person of his or her choice.

2.(c)The right to present grievances on behalf of himself, herself, or others to the facility’s staff or administrator, to government officials, or to any person without fear of reprisal, and to join with other patients or individuals to work for improvements in patient care.

3.(d) The right to be fully informed in writing, prior to or at the time of admission and during his or her attendance, of fees and services not covered under Title XVIII or Title XIX of the Social Security Act or other third party reimbursement agents.

4.(e) The right to be adequately informed of his or her medical condition and proposed treatment unless otherwise indicated in the written medical plan of treatment by the physician, and to participate in the planning of all medical treatment, including the right to refuse medication and treatment, unless otherwise indicated in the written medical plan of treatment by the physician, and to know the consequences of such actions.

5.(f) The right to receive adequate and appropriate health care consistent with established and recognized practice standards within the community and the with rules as promulgated by the Agency AHCA.

6.(g) The right to have privacy in treatment and in caring for personal needs, and confidentiality in the treatment of personal and medical records.

7.(h) The right to be treated courteously, fairly, and with the fullest measure of dignity and to receive a written statement of the services provided by the nursing home licensee facility.

(i) The right to freedom of choice in selecting a nursing home.

1. Each nursing home shall post a copy of the statement required by subsection (1) so that it is clearly evident.

(b)2. Any violation of the patient’s rights set forth in this section shall constitute grounds for action by the Agency AHCA under the provisions of Section 400.102, F.S.

(10) The scope of services Scope of Services of the Geriatric Outpatient Nurse Clinic must include:.

(a) Observation of signs and symptoms.

(b) Assessment of health status/progress.

(c) Nursing diagnosis and plan of care.

(d) Nursing care of patients and counseling to maintain health and prevent disease, including diet counseling.

(e) Health instruction to control progression of disease and/or disability and self-care measures.

(f) Administration of medication and treatment as prescribed by a person licensed in this state to prescribe such medications and treatment.

(g) Provision of progress reports to the attending physician.

(h) Referral for additional services as needed.

(i) Follow-up on a regular basis by communication with the patient, the patient’s physician, and other agencies or persons to which referrals were made.

(j) When staffed by an ARNP or physician’s assistant Advanced Registered Nurse Practitioner or Physician’s Assistant, additional services may be provided dependent upon their respective certification authority. (Sections 458.347, 459.022, 464.003(3)(c), F.S.)

(11) Clinical Records.

(a) The clinic must shall maintain a clinical record for every patient receiving health services that contain the following:

1. Identification data including name, address, telephone number, date of birth, sex, social security number, clinic case number if used, next of kin or guardian and telephone number, name and telephone number of patient’s attending physician.

2. Assessment of problems.

3. A health care plan Health Care Plan including diagnoses diagnose, type, and frequency of services and when receiving medications and medical treatments, the medical treatment plan and dated signature of the physician or designee health professional licensed in this state to prescribe such medications and treatments.

4. Clinical notes, signed and dated by staff providing the service.

a. Progress notes with changes in the patient’s condition.

b. Services rendered with progress reports.

c. Observations.

d. Instructions to the patient and family.

e. Referrals made.

f. Consultation reports.

g. Case conferences.

h. Reports to physicians.

i. Termination summary which must include:.

(I) Date of first and last visit.

(II) Total number of visits by discipline.

(III) Reason for termination of service.

(IV) Evaluation of achievements of previously established goals at time of termination.

(V) Condition of patient on discharge.

j. Clinical records must shall be confidential. Information may be released by the nurse, ARNP or physician’s assistant responsible for clinical services only: in accordance with state and federal regulations related to patient records and confidentiality.

(I) When permission is granted in writing by the patient or guardian.

(II) To those persons or agencies with a legitimate professional need or regulatory authority pursuant to Section 455.241, F.S.

(III) When so ordered by the courts.

(12) Medications. The clinic must shall have policies and procedures for the administration of medications by health care professionals acting within the scope of practice defined by laws and rules of the Department of Health and the Department of Business and Professional Regulation which must shall include, for example, the following:

(a) All prescriptions for medications must shall be noted on the patient record, and include the date, drug, dosage, frequency, method or site of administration and the authorized health care professional’s signature.

(b) All verbal orders for medication or medication changes must shall be taken by the clinic registered nurse, ARNP or physician’s assistant. Such must be in writing and signed by the authorized health care professional within eight (8) days and added to the patient’s record.

(c) The clinic registered nurse, ARNP or physician’s assistant must shall record and sign for each medication administrated, by: drug, dosage, method, time and site on patient’s record.

(d) An emergency plan for reversal of drug reaction to include the nursing licensee’s pro re nata (P.R.N. or “as needed”) facility’s PRN standing orders for medications available in the emergency drug medication kit.

(e) If there is not a separate emergency drug medication kit in the clinic, the nursing home licensee’s facility’s emergency drug medication kit must shall be immediately accessible for use in the outpatient clinic.

(f) A drug storage system which includes:

1. Prescribed medications for individual outpatients may be retained in the clinic. These medications shall be stored separately from those of the nursing home in-patients for preventive measures and treatment of minor illnesses.

2. Multi-dose containers must shall be limited to medications or biologicals commonly prescribed for preventive measures and the treatment of minor illnesses.

3. A list must shall be kept of patients receiving medication from multi-dose medication containers.

Rulemaking Authority 381.493-381.497, 400.141(3), 400.23(2) FS. Law Implemented 400.33, 400.141, 400.333 FS. History–New 4-27-78, Formerly 10D-29.71, 10D-29.071, 59A-4.071, Amended 2-6-97,__________.

 

59A-4.165 Nursing Home Guide.

(1) Pursuant to Section 400.191 F.S., the Agency shall publish the Nursing Home Guide quarterly in electronic form provide information to the public in consumer-friendly printed and electronic formats (hereafter collectively the “Guide”) to assist consumers and their families in comparing and evaluating nursing home facilities.  The Nursing Home Guide or “Guide”, herein incorporated by reference, is available on the web at http://www.floridahealthfinder.gov/LandingPages/NursingHomeGuide.aspx.

(2) The format of the printed Guide is shown in the Nursing Home Guide 2000 document, dated July 2000, incorporated by reference herein.

(3) The format of the electronic Guide will be the same as the printed Guide, but with the addition of the following:

(a) The ability to search for a facility electronically.

(b) Details of which deficiencies the facility has been cited for over the past 45 months.

(2)(4) The electronic data provided in the Guide shall include the following:

(a) The ability to search for a nursing home.

(b)(a) General guidance about when a nursing home is the appropriate choice of care.

(c)(b) General guidance about selecting a nursing home.

(d)(c) Contact information such as phone numbers and web sites where questions can be answered, and further information can be obtained.

(e)(d) A listing of all nursing home facilities in the Sstate of Florida, including hospital based skilled nursing units. This listing shall include for each nursing home facility the following:

1. Name;

2. Address;

3. Telephone Voice and fax phone numbers;

4. Web address of facility;

5. A recognition if the nursing home licensee facility has been awarded a Gold Seal;

6. The current licensee;

7. Which calendar year the current licensee became the licensee;

8. Whether the licensee is a for-profit, or non-profit entity, and whether or not the nursing home facility is part of a retirement community;

9. Any corporate or religious affiliations;

10. The number of private, semi-private, and total beds at the nursing home facility;

11. The lowest daily charge for a semi-private room;

12. The payment forms accepted;

13. Any special services or amenities, or recreational programs provided;

14. Any non-English languages spoken by the administrator or staff of the nursing home facility; and

15. A summary of the deficiencies found at the facility over a 45 month period prior to the publication of the Guide. The summarization procedure is discussed in detail below.

(f) Details of each deficiency the nursing home has been cited for over the time period specified in Section 400.191, F.S.

(3) The format of the published Guide is shown in the Nursing Home Guide Methodology, which is incorporated by reference herein and located on the web at http://www. floridahealthfinder.gov/Comparecare/MethodologyNH.aspx.

(4)(5) The Guide will employ a procedure for summarizing the deficiencies as follows:

(a) All deficiencies cited over the most recently available time period as specified in Section 400.191, F.S., 45 month period prior to the publication of the Guide will be collected.

(b) Each citation will be assigned points based on the type of deficiency and its assigned severity and scope. For those nursing homes facilities that are not federally certified, each citation will be assigned points based on the type of deficiency and its assigned class. Nursing homes Facilities that are federally certified have their deficiencies cited using federal recorded as F-Tags and K-Tags. Nursing homes Facilities that are not federally certified have their deficiencies cited using state receive N-Tags instead of F-Tags and K-Tags. For the non-federally certified nursing homes,facilities the findings supporting each cited state N-Tag or K-Tag shall be reviewed read by the Agency to determine which federal F-Tag or K-Tag the state tag each of the cited N-Tags is equivalent to. The points assigned to a state tag an N-Tag or K-Tag shall be those that would be assigned to the equivalent federal F-Tag or K-Tag, if the nursing home facility were federally certified.

(c) A score for a nursing home facility will be computed by summing the points of all of its citations, and then dividing this sum by the number of annual recertification surveys conducted during the at the facility in the same 45 month period as in paragraph (a) above. For those facilities that are not federally certified, the number of annual licensure surveys will be used in place of the number of annual recertification surveys. For current non-federally certified nursing homes that become federally-certified nursing homes, a combination of the non-federally certified citation score and the federally-certified citation score will be utilized.

(d) For federally certified nursing homes facilities, the above computations will reflect any changes resulting from the Informal Dispute Resolution process, or administrative or appellate proceedings; inasmuch as the federal Centers for Medicare and Medicaid Services Health Care Financing Administration concurs with such changes.

(e) The scores for the freestanding nursing homes facilities will be ranked within each region. The regions are defined in the “Nursing Home Guide Methodology Performance Measures Algorithm” document, dated July 2000, incorporated by reference herein.

(f) Ranks for the hospital based skilled nursing units will be assigned the same rank as the freestanding nursing facility in the same region with an equal or next lower score.

(f)(g) These ranks shall be presented numerically and/or symbolically in the Guide.

(g)(h) Paragraphs (b) through (f)(g) shall be repeated for Components of Inspection which are subsets of the citations. Components of inspection These subsets are discussed in the “Nursing Home Guide Methodology Performance Measures Algorithm” document, dated July 2000, incorporated by reference herein. The subsetting of the tags for non-certified nursing homes shall be accomplished by using the equivalent federal F-Tags and K-tags.

(i) Facilities that are federally certified have their deficiencies recorded as F-Tags and K-Tags. Facilities that are not federally certified receive N-Tags instead of F-Tags and K-Tags. For the non-federally certified facilities the findings supporting each N-Tag shall be read by the Agency to determine which F-Tag or K-Tag each of the cited N-Tags is equivalent to. The subsetting of the tags in (h) for non-certified facilities shall be accomplished by using these equivalent F-Tags and K-Tags.

(j) The documents incorporated by reference may be obtained from the Agency for Health Care Administration, Managed Care and Health Quality Division, 2727 Mahan Dr., Tallahassee, FL 32308.

(6) The internet version of the guide will be available at www.fdhc.state.fl.us and www.floridahealthstat.com.

Rulemaking Specific Authority 400.191(6) FS. Law Implemented 400.191 FS. History–New 2-15-01, Amended_________.

 

59A-4.202 Quality of Care.

(1) The Agency shall determine how a Gold Seal recommended licensee ranks relative to other licensees in the same region.

(2) The agency shall compute a quality of care score and rank nursing home licensees, in accordance with the Nursing Home Guide Methodology, incorporated herein by reference and located on the web at http://www.floridahealthfinder.gov/CompareCare/MethodologyNH.aspx Performance Measures Algorithm, July 2000.

(3) To be considered further for a Gold Seal Award, the facility’s quality of care rank must be in the top 15% of facilities in the applicant’s region or top 10% statewide. The facility must also be ranked in the Nursing Home Guide as a five-star facility overall.

Rulemaking Authority 400.235(9) FS. Law Implemented 400.235 FS. History–New 8-21-01, Amended 5-15-07,___________.

 

59A-4.204 Turnover Ratio.

(1) An applicant for Gold Seal Award must meet at least one of the following to demonstrate a stable workforce:

(a) Have a turnover rate no greater than 50 percent for the most recent 12 month period ending on the last workday of the most recent calendar quarter prior to submission of an application. The turnover rate will be computed in accordance with Section 400.141(15)(b), F.S., The turnover rate is the total number of terminations or resignations of CNAs and licensed nurses during the quarter divided by the number of CNAs and licensed nurses employed at the end of the quarter, or

(b) Have a stability rate indicating that at least 50 percent of its staff has have been employed at the facility for at least one year. The stability rate will be computed in accordance with Section 400.141(15)(c), F.S. The stability rate is the total number of CNAs and licensed nurses that have been employed for more than 12 months, divided by the total number of CNAs and licensed nurses employed at the end of the quarter.

(2) Each applicant for Gold Seal Award must submit evidence of an effective recruitment and retention program.

Rulemaking Authority 400.235(9) FS. Law Implemented 400.235 FS. History–New 8-21-01, Amended 5-15-07,__________.

 

59A-4.206 Termination and Frequency of Review.

(1) Termination of Gold Seal Designation. The occurrence of any one of the following events shall disqualify the licensee from continuing as a Gold Seal facility:

(a) The filing of a petition by or against the owner or its parent company under the Bankruptcy Code;

(b) The issuance of a citation for a Class I or Class II deficiency or the assignment of a conditional license.

(c) The nursing home has a survey, after receipt of the Gold Seal designation that results in an overall rank of less than five stars in the Nursing Home Guide.

(2) For federally certified facilities, if the disqualifying event is the issuance of a citation for a Class I or Class II deficiency or the assignment of a conditional license status, the Gold Seal Award shall be withdrawn only after the results of the federal Informal Dispute Resolution (IDR) process are considered, if an IDR is requested.

(3) The termination or correction of a disqualifying event does not cause the Gold Seal to be reinstated. The licensee shall resubmit a complete application package and must meet all the conditions necessary to be awarded a Gold Seal.

(4) Termination of Gold Seal Applicants. Prior to the Governor’s issuance of the Award, the occurrence of any of the following events shall disqualify the licensee from continuing as a Gold Seal applicant and the application will be denied;

(a) The filing of a petition by or against the owner or its parent company under the Bankruptcy Code;

(b) The licensee fails to maintain a qualifying Quality of Care rank as defined in subsection 59A-4.203(3), F.A.C.;

(c)(4) The issuance of a citation for If a licensee receives a Class I or Class II deficiency or a licensee is assigned a conditional license status while it is being considered for a Gold Seal Award by the panel, the application will be denied.

(5) If the applicant meets criteria for denial or termination, the Agency shall offer the opportunity for the applicant to withdraw the application.

(6)(5) Frequency of Review. A Gold Seal licensee shall submit a complete renewal application every three two years. The renewal application must be received by the agency during the appropriate review period as provided in Rule 59A-4.2015, F.A.C., to ensure the licensee will not have a lapse in the Gold Seal designation.

Rulemaking Authority 400.235(9) FS. Law Implemented 400.235 FS. History–New 8-21-01, Amended 5-15-07,_________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Jacqueline M. Williams

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Elizabeth Dudek

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: October 16, 2014

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: October 31, 2013