[Rev. 1/24/2011 2:29:20 PM]
CHAPTER 449 - MEDICAL AND OTHER RELATED FACILITIES
GENERAL PROVISIONS
449.002 Definitions.
449.0022 “Administrator” defined.
449.0024 “Affiliated facility” defined.
449.0026 “Agent” defined.
449.0028 “Bureau” defined.
449.0029 “Centers for Medicare and Medicaid Services” defined.
449.003 “Deficiency” defined.
449.0031 “Division of Welfare and Supportive Services” defined.
449.0032 “Emergency” defined.
449.0034 “Facility” defined.
449.0038 “Health Division” defined.
449.0042 “Holiday” defined.
449.0043 “Home for individual residential care” defined.
449.0044 “Immediate and serious threat” and “immediate jeopardy” defined.
449.0046 “Incident” defined.
449.0048 “License” defined.
449.005 “Licensee” defined.
449.0052 “Medicaid” defined.
449.0054 “Medicare” defined.
449.0056 “Party” defined.
449.0058 “Person” defined.
449.006 “Recipient” defined.
449.0061 “Referral agency” defined.
449.0062 “Resident” defined.
449.0064 “Residential facility” defined.
449.0066 “Sanction” defined.
449.0068 “Services” defined.
449.007 “Survey” defined.
449.0072 “Treatment” defined.
449.008 Computation of time.
449.010 Severability.
GENERAL REQUIREMENTS FOR LICENSURE
449.011 Application for license.
449.0112 Investigation; prelicensure survey; inspection for fire safety.
449.0114 Display of license; compliance with law; transfer of real property; change in administrator, ownership, location or services.
449.0115 Review of building plans for new construction or remodeling by certain applicants: Required documents; payment of fees and costs.
449.0116 Renewal of license: Application; validity of existing license pending decision on application; inspection of facility; untimely filing or failure to file application.
449.0118 Denial, suspension or revocation of license: Grounds.
449.0119 Denial, suspension or revocation of license: Appeals.
FEES
449.012 Definitions.
449.0121 “Ambulatory surgical center” defined.
449.01215 “Branch office” defined.
449.01225 “Facility for hospice care” defined.
449.01227 “Facility for refractive surgery” defined.
449.01228 “Facility for transitional living for released offenders” defined.
449.01229 “Facility for treatment with narcotics” defined.
449.0123 “Home health agency” defined.
449.01235 “Home office” defined.
449.0124 “Hospice care” defined.
449.01245 “Intermediate care facility for the mentally retarded or persons with developmental disabilities” defined.
449.0125 “Medication unit” defined.
449.01252 “Mobile unit” defined.
449.01255 “Nursing pool” defined.
449.0126 “Rural clinic” defined.
449.01265 “Rural hospital” defined.
449.0127 “Subunit agency” defined.
449.013 License and renewal fees to operate ambulatory surgical center, facility for treatment of irreversible renal disease, home office, subunit agency or branch office of home health agency, rural clinic, obstetric center, program of hospice care, independent center for emergency medical care, nursing pool, facility for treatment with narcotics, medication unit, referral agency, halfway house for recovering alcohol and drug abusers, facility for refractive surgery, mobile unit and facility for transitional living for released offenders; expiration of application for license; refund of certain fees.
449.016 License and renewal fees to operate skilled nursing facility, hospital, rural hospital, intermediate care facilities, residential facility for groups, facility for treatment of abuse of alcohol or drugs, facility for hospice care, home for individual residential care, facility for modified medical detoxification and community triage center; expiration of application for license.
449.0168 Fees for modification of certain licenses.
PROVISION OF HOSPICE CARE
General Provisions
449.017 Definitions.
449.0171 “Bereavement services” defined.
449.0172 “Facility for hospice care” defined.
449.0173 “Governing body” defined.
449.0175 “Hospice care” defined.
449.0176 “Medical director” defined.
449.0177 “Patient” defined.
449.0178 “Terminally ill” defined.
Licensing
449.0181 Compliance with regulations required for license to operate facility for hospice care.
449.0183 Report of change in ownership, address or staff of program of hospice care.
Administration
449.0184 Governing body required; duties of governing body and administrator.
Medical Services
449.0185 Requirements for program of hospice care.
449.0186 Requirements for plan of care.
449.0187 Requirements for operation of facility for hospice care.
449.0188 Continuity of service to patients required.
FACILITIES FOR TREATMENT OF ABUSE OF ALCOHOL OR DRUGS
General Provisions
449.019 Definitions.
449.022 “Administrator” defined.
449.025 “Alcohol and drug abuse treatment” defined.
449.030 “Case management services” defined.
449.031 “Client” defined.
449.034 “Detoxification” defined.
449.043 “Facility” defined.
449.044 “Facility for modified medical detoxification” defined.
449.046 “Governing body” defined.
449.060 “Medically managed intensive detoxification program” defined.
449.064 “Overall program” defined.
449.068 “Qualified social worker” defined.
449.069 “Residential program” defined.
449.072 “Social model detoxification program” defined.
Licensing
449.079 Denial, revocation or suspension of license if facility not certified by Health Division; appeal.
449.081 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of licensing.
Administration and Personnel
449.085 Governing body; bylaws.
449.088 Policies and procedures.
449.091 Transfer of client to another facility.
449.094 Money of clients.
449.098 Preparations for disasters; reporting of fire or disaster.
449.102 Inventory and return of client’s belongings.
449.105 Insurance.
449.108 General requirements for programs.
449.111 Administrator: Duties.
449.114 Employees: General requirements.
449.117 Employees: Proof of compliance with provisions concerning tuberculosis.
Social Model Detoxification Programs
449.121 Certain facilities authorized to offer program.
449.1214 General requirements.
449.1218 Program of ongoing quality improvement.
Operation of Facility
449.123 General sanitary requirements.
449.126 Laundry requirements.
449.129 Design, construction, equipment and maintenance.
449.132 Accommodations for clients.
449.135 Safety from fire.
449.141 Health services.
449.144 Medication.
449.147 Dietary services.
449.150 Records of clients.
449.153 Discrimination prohibited.
FACILITIES FOR MODIFIED MEDICAL DETOXIFICATION
449.15311 Definitions.
449.15313 “Administrator” defined.
449.15315 “Client” defined.
449.15317 “Facility” defined.
449.15319 “Overall program” defined.
449.15321 “Program” defined.
449.15323 Proof of certification required; revocation of license.
449.15325 Governing body; bylaws and policies.
449.15327 Policies and procedures for services and operation of facility.
449.15329 Transfer of client.
449.15331 Handling of money of client.
449.15333 Inventory of belongings of client.
449.15335 Liability insurance.
449.15337 Program: Requirements; review.
449.15339 Responsibilities and duties of administrator.
449.15341 Policies and procedures concerning employees.
449.15343 Nursing services.
449.15345 Health services.
449.15347 Pharmaceutical services.
449.15349 Medication and biologicals.
449.15351 Dietary services.
449.15353 Records of clients.
449.15355 Safety and sanitation; temperature.
449.15357 Laundry requirements.
449.15359 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of facility for licensure.
449.15361 Design, construction, equipment and maintenance.
449.15363 Accommodations for clients.
449.15365 Safety from fire.
449.15367 Preparations for disasters; reporting of fire or disaster.
449.15369 Discrimination prohibited.
FACILITIES FOR TREATMENT WITH NARCOTICS; MEDICATION UNITS
General Provisions
449.154 Definitions.
449.15415 “DEA” defined.
449.1542 “Facility for treatment with narcotics” defined.
449.1543 “Medical director” defined.
449.15435 “Medication unit” defined.
449.15438 “SAMHSA” defined.
449.1544 Health Division is state authority for certain federal regulations.
Licensing
449.15445 License and federal certification required to operate facility or unit.
449.1545 Filing requirements; recommendation for certification.
449.15455 Investigation and prelicensure survey.
449.1547 Suspension, revocation or cancellation of license; provisional license; denial of application.
Operation
449.1548 General operational requirements.
449.15485 Continuing review of operations; investigation of complaints.
HALFWAY HOUSES FOR RECOVERING ALCOHOL AND DRUG ABUSERS
449.1549 Definitions.
449.154901 “Administrator” defined.
449.154903 “Client” defined.
449.154905 “Facility” defined.
449.15491 Administrator: Qualifications.
449.154911 Administrator: General duties.
449.154913 General operational guidelines.
449.154915 Policies and procedures: Establishment; maintenance of manual.
449.154917 Limitation on admissions.
449.154919 Health and sanitation.
449.154921 Laundry facilities.
449.154923 Kitchens; storage of food.
449.154925 Bedrooms; bedding.
449.154927 Use of certain areas as bedroom prohibited.
449.154929 Bathrooms and toilet facilities; toilet articles.
449.154931 Accommodations for residents with restricted mobility.
449.154933 First aid.
449.154935 Medication.
449.154937 Telephones; telephone number.
449.154939 Notification to Bureau under certain circumstances.
449.154941 Rights of clients.
449.154943 Client files: Maintenance; contents; confidentiality.
449.154945 Safety from fire.
FACILITIES FOR TRANSITIONAL LIVING FOR RELEASED OFFENDERS
General Provisions
449.154951 Definitions.
449.154953 “Administrator” defined.
449.154955 “Facility” defined.
449.154957 “Resident” defined.
449.154959 “Supportive services” defined.
Administration
449.154961 Administrator: Qualifications.
449.154963 Administrator: General duties.
449.154965 Operation of facility.
449.154967 Policies and procedures.
449.154969 Preparations for disasters and other emergencies.
Operation
449.154971 Limitation on number of admissions.
449.154973 Prerequisites to provision of particular services.
449.154975 Sanitation, safety and comfort.
449.154977 Laundry facilities.
449.154979 Kitchens; preparation and storage of food.
449.154981 Bedrooms and bedding.
449.154983 Use of certain areas as bedroom prohibited.
449.154985 Bathrooms and toilet facilities; toiletries.
449.154987 First aid.
449.154989 Medication.
449.154991 Telephones.
449.154993 Notification of occurrence of certain incidents.
449.154995 Rights of residents.
449.154997 Files for residents.
449.154999 Safety from fire.
HOMES FOR INDIVIDUAL RESIDENTIAL CARE
449.15511 Definitions.
449.15513 “Caregiver” defined.
449.15515 “Director” defined.
449.15517 “Home” defined.
449.15519 “Protective supervision” defined.
449.15521 Director: Qualifications.
449.15523 Director: Duties.
449.15525 Requirements for safety and sanitation of facility.
449.15527 Agreement between operator of home and resident concerning rates; maintenance of records of residents.
449.15529 On-site survey of home by Bureau.
RESIDENTIAL FACILITIES FOR GROUPS
General Provisions
449.156 Definitions.
449.1565 “Administer” defined.
449.157 “Administrator” defined.
449.1575 “Board” defined.
449.1585 “Caregiver” defined.
449.1591 “Category 1 resident” defined.
449.1595 “Category 2 resident” defined.
449.1597 “Dietary supplement” defined.
449.160 “Division” defined.
449.164 “Hospice care” defined.
449.169 “Medical professional” defined.
449.170 “Placard” defined.
449.172 “Residential facility” defined.
449.173 “Residential facility which provides care to persons with Alzheimer’s disease” defined.
449.175 “Severity and scope score” defined.
449.176 “Staff of a facility” defined.
Licensing
449.179 Submission and approval of plan for new construction or remodeling; inspection; evidence of compliance.
449.180 Requirements for purchasing licensed facility.
449.190 License: Contents; validity; transferability; issuance of more than one type.
Administration and Personnel
449.194 Responsibilities of administrator.
449.196 Qualifications and training of caregivers.
449.197 Medical services may be provided only by medical professional.
449.199 Staffing requirements; limitation on number of residents; written schedule for each shift; direct supervision of certain employees.
449.200 Personnel files.
449.202 Rights of staff members during investigation of facility; duties of investigator.
General Operational Requirements
449.204 System of financial accounting; insurance.
449.205 Advertising and promotional materials.
449.208 Restrictions on conducting other businesses or providing other services on premises.
449.209 Health and sanitation.
449.211 Automatic sprinkler systems.
449.213 Laundry and linen services.
449.216 Common areas; dining rooms.
449.217 Kitchens; storage of food; adequate supplies of food; permits; inspections.
449.2175 Service of food; seating; menus; special diets; nutritional requirements; dietary consultants.
449.218 Bedrooms: Floor space; windows and doors; privacy; storage space; bedding; personal furnishings; lighting.
449.220 Bedroom doors.
449.221 Use of certain areas in facility as bedroom prohibited.
449.222 Bathrooms and toilet facilities; toilet articles.
449.224 Housing for staff members.
449.226 Safety requirements for residents with restricted mobility or poor eyesight; water hazards; auditory systems for bathrooms and bedrooms; access by vehicles.
449.227 Accommodations for residents with restricted mobility.
449.229 Requirements and precautions regarding safety from fire.
449.231 First aid and cardiopulmonary resuscitation.
449.232 Telephone; list of telephone numbers.
449.241 Limitations on use of volunteers; requirements concerning residents who volunteer to assist staff or perform other duties.
449.258 Written policies for facility; policy on visiting hours; residents’ mail; compliance with policies.
449.259 Supervision and treatment of residents generally.
449.260 Activities for residents.
449.262 Provision of dental, optical and hearing care and social services; report of suspected abuse, neglect, isolation or exploitation; restrictions on use of restraints, confinement or sedatives.
449.267 Money and property of residents.
449.268 Rights of residents; procedure for filing grievance, complaint or report of incident; investigation and response.
449.269 Discrimination prohibited.
Admitting, Transferring and Discharging Residents
449.2702 Written policy on admissions; eligibility for residency.
449.2704 Disclosure of information concerning rates and payment for services.
449.2706 Transfer of resident whose condition deteriorates.
449.2708 Discharge of resident; notice of discharge; issuance of notice to quit to resident for improper or harmful behavior.
Restrictions on Admitting or Retaining Residents With Certain Medical Needs or Conditions
449.271 Residents requiring gastrostomy care or suffering from staphylococcus infection or other serious infection or medical condition.
449.2712 Residents requiring use of oxygen.
449.2714 Residents requiring use of intermittent positive pressure breathing equipment.
449.2716 Residents having colostomy or ileostomy.
449.2718 Residents requiring manual removal of fecal impactions or use of enemas or suppositories.
449.272 Residents requiring use of indwelling catheter.
449.2722 Residents having unmanageable condition of bowel or bladder incontinence; residents having manageable condition of bowel or bladder incontinence.
449.2724 Residents having contractures.
449.2726 Residents having diabetes.
449.2728 Residents requiring regular intramuscular, subcutaneous or intradermal injections.
449.2732 Residents requiring protective supervision.
449.2734 Residents having tracheostomy or open wound requiring treatment by medical professional; residents having pressure or stasis ulcers.
449.2736 Procedure to exempt certain residents from restrictions.
449.2738 Review of medical condition of resident; relocation or transfer of resident having certain medical needs or conditions.
Medical Services, Medical Records and Other Records Concerning Residents
449.274 Medical care of resident after illness, injury or accident; periodic physical examination of resident; rejection of medical care by resident; written records.
449.2742 Administration of medication: Responsibilities of administrator, caregiver and employee of facility.
449.2744 Administration of medication: Maintenance and contents of logs and records.
449.2746 Administration of medication: Restrictions concerning medication taken as needed by resident; written records.
449.2748 Medication: Storage; duties upon discharge, transfer and return of resident.
449.2749 Maintenance and contents of separate file for each resident; confidentiality of information.
449.275 Residents receiving hospice care: Responsibilities of staff; retention of resident with special medical needs.
Special Types of Facilities
449.2754 Residential facility which provides care to persons with Alzheimer’s disease: General requirements.
449.2756 Residential facility which provides care to persons with Alzheimer’s disease: Standards for safety; personnel required; training for employees.
449.2758 Residential facility for elderly or disabled persons: Training for caregivers.
449.2762 Residential facility for mentally retarded adults: Training for caregivers; program to modify behavior of resident.
449.2764 Residential facility for persons with mental illnesses: Training for employees.
449.2766 Residential facility for persons with chronic illnesses: Training for employees.
Deficiencies
449.27702 Determination of severity and scope of deficiency; assignment of grade.
449.27704 Placard: Issuance and display; failure to comply.
449.27706 Resurvey: Application and fee; failure to comply.
BUSINESSES THAT PROVIDE REFERRALS TO RESIDENTIAL FACILITIES FOR GROUPS
449.27811 Definitions.
449.27813 “Client” defined.
449.27817 “Financial assessment” defined.
449.27819 “Needs assessment” defined.
449.27821 “Residential facility for groups” defined.
449.27823 License not required by certain persons to make referrals; application for licensure.
449.27827 Requirements for employees.
449.27829 Responsibilities of referral agency.
449.27831 Contract for services; fees; maintenance of client records.
HOSPITALS
General Provisions
449.279 Definitions.
449.285 “General hospital” defined.
449.286 “Governing body” defined.
449.287 “Hospital” defined.
449.289 “Inpatient” defined.
449.297 “Outpatient” defined.
449.298 “Outpatient department” defined.
449.299 “Patient” defined.
449.300 “Restraint” defined.
Licensing and Administration
449.307 Applicability of license; coverage against certain liabilities.
449.310 Limitation on number of patients; annual on-site inspection not required under certain circumstances.
449.312 Change in ownership, use or construction; correction of deficiencies.
449.313 Responsibilities and duties of governing body; bylaws; appointment and duties of chief executive officer; protocol for organ donations; annual operating budget.
449.314 Quality of care; scope of services.
449.3152 Quality improvement program.
449.3154 Construction, remodeling, maintenance and change of use: General requirements; prerequisites to approval of licensure.
449.3156 Compliance with certain guidelines for design and construction; correction of deficiencies.
Policies and Procedures for Operation of Hospital
449.316 Physical environment: Safety and well-being of patients; plan for emergency preparedness; safety management.
449.317 Risk management.
449.319 Requirements for personal needs of patients.
449.322 Housekeeping and laundry services.
449.325 Prevention, control and investigation of infections and communicable diseases.
449.327 Preparation, sterilization, storage and distribution of sterile supplies and medical and surgical equipment.
449.329 Admission of patients.
449.331 Emergency services and medical care; transfer agreements.
449.332 Discharge planning.
449.337 Dietary services: General requirements.
449.338 Dietary services: Provision for needs of patients; facilities; standards; permits; records.
449.3385 Dietary services: Personnel.
449.339 Dietary services: Nutritional status of patients.
449.3395 Dietary services: Sanitary conditions; supplies.
449.340 Pharmaceutical services.
449.343 Orders for medication and biologicals.
449.344 Administration of medication; security.
449.346 Rehabilitative services.
449.349 Emergency services.
449.352 Social services.
449.355 Discrimination prohibited.
449.358 Medical staff.
449.361 Nursing services.
449.3622 Appropriate care of patients.
449.3624 Assessment of patients.
449.3626 Rights of patients.
449.3628 Protection of patients; use of physical restraints.
449.363 Personnel policies concerning employment, licensing and certification.
449.364 Obstetrical services: Administration; staffing and equipment.
449.3645 Obstetrical services: Labor rooms; delivery rooms; utility rooms; area for cleaning instruments.
449.365 Obstetrical services: Required services.
449.3655 Obstetrical services: Transfer or discharge of patient.
449.367 Obstetrical services: Nurseries.
449.370 Outpatient services.
449.371 Intensive care services.
449.373 Laboratory services; pathology services; blood and blood products.
449.3735 Transfusions of blood.
449.374 Nuclear medicine services.
449.375 Records for nuclear medicine services; authorization.
449.376 Radiological services.
449.377 Radiological therapeutic services.
449.379 Medical records.
449.382 Medical library.
449.385 Surgical services.
449.388 Anesthesia services.
449.389 Respiratory care services.
449.391 Dental services.
449.394 Psychiatric services.
FACILITIES FOR CARE OF ADULTS DURING THE DAY
General Provisions
449.4061 Definitions.
Licensing
449.4063 Design, construction, equipment and maintenance of facility: General requirements; prerequisites to approval for licensure.
449.4065 Consultation with representative of Division; notice of nonconformity.
449.4067 Operation in combination with other medical facility or facility for the dependent.
449.4069 Insurance.
Operation of Facility
449.407 Advertising and promotional materials.
449.4071 Policies and procedures; accounting.
449.4072 Director and employees: Qualifications and duties; physical and mental health.
449.40723 Supervision of clients; volunteers.
449.40725 Orientation and training of employees and volunteers.
449.4073 Files concerning employees.
449.4074 Requirements of facility; health and sanitation; medications; exits.
449.4075 Preparations for fires and other emergencies; reporting of fire or disaster.
449.4076 First aid.
449.4077 Policy for admissions; retention of signed copy.
449.4078 Requirements for admission; designation of physician.
449.4079 Required services.
449.408 Housekeeping and maintenance.
449.4081 Administration of medication; accidents or illnesses.
449.4082 Service of food; dietary consultants.
449.4083 Discrimination prohibited.
449.40833 Summary of client’s care; referrals.
449.40835 Records.
Medical and Ancillary Services
449.4084 Contract for provision by another person.
449.4085 Provision by facility authorized.
449.4086 Evaluation of programs and policies.
449.4087 Written assessments of clients.
449.4088 Plan of care; periodic assessment.
449.4089 Menus.
FACILITIES FOR REFRACTIVE SURGERY
449.450 “Facility” defined.
449.4502 Applicability of provisions.
449.4504 Administrator: Appointment; duties; qualifications.
449.4505 Administrator of facility that performs intraocular lens implants: Duties.
449.4506 Staffing requirements; personnel files.
449.4508 Maintenance of patient records.
449.451 Written policies and procedures.
449.4512 Program of quality improvement.
449.4514 Rights of patients; informed consent.
449.4516 Equipment and supplies.
449.4518 Liability for use of leased equipment.
449.4522 Sanitation and hygiene; space and storage.
449.4524 Medical care of patients.
449.4526 Application for indemnification for certain damages; claims against surety bond or substitute thereof.
FACILITIES FOR TREATMENT OF IRREVERSIBLE RENAL DISEASE
General Provisions
449.501 Definitions.
449.502 “Advanced practitioner of nursing” defined.
449.504 “Charge nurse” defined.
449.5045 “Competency” defined.
449.505 “Dialysis” defined.
449.5053 “Dialysis technician” defined.
449.5055 “Direct supervision” defined.
449.5065 “End-stage renal disease” defined.
449.507 “Facility” defined.
449.508 “Hemodialysis” defined.
449.510 “Immediate supervision” defined.
449.511 “Intermediate level disinfection” defined.
449.513 “Licensed practical nurse” defined.
449.516 “Product water” defined.
449.517 “Supervision” defined.
449.519 “Training” defined.
Construction; Health and Safety
449.520 New construction or remodeling: Notification; increase in number of stations for which facility is licensed.
449.5205 New construction or remodeling: Submission of plans and specifications; minor changes; inspection.
449.522 Construction, space and design; physical environment; restrictions for treatment of patients with hepatitis B.
449.5225 Safety and comfort of patients during construction; imposition of more stringent design and space requirements.
449.523 Safety requirements.
449.5235 Maintenance and repair of equipment.
449.525 Water treatment system: General requirements.
449.5255 Water treatment system: Chemical testing of product water; records.
449.526 Water treatment system: Microbiological testing of product water.
449.5265 Reuse of hemodialyzer; transport of used dialyzer.
449.528 Adoption of more stringent requirements for treatment of water and reuse of hemodialyzers.
449.5285 Sanitation: Precautions regarding blood and bodily fluids.
449.529 Sanitation: Control of infections; nonsmoking policy.
449.5295 Sanitation: Provision of sanitary environment; walls, floors and ceilings; blood spills.
449.531 Sanitation: Disinfection of dialysis machines; culturing dialysate; cleaning of machines and equipment; handling of waste.
449.5315 Hepatitis B: Vaccinations for certain staff members; postvaccination screening; adoption of related provisions.
449.532 Hepatitis B: Vaccinations for certain patients.
449.5325 Hepatitis B surface antigen: Screening of patients; additional serologic screening.
449.534 Hepatitis B surface antigen: Treatment of patients who test positive.
449.5345 Tuberculosis: Screening of staff and patients.
Provision of Services
449.540 Program of quality assurance; recordation of accidents and incidents; reporting of certain events.
449.5405 Rights of patients.
449.541 Interdisciplinary teams; plans for care of patients.
449.5415 Preparations for emergencies and disasters.
449.543 Pharmaceutical services.
449.5435 Nursing services; physicians and other staff.
449.544 Nutrition services.
449.5445 Social services.
449.546 Patient care: Advanced practitioners of nursing and physician assistants; medical emergencies.
449.5465 Patient care: Licensed practical nurses and dialysis technicians.
449.547 Self-dialysis: Provision of training and certain services.
449.5475 Continuous ambulatory peritoneal dialysis.
449.549 Continuous cycling peritoneal dialysis.
449.5495 Patient services by contract; laboratory.
Administration and Personnel
449.550 Governing body.
449.5505 Medical director.
449.552 Physicians.
449.5525 Orientation program for new employees; continuing education.
449.553 Medical staff: Generally.
449.5535 Nurses.
449.555 Dietitians.
449.5555 Social workers.
449.556 Staff responsible for operating water treatment system.
449.5565 Staff that repairs or maintains equipment used to provide care to patients.
Clinical Records
449.558 Preparation and maintenance.
449.5585 Additional requirements.
449.559 Medical history and physical examination.
449.5595 Transient patients.
449.561 Discharge or transfer of patients; removal of records.
449.5615 Cessation of operation of facility.
Dialysis Technicians
449.570 General qualifications; identification to be worn during training; provision of care; requirements to act as preceptor.
449.5705 Qualification of technician determined to be qualified before July 1, 2001.
449.571 Program of training: Curriculum; duties of instructor; written examinations.
449.5715 Program of training: Qualifications of instructors.
449.573 Program of training: Certain persons authorized to provide instruction and serve as preceptor.
449.5735 Program of training: Required hours.
449.574 Committee to review program of training.
449.5745 Written list concerning knowledge and skills.
449.576 Peritoneal dialysis: Additional activities required.
449.5765 Cannulation or administration of normal saline or heparin: Additional activities required.
449.577 Cannulation or administration of normal saline, heparin or lidocaine: Verification and documentation of competency required.
449.5775 Documentation of successful completion of program of training; employment by another facility.
449.579 Patient care: Technicians must demonstrate certain knowledge and competency.
449.5795 Prohibited acts.
PROVISION OF CERTAIN SPECIAL SERVICES
Obstetric Care
449.6113 Definitions.
449.61132 Authorized obstetric care.
449.61134 Eligible maternal patients.
449.61138 Denial of application for or renewal of license; revocation or suspension of license.
449.6114 Design, construction, equipment and maintenance of obstetric center: General requirements; prerequisites to approval for licensure.
449.61142 Required facilities and services.
449.61144 Required emergency electrical power.
449.61146 Requirements for birth room, toilet and bathing facilities, hallways and doors, water supply and office-based facilities.
449.61148 Governing body of obstetric center; duties.
449.6115 Physician operator or advanced practitioner of nursing operator as licensee.
449.61152 Designation and responsibilities of medical director; privileges of members of medical staff; provision of consultation services with specialists.
449.61154 Medical records: Maintenance; access.
449.61156 Medical records: Contents.
449.61158 Program for review of quality of care.
449.6116 Miscellaneous requirements concerning staff, provision of service and equipment.
449.61162 Requirements for transfer or discharge of patient.
449.61164 Written protocol for discharge of patient.
449.61166 Policies and procedures for control of infectious agents and diseases; program to monitor health of employees.
449.61168 Laboratory services; transfer of maternal patient who needs blood or blood products.
449.6117 Possession, distribution, administration and storage of drugs and controlled substances.
449.61172 Anesthesia.
449.61174 Transfer of patient to hospital or medical facility licensed to provide high-risk perinatal care.
449.61176 Death of patient; notification of Health Division; provision of counseling.
449.61178 Required information to be provided or made available to patient; complaints.
Open-Heart Surgery
449.612 Definitions.
449.612011 “Approval” defined.
449.612012 “Approved hospital” defined.
449.612014 “Cardiac surgery” defined.
449.612017 “Open-heart surgery” defined.
449.61202 Prerequisites to initial provision of service.
449.61204 Form and contents of application for approval to provide service.
449.61206 Notification of applicant upon review of application; site inspection required.
449.61208 Composition and duties of site inspection team.
449.6121 Hospital to pay costs of inspection.
449.61212 Approval or denial of application; period of validity of approval; cessation of performance of surgeries.
449.61214 Amount of surgery required following approval.
449.61216 Provision of patient with preoperative instruction.
449.61218 Surgical team: Composition; privileges and qualifications of members; participation of qualified nurses.
449.6122 Qualifications of anesthesiologist.
449.61222 Qualifications of nurse in charge of service.
449.61224 Perfusion team: Use required; qualifications; approval of members by surgeon of record.
449.61226 Operating rooms: General requirements.
449.61228 Operating rooms: Equipment and staff.
449.6123 Intensive care facility: General requirements.
449.61232 Intensive care facility: Staff.
449.61234 Intensive care facility: Equipment and supplies.
449.61236 Orientation and continuing education of personnel.
449.61238 Maintenance of blood bank.
449.6124 Maintenance of cardiac catheterization laboratory.
449.61242 Maintenance of medical laboratory.
449.61244 Maintenance of facilities to perform contrast studies and equipment to review films of operations.
449.61246 Maintenance of registry to record results for each patient.
449.61248 Maintenance of program to follow recovery of patient.
449.6125 Annual review and inspection of hospital.
449.61252 Annual inspection of hospital: Assessment of rate of mortality.
449.61254 Further review or on-site inspection for failure to comply with provisions or for excessive rate of mortality; notice; plan for compliance.
449.61256 Denial, suspension or revocation of approval: Grounds; hearing.
Transplantation of Organs
449.6126 Definitions.
449.61262 Application for approval to provide services.
449.61264 Evaluation of application for approval.
449.61266 Duties of hospital providing services.
449.61268 Revocation of approval.
449.6127 Notice of intent to deny application or revoke approval; hearing.
INDEPENDENT CENTERS FOR EMERGENCY MEDICAL CARE
Licensing
449.61302 Limitations on issuance of license.
449.61306 Denial of application for license or renewal of license.
449.61308 Compliance with regulations; ground for suspension or revocation of license.
Administration and Personnel
449.6132 Requirement of governing body; adoption of written rules.
449.61322 Exception to requirements of governing body.
449.61324 Standards of care; policy for authentication.
449.61326 Program to review quality of care; contents of program.
449.61328 Integration into local emergency medical system.
449.6133 Appointment and responsibilities of administrator.
449.61332 Employment and duties of medical director.
449.61334 Standards and procedures for selection, treatment and retention of medical staff and members of allied health professions.
449.61336 Rules for organization of medical staff.
449.61338 Employment and duties of chief nurse; size of on-duty nursing staff; limitation on scope of practice by person who is not registered nurse; oversight of nursing staff.
Facilities
449.6135 Design, construction, equipment and maintenance: General requirements; prerequisites to approval for licensure.
449.61352 Contents of center: Emergency entrance; reception and waiting areas; treatment and examination rooms; space for storage and maintenance of medical records and supplies.
449.61354 Contents of treatment rooms; accessibility to person in wheelchair.
Medical Services and Medical Records
449.6137 Requirement for minimum level of care in certain situations.
449.61372 Criteria for denial of care, transfer or discharge of patient; compliance with state and federal laws.
449.61374 Laboratory services and reports; procedures for storage and administration of tissue specimens, blood and blood products; agreements with outside blood banks; review of blood transfusions and reactions.
449.61376 Program for control of infection.
449.61378 Radiological services: Availability; interpretation and reporting of films; storage and retention.
449.6138 Distribution and administration of drugs and controlled substances.
449.61382 Medical records: Maintenance; access; authorized release; completion after discharge.
449.61384 Contents of medical records.
INTERMEDIATE CARE FACILITIES
General Provisions
449.614 Definitions.
449.617 “Administrator” defined.
449.620 “Developmentally disabled person” defined.
449.623 “Facility” defined.
449.629 “Intermediate care facility as a distinct part of a health and care facility furnishing more than one level of care” defined.
449.632 “Intermediate care facility for the mentally retarded or persons with developmental disabilities” defined.
449.635 “Licensee” defined.
449.638 “Long-term care facility” defined.
449.641 “Mentally retarded person” defined.
449.644 “Mixed facility” defined.
449.647 “New facility” defined.
449.650 “Nursing home” defined.
449.653 “Patient in an intermediate care facility I” defined.
449.656 “Patient in an intermediate care facility II” defined.
449.659 “Resident” defined.
Licensing
449.668 Provisional licenses.
Administration and Personnel
449.671 Financing; liability insurance.
449.674 Administrator: Qualifications.
449.677 Employees: General requirements.
449.680 Employees: Health; physical examinations.
449.681 Employees of facility which provides care to persons with dementia: Continuing education.
Construction and Operation: Generally
449.685 Design, construction, equipment and maintenance: General requirements; prerequisites to approval of facility for licensure.
449.692 Sanitary requirements.
449.695 Laundry requirements.
449.698 Fire inspections; hazardous conditions; operation of other business.
449.701 Preparations for emergencies; reporting of fire or disaster.
449.704 Written policies and procedures for facility; admission agreements; transfer agreements.
449.707 Money of residents.
449.710 Inventory of residents’ belongings.
449.713 Program requirements.
449.716 Dietary services.
449.719 Health services.
449.722 Pharmaceutical services.
449.725 Records.
449.728 Supervision by physician; volunteers; advertising.
449.731 Discrimination prohibited.
Construction and Operation: Facilities for Mentally Retarded or Persons With Developmental Disabilities
449.732 Definitions.
449.7322 “Facility” defined.
449.7324 “New facility” defined.
449.7326 Standards for construction, remodeling or change in use of facility; fire alarms; emergency radio system; submission and approval of building plans.
449.7328 Elevators
449.733 Electrical systems.
449.7332 Mechanical systems.
449.7334 Doors, windows, ceilings, walls and floors.
449.7336 Entrances and lobbies; miscellaneous space.
449.7338 Dining and storage space.
449.7342 Facilities for employees and volunteers.
449.7344 Areas for engineering and maintenance.
449.7346 Janitors’ closets.
449.7348 Linen service.
449.735 Area for medical records.
449.7352 Nursing units.
449.7354 Service areas.
449.7356 Processing of waste.
449.736 Personnel.
449.737 Plan of care.
449.740 Corporal punishment; restraints.
449.743 Records.
COMMUNITY TRIAGE CENTERS
449.74311 Definitions.
449.74313 “Administrator” defined.
449.74315 “Facility” defined.
449.74317 “Governing body” defined.
449.74319 “Mentally ill person” defined.
449.74321 “Patient” defined.
449.74323 “Program” defined.
449.74325 “Psychologist” defined.
449.74327 Governing body; bylaws and policies.
449.74329 Policies and procedures for services and operation of facility.
449.74331 Transfer of patient.
449.74333 Handling of money of patient.
449.74335 Inventory of belongings of patient.
449.74337 Liability insurance.
449.74339 General requirements for programs and services.
449.74341 Responsibilities and duties of administrator.
449.74343 Policies and procedures concerning employees.
449.74345 Nursing services.
449.74347 Health services.
449.74349 Mental health services.
449.74351 Pharmaceutical services.
449.74353 Medication and biologicals.
449.74355 Records of patients.
449.74357 Laundry requirements.
449.74359 Dietary services.
449.74361 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of facility for licensure.
449.74363 Design, construction, equipment and maintenance of facility.
449.74365 Entrances, lobbies and offices; storage space.
449.74367 Patients’ rooms; toilet and bathing facilities.
449.74369 Service areas; miscellaneous requirements.
449.74371 Safety and sanitation.
449.74373 Preparations for disasters; reporting of fire or disaster.
449.74375 Discrimination prohibited.
FACILITIES FOR SKILLED NURSING
General Provisions
449.744 “Facility for skilled nursing” defined.
Licensing and Administration of Facility
449.74411 Applicability of license; limitation on number of patients; coverage against certain liabilities.
449.74413 Change in ownership, use or construction of facility.
449.74415 Responsibilities of governing body.
449.74417 Administrator of facility.
449.74419 Committee for quality assurance.
449.74421 Procedures for emergency or disaster.
Admission, Transfer and Discharge of Patient
449.74423 Certain conditions for admission prohibited.
449.74425 Admission of patient with mental illness or mental retardation.
449.74427 Agreement with hospital for transfer of patients.
449.74429 Transfer or discharge of patient.
449.74431 Summary of discharge.
Assessment of Patients and Plan of Care
449.74433 Comprehensive assessment of needs of patient.
449.74435 Quarterly assessment of patient.
449.74437 Conduct of assessments.
449.74439 Comprehensive plan of care.
Medical Records
449.74441 Maintenance.
449.74443 Inspection.
Rights of Patients
449.74445 Generally.
449.74447 Communications with other persons; examination of records by advocate.
449.74449 Notice to patients of rights, services and charges.
449.74451 Charges to be consistent with notice of charges.
449.74453 Notice to patients of programs available for assistance in payment of services.
449.74455 Discrimination prohibited.
449.74457 Policies and procedures for advance directives by patient; information to be furnished regarding physicians.
449.74459 Examination by patient of survey of facility and plan of correction.
449.74461 Finances of patient: System for maintenance and accounting.
449.74463 Finances of patient: Authorization to withhold money.
449.74465 Sending and receiving mail.
449.74467 Performance of services for facility by patient.
Quality of Care
449.74469 Standards of care.
449.74471 Administration of drugs.
449.74473 Program for control of infections.
449.74475 Vision and hearing.
449.74477 Pressure sores.
449.74479 Urinary problems.
449.74481 Range of motion.
449.74483 Mental or psychosocial behavior.
449.74485 Nasogastric tubes.
449.74487 Nutritional health; hydration.
449.74489 Physical or chemical restraint of patients.
449.74491 Prohibition of certain practices regarding patients; investigation of certain violations and injuries to patients; unfit employees.
449.74493 Notification of changes or condition of patient.
449.74495 Development of program of activities.
449.74497 Daily activities of patient.
449.74499 Participation in activities.
Staff and Attending Physicians
449.74511 Personnel policies; personnel records.
449.74513 Medical director.
449.74515 Physicians.
449.74517 Nursing staff.
449.74519 Nursing assistants and nursing assistant trainees.
449.74521 Other health care professionals.
449.74522 Employees of facility which provides care to persons with dementia.
Provision of Services
449.74523 Social services.
449.74525 Dietary services.
449.74527 Specialized rehabilitative services.
449.74529 Dental services.
449.74531 Pharmaceutical services.
449.74533 Laboratory services.
449.74535 Radiological and other diagnostic services.
449.74537 Special services.
Physical Environment
449.74539 General requirements.
449.74543 Design, construction, equipment and maintenance: General requirements; prerequisites to approval of facility for licensure.
449.74549 Patients’ rooms.
NURSING POOLS
General Provisions
449.747 Definitions.
Licensing
449.7471 License required.
449.7473 Location to which license applies; persons named in license; restrictions on use of license.
449.7474 Duties of licensee or applicant for license.
Administration and Personnel
449.7475 Administrator: Qualifications and duties.
449.7476 Director of professional services: Qualifications and duties.
449.7477 Personnel policies: Maintenance and availability.
449.7478 Requirements for contracts to provide nursing services.
449.7479 Referral of patients when services not available; provision of services; bonding of staff.
449.748 Duties of registered nurse; provision of nursing care by practical nurse or nursing assistant.
449.7481 Annual evaluation of nursing pool by licensee.
HOME HEALTH AGENCIES
General Provisions
449.749 Definitions.
Licensing and Inspection
449.752 License required.
449.758 Applicability of license; coverage against certain liabilities.
449.761 Periodic inspections.
449.767 Action to enjoin operation without license.
449.768 Applicant or licensee to maintain home office in Nevada.
Administration and Personnel
449.770 Governing body; bylaws.
449.773 Administrator: Qualifications; duties.
449.776 Director of professional services.
449.779 Professional advisory group.
449.782 Personnel policies.
449.785 Contracts for home health services.
449.787 Duty to provide skilled nursing care and home health aide services; inclusion of additional services.
449.788 Services to patients.
449.791 Duties of personnel.
449.793 Evaluation by governing body; periodic review of contracts, operations, policies and procedures.
Medical Services and Medical Records
449.794 Clinical records: General requirements.
449.797 Contents of clinical records.
449.800 Medical orders.
FINANCIAL REPORTING
449.951 Definitions.
449.953 Annual fee for insurers: Amount; notice; administrative fine for failure to pay.
449.957 Hospitals to file certain reports; certification; exception; extension.
449.960 Hospitals to submit quarterly financial and utilization report; certification; extension.
449.962 Facility for intermediate care or facility for skilled nursing to submit quarterly financial and utilization report; certification; extension.
449.9625 Institution to submit quarterly financial and utilization report; certification; extension; exception.
449.963 Information concerning discharged patients: Submission; limitation on disclosure.
449.966 Notice of insufficiency of submitted information.
449.969 Administrative fine for failing to meet deadlines.
MOBILE UNITS
449.970 Definitions.
449.9701 “Independent facility” defined.
449.97012 “Mobile unit” defined.
449.97014 “Parent facility” defined.
449.97016 “Service site” defined.
449.97018 “Staging area” defined.
449.9702 Applicability of provisions.
449.97022 Licensure.
449.97024 Application for licensure.
449.97026 Design, construction, equipment, maintenance and parking.
449.97028 Staging areas; disposal of biohazards and waste.
449.9703 Compliance with certain statutes and regulations.
449.97032 Compliance with regulations relating to evaluation of quality of services.
449.97034 Written policies for operation of unit; agreement with hospital or medical facility for transfer of patients during emergencies.
449.97036 Rights of patients.
449.97038 Maintenance of schedule and records; supplies and equipment; diagnostic radiological services; laboratory services.
449.9704 Occupancy; fire safety; exits; use and maintenance of equipment; telecommunications device.
449.97042 Restrictions on operation; office of independent facility; operation pursuant to contract.
SURGICAL CENTERS FOR AMBULATORY PATIENTS
General Provisions
449.971 Definitions.
449.9715 “Allied health profession” defined.
449.972 “Ambulatory surgical center” defined.
449.9725 “Division” defined.
449.973 “Governing body” defined.
449.9735 “Licensee” defined.
449.974 “Patient” defined.
449.9741 “Physician” defined.
449.9742 “Registered nurse” defined.
449.9743 “Surgery” defined.
Licensing
449.9745 Compliance with requirements by accreditation.
449.9755 Investigation of applicant and inspection of center.
449.978 Effect of expiration of license.
449.9785 Conformance with regulations required.
Administration
449.979 Governing body required.
449.9795 Duties of governing body.
449.980 Responsibilities of governing body.
449.9801 Procedures for granting privileges to members of medical staff.
449.9805 Establishment of policy for authentication.
449.981 Appointment and responsibilities of administrator.
449.9812 Program for quality assurance.
449.9813 Committee for quality assurance.
449.9815 Maintenance.
449.982 Sanitation and housekeeping.
449.983 Protection from fire and other disasters.
449.9835 Exemption from requirements for governing body and administrator.
449.9837 Restrictions on operation of ambulatory surgical center; maintenance of records.
449.9843 Compliance with certain standards, laws, ordinances and codes; submission and approval of building plans; prerequisites to approval of center for licensure.
Personnel
449.9855 Policies and requirements for personnel.
449.9865 Medical staff.
449.988 Nursing staff.
Medical Records, Services and Facilities
449.9885 Medical records: Maintenance.
449.989 Medical records: Contents.
449.9895 Sterilization.
449.990 Medication and treatment.
449.9902 Emergency equipment and supplies required.
449.9905 Pharmacist required; records, storage and administration of drugs.
449.991 Laboratory services.
449.992 Pathological services.
449.9925 Procurement, storage and transfusion of blood.
449.993 Diagnostic radiological services.
449.9935 Operating and recovery rooms; endoscopy suite.
449.9937 Extended recovery units.
449.994 Records required before surgery; report of surgery.
449.9945 Administration and record of anesthesia.
449.9955 Informing patient of rights, services and cost.
449.996 Transfer of patients.
449.9965 Prohibited locations for construction of center.
449.997 Conversion of hazardous building into center prohibited.
RECEIVERS
449.9981 List of interested and qualified persons.
449.99811 Experience.
449.99812 Authority.
449.99813 Compensation and payment of bond.
449.99814 Operation of facility.
ADMINISTRATIVE SANCTIONS
General Provisions
449.9982 Definitions.
449.99821 “Ban on admissions” defined.
449.99822 “Cluster” defined.
449.99823 “Compliance” and “substantially correct the deficiency” defined.
449.99824 “Costs” defined.
449.99825 “De minimis deficiency” defined.
449.998253 “Division of Health Care Financing and Policy” defined.
449.998255 “Facility” defined.
449.99826 “Immediate family” defined.
449.99827 “Initial deficiency” defined.
449.99828 “Major deficiency” defined.
449.99829 “Medicaid facility” defined.
449.9983 “Medicare facility” defined.
449.99832 “Monitor” defined.
449.99833 “New admission” defined.
449.99834 “Particular kinds of care, treatment or services” defined.
449.99835 “Plan of correction” defined.
449.99836 “Provider agreement” defined.
449.99837 “Repeated deficiency” defined.
449.99838 “Resurvey” defined.
449.99839 “Severity and scope score” defined.
449.9984 “Subsequent deficiency” defined.
449.99841 “Temporary management” defined.
449.99843 Purposes of administrative sanctions.
449.99844 Interpretation of provisions in accordance with federal standards.
Imposition: Generally
449.9985 Authority of Health Division and Bureau.
449.99851 Requirement for imposition; optional imposition.
449.99852 Requirement for imposition; multiple sanctions.
449.99853 Imposition of one or more sanctions; criteria for imposition of particular sanction.
449.99854 Imposition in lieu of or in addition to recommendation to terminate provider agreement; duration of sanctions.
449.99855 Imposition in emergencies: Authority; notice.
449.99856 Deficiencies: Basis for imposition of sanctions; reporting; presumption of de minimis deficiency.
449.99857 Classifications of severity and scope of deficiencies: Use.
449.99858 Scope of violations: Evaluation of representative sample of recipients; size of sample.
449.99859 Scope of deficiencies: Use of scope scale; basis for assessment.
449.9986 Scope of deficiencies: Criteria for evaluation.
449.99861 Severity of deficiencies: Use of severity scale; basis for assessment; criteria for evaluation.
449.99862 Presumption when same deficiency found on resurvey; imposition of sanction for subsequent deficiency.
449.99863 Available sanctions.
449.99864 Determination of appropriate sanction: Procedure.
449.99865 Determination of appropriate sanction: Initial assessment.
449.99866 Determination of appropriate sanction: Consideration of secondary factors.
449.99867 Determination of appropriate sanction: Basis for selection; presumption.
Plan of Correction
449.9987 Development and submission of plan; authority of Bureau when plan is not acceptable; effect of failure to submit plan.
Limitation on Occupancy of Residential Facility
449.99875 Purpose and scope of limitation; imposition in addition to partial ban on admissions.
449.99876 Criteria for imposition.
449.99877 Duration and termination of limitation.
449.99878 Notice of limitation: General requirements; effect of noncompliance.
Ban on Admissions
449.9988 Purpose and scope of ban.
449.99881 Criteria for imposition.
449.99882 Duration and termination of ban.
449.99883 Notice of ban: General requirements; effect of noncompliance.
Monitoring of Facility
449.99885 Authority of Bureau.
Monetary Penalties
449.99895 Imposition by Bureau; purpose; applicable criteria.
449.99896 Criteria for imposition; imposition of initial and daily penalties.
449.99897 Imposition of initial penalty pending hearing or appeal; stay of payment of penalties pending appeal.
449.99898 Procedure for imposition; interest on total penalty assessed.
449.99899 Determination of amount of penalties.
449.999 Limitation on principal amount of total daily penalty.
449.99901 Daily penalty: Computation according to number of recipients.
449.99902 Increase in penalty for repeated deficiencies or false compliance.
449.99903 Presumption regarding deficiencies identified on resurvey.
449.99904 Reduction of penalty.
449.99905 Daily penalty: Effective beginning date.
449.99906 Daily penalty: Date and period of computation; notice to facility.
449.99907 Termination of daily penalties; failure of Medicaid facility to remove immediate and serious threat after appointment of temporary management.
449.99908 Time for payment of penalties.
449.99909 Assessment of interest on unpaid balance of penalty.
449.9991 Recovery of costs for collection of penalty.
449.99911 Failure to pay penalty: Suspension of license of facility.
449.99912 Disposition of money collected.
Temporary Management
449.99915 Appointment of temporary manager when there is immediate and serious threat: Notice; effect of failure to accept manager and to remove threat.
449.99916 Appointment of temporary manager when there is no immediate and serious threat: Notice.
449.99917 Temporary manager: Qualifications.
449.99918 Temporary manager: Authority.
449.99919 Effect of failure to agree to appointment of or to relinquish authority to temporary manager.
449.9992 Events requiring termination of management; initiation of judicial proceedings.
449.99921 Payment of costs and expenses.
Closure of Facility and Transfer of Residents
449.99925 Authority of Bureau.
449.99926 Requirements for notification.
449.99927 Appointment of temporary manager.
449.99928 Bureau to supervise or appoint temporary manager to supervise transfer; imposition of other appropriate sanctions.
449.99929 Determination of appropriate placement of residents.
449.9993 Rights of appeal for transferred residents.
Facilities Participating in Medicaid
449.99935 Authorized recommendations in addition to available sanctions.
449.99936 Withholding of monetary penalties from payments owed to facility.
449.99937 Denial of payments for new admissions generally.
449.99938 Denial of payments for new admissions who have certain specified diagnoses or special care needs.
449.99939 Suspension of payments for services furnished to Medicaid recipient on or after date of deficiency.
GENERAL PROVISIONS
NAC 449.002 Definitions. (NRS 449.037, 449.249) As used in this chapter, unless the context otherwise requires, the words and terms defined in NAC 449.0022 to 449.0072, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R131-99 & R132-99, 11-29-99; R051-02, 7-24-2002)
NAC 449.0022 “Administrator” defined. (NRS 449.037) “Administrator” means the person responsible for the day-to-day management of a facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0024 “Affiliated facility” defined. (NRS 449.037) “Affiliated facility” means a facility that owns, directly or indirectly, an equity interest of 5 percent or more in the capital, the stock, the profits or the assets of another facility or is, as a subcontractor, agent or otherwise, responsible for the management or control of that facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0026 “Agent” defined. (NRS 449.037) “Agent” means a person having actual or apparent authority to act on behalf of a licensee.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0028 “Bureau” defined. (NRS 449.037) “Bureau” means the Bureau of Licensure and Certification of the Health Division.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0029 “Centers for Medicare and Medicaid Services” defined. (NRS 449.037) “Centers for Medicare and Medicaid Services” means the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services.
(Added to NAC by Bd. of Health by R051-02, eff. 7-24-2002)
NAC 449.003 “Deficiency” defined. (NRS 449.037)
1. “Deficiency” means noncompliance with any federal or state statute or of the rules or regulations of the Health Division or the Centers for Medicare and Medicaid Services or conditions and standards of or requirements for participation in the Medicare or Medicaid program pertaining to a facility.
2. The term includes an incident concerning a facility where there are no extenuating circumstances or where the facility has made an inappropriate response to a complaint, including the failure to:
(a) Prevent an incident from occurring, if the incident could have been avoided;
(b) Identify an incident;
(c) Take action to correct an incident before the identification of the incident by the Bureau; or
(d) Implement a contingency plan if permanent action to correct an incident has not been undertaken.
3. In determining whether an incident is a deficiency, the right of the recipient to refuse treatment, where applicable, shall be deemed an extenuating circumstance.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.0031 “Division of Welfare and Supportive Services” defined. (NRS 449.037) “Division of Welfare and Supportive Services” means the Division of Welfare and Supportive Services of the Department of Health and Human Services.
(Added to NAC by Bd. of Health, eff. 8-1-91)—(Substituted in revision for NAC 449.0074)
NAC 449.0032 “Emergency” defined. (NRS 449.037) “Emergency” means a major deficiency that places one or more recipients in immediate jeopardy. The term includes, without limitation, any fire, flood, contagious infection, loss of utilities or inappropriate transfer of residents.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0034 “Facility” defined. (NRS 449.037, 449.249) “Facility” means a medical facility, facility for the dependent, home for individual residential care or referral agency.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R131-99 & R132-99, 11-29-99)
NAC 449.0038 “Health Division” defined. (NRS 449.037) “Health Division” means the Health Division of the Department of Health and Human Services.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R094-06 & R098-06, 7-14-2006)
NAC 449.0042 “Holiday” defined. (NRS 449.037) “Holiday” means a day on which the offices of State Government are closed.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0043 “Home for individual residential care” defined. (NRS 449.249) “Home for individual residential care” has the meaning ascribed to it in NRS 449.0105.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.0044 “Immediate and serious threat” and “immediate jeopardy” defined. (NRS 449.037) “Immediate and serious threat” or “immediate jeopardy” means a situation in which corrective action within 48 hours is necessary because the failure by a facility to comply with a requirement for licensure, certification or participation in Medicare or Medicaid has caused, or if uncorrected is likely to cause, serious injury or harm, or even death, to a recipient.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0046 “Incident” defined. (NRS 449.037) “Incident” means an action, practice or situation that appears to be inconsistent with a federal or state statute, rule or regulation of the Health Division or the Centers for Medicare and Medicaid Services or conditions and standards of or requirement for participation in Medicare or Medicaid.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.0048 “License” defined. (NRS 449.037) “License” means all or part of any permit, certificate, approval, registration, charter or similar grant of permission to operate issued to a facility by the Health Division.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.005 “Licensee” defined. (NRS 449.037) “Licensee” means any person, corporation, partnership, voluntary association or other public or private entity, including any governmental body, licensed to operate a facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0052 “Medicaid” defined. (NRS 449.037) “Medicaid” means the program established pursuant to Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., to provide assistance for part or all of the cost of medical care rendered on behalf of indigent persons.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0054 “Medicare” defined. (NRS 449.037) “Medicare” means the program of health insurance for aged and disabled persons established pursuant to Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395 et seq.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0056 “Party” defined. (NRS 449.037) “Party” means each person or agency as defined in NRS 233B.035.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0058 “Person” defined. (NRS 449.037) “Person” means a natural person, trust, estate, partnership, corporation, professional association, governmental body or any other entity, public or private.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.006 “Recipient” defined. (NRS 449.037) “Recipient” means a person receiving care, services or treatment from a facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0061 “Referral agency” defined. (NRS 449.0305, 449.037) “Referral agency” means a business that provides referrals to residential facilities for groups which is subject to regulation pursuant to NRS 449.0305, including, without limitation, any business entity that engages in the process of referring clients for compensation to residential facilities for groups.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99)
NAC 449.0062 “Resident” defined. (NRS 449.037) “Resident” means a person who resides in a residential facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0064 “Residential facility” defined. (NRS 449.037) “Residential facility” means a facility operated 24 hours per day in which one or more persons receiving care, treatment or services ordinarily remain for 24 hours a day.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0066 “Sanction” defined. (NRS 449.037) “Sanction” means a corrective measure or penalty that is imposed by the Bureau upon a facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.0068 “Services” defined. (NRS 449.037) “Services” means medical or personal care, including necessary preparation of food, laundry and housekeeping in the case of a residential facility and items such as medical diagnosis and treatment, drugs and biologicals, supplies, appliances, equipment, medical-social services and use of a facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.007 “Survey” defined. (NRS 449.037)
1. “Survey” means a regularly scheduled inspection of a facility conducted by employees of the Bureau to verify the facility’s compliance with the regulations of the Health Division, the Centers for Medicare and Medicaid Services, eligibility for participation in the Medicare or Medicaid programs and eligibility for licensure.
2. The term includes a follow-up inspection to recertify a facility or evaluate compliance with a plan of correction or an inspection made in response to a complaint.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.0072 “Treatment” defined. (NRS 449.037) “Treatment” means any medication, drug, test or procedure conducted or administered to diagnose or remedy a physical or mental illness or condition.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.008 Computation of time. (NRS 449.037) For the purposes of any computation of time required by this chapter:
1. Any prescribed period of more than 5 days includes Saturdays, Sundays and holidays.
2. Any prescribed period of 5 days or less does not include Saturdays, Sundays or holidays.
3. If the date on which any action required to be performed falls on a Saturday, Sunday or holiday, the time is extended until the next day that is not a Saturday, Sunday or holiday.
4. The day of any act or event or on which notice is received is not included in the computation.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.010 Severability. (NRS 449.037) If any of the provisions of this chapter or any application thereof to any person, thing or circumstance is held invalid, it is intended that such invalidity not affect the remaining provisions, or their application, that can be given effect without the invalid provision or application.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 17, eff. 3-27-76]
NAC 449.0105 Adoption of certain publications by reference; revision of publication after adoption. (NRS 449.037)
1. The State Board of Health hereby adopts by reference:
(a) NFPA 101: Life Safety Code, in the form most recently published by the National Fire Protection Association, unless the Board gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the code may be obtained from the National Fire Protection Association at 11 Tracy Drive, Avon, Massachusetts 02322, at the Internet address http://www.nfpa.org or by telephone at (800) 344-3555, for the price of $55.80 for members or $62 for nonmembers, plus $7.95 for shipping and handling.
(b) NFPA 99: Standard for Health Care Facilities, in the form most recently published by the National Fire Protection Association, unless the Board gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the standard may be obtained from the National Fire Protection Association at 11 Tracy Drive, Avon, Massachusetts 02322, at the Internet address http://www.nfpa.org or by telephone at (800) 344-3555, for the price of $41.63 for members or $46.25 for nonmembers, plus $7.95 for shipping and handling.
(c) Guidelines for Design and Construction of Hospital and Health Care Facilities, in the form most recently published by the American Institute of Architects, unless the Board gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the guidelines may be obtained from the American Institute of Architects at the AIA Store, 1735 New York Avenue, NW, Washington, D.C. 20006-5292, at the Internet address http://www.aia.org or by telephone at (800) 242-3837, for the price of $52.50 for members or $75 for nonmembers, plus $9 for shipping and handling.
2. The State Board of Health will review each revision of the publications adopted by reference pursuant to subsection 1 to ensure its suitability for this State. If the Board determines that a revision is not suitable for this State, the Board will hold a public hearing to review its determination within 6 months after the date of the publication of the revision and give notice of that hearing. If, after the hearing, the Board does not revise its determination, the Board will give notice within 30 days after the hearing that the revision is not suitable for this State. If the Board does not give such notice, the revision becomes part of the publication adopted by reference pursuant to subsection 1.
(Added to NAC by Bd. of Health by R066-04, R067-04, R068-04, R069-04, R073-04, R076-04 & R077-04, eff. 8-4-2004)
GENERAL REQUIREMENTS FOR LICENSURE
NAC 449.011 Application for license. (NRS 449.037, 449.040) An application for a license that is filed with the Health Division pursuant to NRS 449.040:
1. Must be complete and notarized.
2. In accordance with NRS 449.050, must be accompanied by the appropriate application fee specified in this chapter.
3. In establishing that the applicant is of reputable and responsible character as required by NRS 449.040, must include personal references and information concerning the applicant’s financial status and business activities and associations in and out of this State during the immediately preceding 3-year period. If the applicant is a firm, association, organization, partnership, business trust, corporation or company, such references and information must be provided with respect to the members thereof and the person in charge of the facility or program for which application is made.
4. In addition to the information required by NRS 449.040 and any other information specifically required for a particular license, must include:
(a) Full, complete and accurate information regarding the ownership of the facility or program and all changes to that ownership that occur while the application is pending. The information must include the name of:
(1) Each natural person who is an owner of the facility or program;
(2) Each person who has a direct or indirect ownership interest in the facility or program of 10 percent or more and who is the owner, in whole or in part, of any mortgage, deed of trust, note or other obligation secured in whole or in part by the facility or program or any of the property or assets of the facility or program;
(3) If the applicant is a corporation, each officer and director; and
(4) If the applicant is a partnership, each partner.
(b) The address of the applicant’s principal office.
(c) Evidence satisfactory to the Health Division that the facility or program meets all applicable federal, state and local laws and complies with all safety, health, building and fire codes. If there are any differences between the state and local codes, the more restrictive standards apply.
(d) If required by NRS 439A.100, a copy of a letter of approval issued by the Director of the Department of Health and Human Services.
(e) A copy of the certificate of occupancy, a copy of the applicant’s business license and a copy of any special use permits obtained in connection with the operation of the facility or program.
(f ) A copy of any property lease or rental agreements concerning the facility or program.
(g) If the applicant is a corporation, a copy of its bylaws and articles of incorporation.
(Added to NAC by Bd. of Health by R044-97, eff. 10-30-97)
NAC 449.0112 Investigation; prelicensure survey; inspection for fire safety. (NRS 449.037)
1. Upon receipt of a properly completed and notarized application and the appropriate fee, the Health Division shall conduct an investigation concerning the premises, facilities, qualifications of personnel, methods of operation and policies of the applicant and perform a prelicensure survey of:
(a) The applicant; and
(b) The facility, program plan and management plan, as appropriate.
2. Before issuing a license, the Health Division must receive a satisfactory report of inspection of the facility from the State Fire Marshal or the local fire department.
(Added to NAC by Bd. of Health by R044-97, eff. 10-30-97)
NAC 449.0114 Display of license; compliance with law; transfer of real property; change in administrator, ownership, location or services. (NRS 449.037, 449.050)
1. Upon receipt of a license, the licensee shall display the license at a conspicuous location within the facility.
2. During the term of the license, the licensee shall continuously maintain the facility in conformance with the provisions of this chapter and chapter 449 of NRS.
3. If there is a transfer of the real property on which the facility is located, but no change in the operator of the facility, the licensee shall, within 10 days, notify the Health Division of the transfer in writing and provide the Health Division with a copy of any lease agreement relating to the transfer.
4. If there is a change in the administrator of the facility, the licensee shall notify the Health Division of the change within 10 days. The notification must provide evidence that the new administrator is currently licensed pursuant to chapter 654 of NRS and the regulations adopted pursuant thereto. If the licensee fails to notify the Health Division and submit an application for a new license within 10 days after the change, the licensee shall pay to the Health Division a fee in an amount equal to 150 percent of the fee required for a new application set forth in subsection 1 of NAC 449.0168.
5. A licensee shall notify the Health Division immediately of any change in the ownership of, the location of, or the services provided at, the facility.
(Added to NAC by Bd. of Health by R044-97, eff. 10-30-97; A by R122-05, 11-17-2005)
NAC 449.0115 Review of building plans for new construction or remodeling by certain applicants: Required documents; payment of fees and costs. (NRS 439.150, 439.200, 449.037)
1. An applicant for a license or the renewal of a license to operate a medical facility or facility for the dependent who wishes or is required to have building plans for new construction or remodeling reviewed by the Health Division must:
(a) Submit to the Health Division or have on file a current application for a license or renewal of a license;
(b) Pay to the Health Division any fees required for the issuance or renewal of a license pursuant to NAC 449.013 or 449.016; and
(c) Submit two complete sets of building plans for new construction or remodeling prepared by a registered architect, registered residential designer or licensed general contractor to the entity designated to review such plans by the Health Division.
2. All costs incurred for the review of building plans and any changes or revisions made to the plans must be borne by the applicant and paid directly to the designee of the Health Division conducting the review of the plans.
3. The costs required to be paid pursuant to subsection 2 are not refundable and are in addition to the fees charged for the issuance or renewal of the license pursuant to NAC 449.013 or 449.016.
(Added to NAC by Bd. of Health, eff. 11-1-95; A by R035-97, 10-30-97; R129-99, 11-29-99, eff. 1-1-2000; R076-01, 10-18-2001; R067-04, R070-04 & R072-04, 8-4-2004; R076-04, 8-5-2004; R122-05, 11-17-2005; R051-06, 7-14-2006)
NAC 449.01153 Approval of building plans for construction or remodeling of certain facilities: Period of validity. (NRS 449.037) If the Health Division approves building plans for the construction or remodeling of a facility for modified medical detoxification, a facility for skilled nursing, a facility for the care of adults during the day, a facility for the treatment of abuse of alcohol or drugs, a hospital, a mobile unit, a residential facility for groups or a surgical center for ambulatory patients, the approval is valid for 42 months after it is issued, unless there has been:
1. A modification of the building plans;
2. A change in the ownership of the facility; or
3. A change in the intended use of the facility.
(Added to NAC by Bd. of Health by R065-04, eff. 8-4-2004)
NAC 449.01156 On-site advisory inspection of facility: Written request; action by Health Division; fee. (NRS 439.150, 439.200, 449.037)
1. A licensee or an applicant for the issuance or renewal of a license whose building plans for the construction of a facility have been reviewed pursuant to NAC 449.0115 may submit a written request to the Health Division for an on-site advisory inspection to be conducted by the Health Division after at least 80 percent of the construction of the facility is completed. The written request must include, without limitation, the anticipated date on which 80 percent of the construction of the facility will be completed.
2. If the Health Division receives a request submitted pursuant to subsection 1, the Health Division shall determine its ability to grant the request and shall issue a notice of that determination to the licensee or applicant who submitted the request.
3. If the Health Division grants a request submitted pursuant to subsection 1, the licensee or applicant who submitted the request shall, before the Health Division conducts the on-site inspection, submit to the Health Division a fee of:
(a) Five hundred dollars, if the project is valued at not more than $500,000;
(b) One thousand dollars, if the project is valued at more than $500,000 but not more than $1,000,000; or
(c) Two thousand dollars, if the project is valued at more than $1,000,000.
(Added to NAC by Bd. of Health by R065-04, eff. 8-4-2004)
NAC 449.0116 Renewal of license: Application; validity of existing license pending decision on application; inspection of facility; untimely filing or failure to file application. (NRS 439.150, 439.200, 449.037, 449.050, 449.060)
1. Except as otherwise provided in subsection 2, a licensee who wishes to renew his license must submit a complete application for renewal to the Health Division on or before November 15 of the calendar year in which the license expires. The existing license shall be deemed valid until the submitted application for renewal is evaluated and a final determination is made by the Health Division concerning whether to renew the license. The Health Division may require an inspection of the facility to ensure that it meets the requirements of this chapter before deciding whether to renew a license.
2. A licensee who, without good cause, files an application for the renewal of his license after the date set forth in subsection 1 but on or before December 31 of the calendar year in which the license expires and who wishes to renew his license must pay:
(a) The fee required for the renewal of the license pursuant to NAC 449.013 or 449.016, as appropriate; and
(b) An additional charge equal to one-half the amount of the fee required for the renewal of the license pursuant to NAC 449.013 or 449.016, as appropriate.
3. A licensee who fails to file an application for the renewal of his license before the license expires is not eligible to renew the license and, if he wishes to be licensed, must submit an application for a new license.
(Added to NAC by Bd. of Health by R044-97, eff. 10-30-97; A by R065-04, 8-4-2004)
NAC 449.0118 Denial, suspension or revocation of license: Grounds. (NRS 449.037) In addition to the grounds set forth in NRS 449.160 and any other grounds specifically applicable to a particular license, the Health Division may deny an application for a license or may suspend or revoke a license upon any of the following grounds:
1. The failure or refusal of an applicant or licensee to comply with any of the provisions of chapter 449 of NRS or the regulations adopted by the State Board of Health.
2. The failure or refusal of an applicant or licensee to comply with a reasonable order from the Health Division to remove a resident from a facility or program.
3. Operating a facility or program without a license, if a license is required before operating.
4. Accepting for care, at any given time, more residents than the number specified in the license.
5. The failure or refusal of a licensee to return an adequate plan of correction to the Health Division within 10 days after the receipt by the licensee of a statement of deficiencies.
6. The failure or refusal to cooperate fully with an investigation or inspection by the Bureau.
7. Misappropriation of the property of a resident of a facility.
8. Abuse, neglect or exploitation of an infirm, mentally retarded or disabled person, or of a person who is 60 years of age or older.
(Added to NAC by Bd. of Health by R044-97, eff. 10-30-97)
NAC 449.0119 Denial, suspension or revocation of license: Appeals. (NRS 449.037, 449.170) An applicant or licensee who is aggrieved by an action of the Health Division relating to the denial, suspension or revocation of a license may appeal pursuant to the procedures set forth in NAC 439.300 to 439.395, inclusive.
(Added to NAC by Bd. of Health by R044-97, eff. 10-30-97)
FEES
NAC 449.012 Definitions. (NRS 449.037, 449.038) As used in NAC 449.012 to 449.0168, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.0121 to 449.0127, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97; A by R229-97, 4-15-98; R052-02 & R063-02, 7-24-2002; R065-04, 8-4-2004; R051-06 & R095-06, 7-14-2006)
NAC 449.0121 “Ambulatory surgical center” defined. (NRS 449.037) “Ambulatory surgical center” has the meaning ascribed to it in NAC 449.972.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.01215 “Branch office” defined. (NRS 449.037) “Branch office” has the meaning ascribed to it in NAC 449.749.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.01219 “Community triage center” defined. (NRS 449.037) “Community triage center” has the meaning ascribed to it in NRS 449.0031.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.01225 “Facility for hospice care” defined. (NRS 449.037) “Facility for hospice care” has the meaning ascribed to it in NAC 449.0172.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97; A by R123-99, 11-29-99)
NAC 449.01227 “Facility for refractive surgery” defined. (NRS 449.037) “Facility for refractive surgery” has the meaning ascribed to it in NRS 449.00387.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002; A by R042-06, 7-14-2006)
NAC 449.01228 “Facility for transitional living for released offenders” defined. (NRS 449.037) “Facility for transitional living for released offenders” has the meaning ascribed to it in NRS 449.0055.
(Added to NAC by Bd. of Health by R095-06, eff. 7-14-2006)
NAC 449.01229 “Facility for treatment with narcotics” defined. (NRS 449.037, 449.038) “Facility for treatment with narcotics” has the meaning ascribed to it in NAC 449.1542.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98)—(Substituted in revision for NAC 449.0122)
NAC 449.0123 “Home health agency” defined. (NRS 449.037) “Home health agency” has the meaning ascribed to it in NAC 449.749.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.01235 “Home office” defined. (NRS 449.037) “Home office” has the meaning ascribed to it in NAC 449.749.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.0124 “Hospice care” defined. (NRS 449.037) “Hospice care” has the meaning ascribed to it in NAC 449.0175.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.01245 “Intermediate care facility for the mentally retarded or persons with developmental disabilities” defined. (NRS 449.037) “Intermediate care facility for the mentally retarded or persons with developmental disabilities” has the meaning ascribed to it in NAC 449.632.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.0125 “Medication unit” defined. (NRS 449.037, 449.038) “Medication unit” has the meaning ascribed to it in NAC 449.15435.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98)
NAC 449.01252 “Mobile unit” defined. (NRS 449.037) “Mobile unit” has the meaning ascribed to it in NRS 449.01515.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.01255 “Nursing pool” defined. (NRS 449.037) “Nursing pool” has the meaning ascribed to it in NRS 449.0153.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.0126 “Rural clinic” defined. (NRS 449.037) “Rural clinic” has the meaning ascribed to it in NRS 449.0175.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.01265 “Rural hospital” defined. (NRS 449.037) “Rural hospital” has the meaning ascribed to it in NRS 449.0177.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.0127 “Subunit agency” defined. (NRS 449.037) “Subunit agency” has the meaning ascribed to it in NAC 449.749.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97)
NAC 449.013 License and renewal fees to operate ambulatory surgical center, facility for treatment of irreversible renal disease, home office, subunit agency or branch office of home health agency, rural clinic, obstetric center, program of hospice care, independent center for emergency medical care, nursing pool, facility for treatment with narcotics, medication unit, referral agency, halfway house for recovering alcohol and drug abusers, facility for refractive surgery, mobile unit and facility for transitional living for released offenders; expiration of application for license; refund of certain fees. (NRS 439.150, 439.200, 449.0305, 449.037, 449.038, 449.050)
1. Except as otherwise provided in subsection 4 and NAC 449.0168, an applicant for a license to operate any of the following facilities, programs of hospice care or agencies must pay to the Health Division the following nonrefundable fees:
|
(a) An ambulatory surgical center.................................................................... |
$3,570 |
|
(b) A facility for the treatment of irreversible renal disease........................... |
2,748 |
|
(c) A home office or subunit agency of a home health agency....................... |
3,034 |
|
(d) A branch office of a home health agency................................................... |
2,000 |
|
(e) A rural clinic............................................................................................... |
2,160 |
|
(f ) An obstetric center...................................................................................... |
1,564 |
|
(g) A program of hospice care.......................................................................... |
2,106 |
|
(h) An independent center for emergency medical care.................................. |
2,950 |
|
(i) A nursing pool.............................................................................................. |
4,272 |
|
( j) A facility for treatment with narcotics........................................................ |
2,482 |
|
(k) A medication unit........................................................................................ |
1,200 |
|
(l) A referral agency......................................................................................... |
2,000 |
|
(m) A halfway house for recovering alcohol and drug abusers....................... |
2,020 |
|
(n) A facility for refractive surgery.................................................................. |
7,556 |
|
(o) A mobile unit.............................................................................................. |
2,090 |
|
( p) A facility for transitional living for released offenders............................. |
2,020 |
2. Except as otherwise provided in subsection 4, an applicant for the renewal of such a license must pay to the Health Division the following nonrefundable fees:
|
(a) An ambulatory surgical center..................................................................... |
$1,785 |
|
(b) A facility for the treatment of irreversible renal disease............................ |
1,374 |
|
(c) A home office or subunit agency of a home health agency........................ |
1,517 |
|
(d) A branch office of a home health agency.................................................... |
1,000 |
|
(e) A rural clinic................................................................................................ |
1,080 |
|
(f ) An obstetric center....................................................................................... |
782 |
|
(g) A program of hospice care........................................................................... |
1,053 |
|
(h) An independent center for emergency medical care................................... |
1,475 |
|
(i) A nursing pool.............................................................................................. |
2,136 |
|
( j) A facility for treatment with narcotics........................................................ |
1,241 |
|
(k) A medication unit........................................................................................ |
600 |
|
(l) A referral agency.......................................................................................... |
1,000 |
|
(m) A halfway house for recovering alcohol and drug abusers........................ |
1,010 |
|
(n) A facility for refractive surgery.................................................................. |
3,912 |
|
(o) A mobile unit............................................................................................... |
1,045 |
|
( p) A facility for transitional living for released offenders............................. |
1,010 |
3. An application for a license is valid for 1 year after the date on which the application is submitted. If an applicant does not meet the requirements for licensure imposed by chapter 449 of NRS or the regulations adopted pursuant thereto within 1 year after the date on which he submits his application, he must submit a new application and pay the required fee to be considered for licensure.
4. Pursuant to NRS 449.050, if an application for a license to operate a facility for transitional living for released offenders or the renewal of such a license is denied, any amount of a fee paid pursuant to paragraph ( p) of subsection 1 or paragraph ( p) of subsection 2 that exceeds the expenses and costs incurred by the Health Division must be refunded to the applicant.
[Bd. of Health, Health Facility Fees Art. 1, eff. 1-20-77]—(NAC A 7-22-87; 1-31-90; 9-1-93; 11-1-95; 10-3-96; R035-97 & R044-97, 10-30-97; R229-97, 4-15-98; R105-98, 9-23-98; R132-99, 11-29-99; R123-01, 12-17-2001, eff. 1-1-2002; R052-02 & R063-02, 7-24-2002; R050-02, 10-22-2002; R074-03, 10-22-2003; R065-04, 8-4-2004; R042-06 & R095-06, 7-14-2006)
NAC 449.016 License and renewal fees to operate skilled nursing facility, hospital, rural hospital, intermediate care facilities, residential facility for groups, facility for treatment of abuse of alcohol or drugs, facility for hospice care, home for individual residential care, facility for modified medical detoxification and community triage center; expiration of application for license. (NRS 439.150, 439.200, 449.037, 449.050, 449.249)
1. Except as otherwise provided in NAC 449.0168, an applicant for a license to operate any of the following facilities must pay to the Health Division the following nonrefundable fees:
|
|
Fee per facility |
Fee per bed in the facility |
|
|
|
|
|
(a) A skilled nursing facility........................................................... |
$2,200 |
$60 |
|
(b) A hospital, other than a rural hospital...................................... |
10,000 |
60 |
|
(c) A rural hospital.......................................................................... |
1,500 |
60 |
|
(d) An intermediate care facility for the mentally retarded or persons with developmental disabilities............................................. |
1,564 |
184 |
|
(e) An intermediate care facility, other than an intermediate care facility for the mentally retarded or persons with developmental disabilities............................................................................................ |
1,200 |
90 |
|
(f ) Except as otherwise provided in subsection 3, a residential facility for groups................................................................................ |
2,400 |
184 |
|
(g) A facility for the treatment of abuse of alcohol or drugs......... |
782 |
184 |
|
(h) A facility for hospice care......................................................... |
1,564 |
184 |
|
(i) A home for individual residential care...................................... |
1,764 |
184 |
|
( j) A facility for modified medical detoxification......................... |
782 |
184 |
|
(k) A community triage center....................................................... |
782 |
184 |
2. An applicant for the renewal of such a license must pay to the Health Division the following nonrefundable fees:
|
|
Fee per facility |
Fee per bed in the facility |
||
|
|
|
|
||
|
(a) A skilled nursing facility........................................................... |
$1,100 |
$30 |
|
|
|
(b) A hospital, other than a rural hospital...................................... |
5,000 |
30 |
|
|
|
(c) A rural hospital.......................................................................... |
750 |
30 |
|
|
|
(d) An intermediate care facility for the mentally retarded or persons with developmental disabilities............................................. |
782 |
92 |
|
|
|
(e) An intermediate care facility, other than an intermediate care facility for the mentally retarded or persons with developmental disabilities............................................................................................ |
600 |
40 |
|
|
|
(f ) Except as otherwise provided in subsection 4, a residential facility for groups which has 11 beds or more.................................... |
1,182 |
92 |
|
|
|
(g) Except as otherwise provided in subsection 5, a residential facility for groups which has less than 11 beds.................................. |
$1,085 |
$92 |
|
|
|
(h) A facility for the treatment of abuse of alcohol or drugs......... |
391 |
92 |
|
|
|
(i) A facility for hospice care......................................................... |
782 |
92 |
|
|
|
( j) A home for individual residential care...................................... |
500 |
92 |
|
|
|
(k) A facility for modified medical detoxification........................ |
391 |
92 |
|
|
|
(1) A community triage center....................................................... |
391 |
92 |
|
|
3. An applicant for a license for a residential facility for groups shall pay a fee of $100 for each bed in the facility which is paid entirely with money from:
(a) The Supplemental Security Income Program as defined in NRS 422.053;
(b) The home and community-based services program pursuant to 42 U.S.C. § 1396n; or
(c) A program for group care of adults established by a county.
4. An applicant for the renewal of a license for a residential facility for groups shall pay a fee of $35 for each bed in the facility which is paid entirely with money from:
(a) The Supplemental Security Income Program as defined in NRS 422.053;
(b) The home and community-based services program pursuant to 42 U.S.C. § 1396n; or
(c) A program for group care of adults established by a county.
5. An applicant for the renewal of a license for a residential facility for groups which has less than 11 beds who attests that, during the following licensure period, at least 75 percent of those beds will be paid for entirely with money from the sources described in subsection 4 shall pay a fee of $500 plus:
(a) For each bed that will be paid for entirely with money from the sources described in subsection 4, a fee of $35 in accordance with that subsection; and
(b) For each remaining bed, a fee of $92.
6. An application for a license is valid for 1 year after the date on which the application is submitted. If an applicant does not meet the requirements for licensure imposed by chapter 449 of NRS or the regulations adopted pursuant thereto within 1 year after the date on which he submits his application, he must submit a new application and pay the required fee to be considered for licensure.
[Bd. of Health, Health Facility Fees Art. 2, eff. 1-20-77]—(NAC A 7-22-87; 8-31-89; 9-1-93; 11-1-95; R035-97 & R044-97, 10-30-97; R105-98, 9-23-98; R123-99 & R131-99, 11-29-99; R129-99, 11-29-99, eff. 1-1-2000; R110-01, 11-21-2001; R050-02, 10-22-2002; R074-03, 10-22-2003; R065-04, 8-4-2004; R051-06, 7-14-2006)
NAC 449.0164 Fees for renewal of licenses for certain facilities: Payment in two equal installments. (NRS 439.150, 439.200, 449.037, 449.050, 449.249) An applicant for the renewal of a license for a residential facility for groups, a halfway house for recovering alcohol and drug abusers, a home for individual residential care or a facility for transitional living for released offenders may pay the fee required for the renewal of his license in two equal installments if:
1. On or before November 1 of the calendar year in which his license expires, he submits a complete application for the renewal of the license which includes, without limitation:
(a) The first installment payment which is equal to one-half the amount of the fee required for the renewal of the license pursuant to NAC 449.013 or 449.016, as appropriate;
(b) An additional fee of $100 for the administrative costs of billing and collecting such payments; and
(c) A signed payment agreement and a confession of judgment for the total amount of the second installment payment which may be filed with a court of competent jurisdiction if he fails to make the second installment payment in accordance with the agreement;
2. On or before April 15 of the calendar year for which the license is renewed, he submits the second installment payment for the remainder of the fee required for the renewal of the license pursuant to NAC 449.013 or 449.016, as appropriate; and
3. He has not failed to make a payment in accordance with any other similar agreement.
(Added to NAC by Bd. of Health by R065-04, eff. 8-4-2004; A by R095-06, 7-14-2006)
NAC 449.0168 Fees for modification of certain licenses. (NRS 449.0305, 449.037, 449.050)
1. Except as otherwise provided in subsection 2, a holder of a license to operate a medical facility, facility for the dependent, program of hospice care or referral agency who wishes or is required pursuant to NAC 449.190, 449.307, 449.7473 or 449.758 to modify his license to reflect:
(a) A change in the name of the facility, program or agency;
(b) A change of the administrator of the facility, program or agency;
(c) A change in the number of beds in the facility;
(d) A change in the type of facility licensed or the addition of another type of facility to be licensed;
(e) A change in the category of residents who may reside at the facility;
(f ) A change in the designation of a staging area for a mobile unit or, if the mobile unit is operated by an independent facility, a change in the address of the independent facility; or
(g) A change in any of the services provided by an agency to provide nursing in the home,
Ê must submit an application for a new license to the Health Division and pay to the Health Division a fee of $250.
2. An applicant who applies for a license pursuant to paragraph (c) of subsection 1 because of an increase in the number of beds in the facility must pay to the Health Division:
(a) A fee of $250; and
(b) A fee for each additional bed as follows:
|
(1) If the facility is an intermediate care facility for the mentally retarded or persons with developmental disabilities........................................................................ |
$184 |
|
(2) Except as otherwise provided in subparagraph (3), if the facility is a residential facility for groups......................................................................................... |
184 |
|
(3) If the facility is a residential facility for groups and the fee for each bed in the facility is paid entirely with money from sources described in subsection 3 of NAC 449.016................................................................................................................... |
100 |
|
(4) If the facility is a facility for the treatment of abuse of alcohol or drugs...... |
184 |
|
(5) If the facility is a facility for hospice care...................................................... |
184 |
|
(6) If the facility is a home for individual residential care.................................. |
184 |
|
(7) If the facility is a facility for modified medical detoxification..................... |
184 |
|
(8) If the facility is a hospital............................................................................... |
80 |
|
(9) If the facility is a rural hospital....................................................................... |
80 |
|
(10) If the facility is a skilled nursing facility..................................................... |
60 |
|
(11) If the facility is an intermediate care facility, other than an intermediate care facility for the mentally retarded or persons with developmental disabilities...... |
90 |
3. If the address of the home office of a home health agency has not changed, a holder of a license to operate a subunit agency or branch office of the home health agency who wishes or is required pursuant to NAC 449.758 to modify his license to reflect a change in the address of the subunit agency or branch office of the home health agency must:
(a) Submit an application for a new license to the Health Division; and
(b) Pay to the Health Division a fee of $250.
4. A fee paid pursuant to this section is nonrefundable.
5. As used in this section:
(a) “Administrator” means the person who is responsible for the daily management of a medical facility, facility for the dependent or program of hospice care.
(b) “Independent facility” has the meaning ascribed to it in NAC 449.9701.
(c) “Staging area” has the meaning ascribed to it in NAC 449.97018.
(Added to NAC by Bd. of Health by R035-97, eff. 10-30-97; A by R053-99, 9-27-99; R132-99, 11-29-99; R110-01, 11-21-2001; R063-02, 7-24-2002; R050-02, 10-22-2002; R074-03, 10-22-2003; R123-05, 11-17-2005)
PROVISION OF HOSPICE CARE
General Provisions
NAC 449.017 Definitions. (NRS 449.037) As used in NAC 449.017 to 449.0188, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.0171 to 449.0178, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health, eff. 7-20-90; A by R041-06, 7-14-2006)
NAC 449.0171 “Bereavement services” defined. (NRS 449.037) “Bereavement services” means social and emotional support offered to the family of a patient in a program of hospice care for at least 1 year following the death of the patient.
(Added to NAC by Bd. of Health, eff. 7-20-90)
NAC 449.0172 “Facility for hospice care” defined. (NRS 449.037) “Facility for hospice care” has the meaning ascribed to it in NRS 449.0033.
(Added to NAC by Bd. of Health, eff. 7-20-90; A by R123-99, 11-29-99)
NAC 449.0173 “Governing body” defined. (NRS 449.037) “Governing body” means the person or group of persons responsible for carrying out and monitoring the administration of a program of hospice care or for the operation of a facility for hospice care.
(Added to NAC by Bd. of Health, eff. 7-20-90; A by R123-99, 11-29-99)
NAC 449.0175 “Hospice care” defined. (NRS 449.037) “Hospice care” has the meaning ascribed to it in NRS 449.0115.
(Added to NAC by Bd. of Health, eff. 7-20-90)
NAC 449.0176 “Medical director” defined. (NRS 449.037) “Medical director” means the physician who is responsible for acting as a medical resource to an interdisciplinary team which provides hospice care.
(Added to NAC by Bd. of Health, eff. 7-20-90)
NAC 449.01765 “Palliative services” defined. (NRS 449.037) “Palliative services” has the meaning ascribed to it in NRS 449.0156.
(Added to NAC by Bd. of Health by R041-06, eff. 7-14-2006)
NAC 449.0177 “Patient” defined. (NRS 449.037) “Patient” means a person who is terminally ill and who is receiving hospice care.
(Added to NAC by Bd. of Health, eff. 7-20-90)
NAC 449.0178 “Terminally ill” defined. (NRS 449.037) “Terminally ill” has the meaning ascribed to it in NRS 449.0195.
(Added to NAC by Bd. of Health, eff. 7-20-90; A by R041-06, 7-14-2006)
Licensing
NAC 449.0181 Compliance with regulations required for license to operate facility for hospice care. (NRS 449.037) The Health Division shall not issue a license to operate a facility for hospice care unless the program of hospice care which it provides complies with the requirements of NAC 449.017 to 449.0188, inclusive.
(Added to NAC by Bd. of Health, eff. 7-20-90; A by R123-99, 11-29-99)
NAC 449.0183 Report of change in ownership, address or staff of program of hospice care. (NRS 449.037) An applicant for a license to administer a program of hospice care or a person licensed to administer such a program shall immediately advise the Health Division of any change in:
1. The ownership of the program;
2. The address of the principal office of the program; or
3. The membership of the staff which prevents the program from providing adequate hospice care to each patient.
(Added to NAC by Bd. of Health, eff. 7-20-90)
Administration
NAC 449.0184 Governing body required; duties of governing body and administrator. (NRS 449.037) Every facility which provides a program of hospice care must have a governing body which shall:
1. Appoint an administrator of the program of hospice care. The administrator shall be available on a daily basis for consultation with members of the interdisciplinary team of the program of hospice care.
2. Ensure that all services provided by the program of hospice care are consistent with accepted standards of practice for the care of the patients.
(Added to NAC by Bd. of Health, eff. 7-20-90)
Medical Services
NAC 449.0185 Requirements for program of hospice care. (NRS 449.037) A program of hospice care must comply with the following requirements:
1. A qualified person must be available when required to evaluate the dietary patterns of each patient and plan diets to meet the individual nutritional needs of each patient.
2. Each patient must be advised regarding the availability of pastoral care.
3. Bereavement services must be available to each member of a patient’s family after the patient dies to provide appropriate counseling.
4. Nursing care must be provided by a registered nurse or under the supervision of a registered nurse.
5. A social worker must provide social services to each patient in the program under the direction of the interdisciplinary team.
6. The services of:
(a) A physical therapist;
(b) An occupational therapist; and
(c) A speech and language pathologist,
Ê must be provided when such services are prescribed for a patient by his physician.
7. Home health aide and homemaker services must be available to each patient and provided at intervals which meet the needs of each patient. A registered nurse must:
(a) Supervise the persons providing such services; and
(b) Prepare written instructions for the persons providing such services which identify the duties they are to perform.
8. Arrangements must be made to provide any medical supplies and appliances which are required by a patient, including any drug or biological needed for palliative services.
(Added to NAC by Bd. of Health, eff. 7-20-90; A by R041-06, 7-14-2006)
NAC 449.0186 Requirements for plan of care. (NRS 449.037)
1. The medical director of a program of hospice care shall cause a written plan of care to be established for each patient in the program. Any person who furnishes care for the patient shall adhere to the plan.
2. A plan of care must:
(a) Be established by the physician of the patient or by the medical director of the program of hospice care, and the interdisciplinary team which provides the hospice care;
(b) Include an assessment of the needs of the patient and identify the services required by the patient, which must include the management of discomfort and relief of symptoms of the patient;
(c) State the scope and frequency of each service to be provided to the patient and members of his family; and
(d) Be reviewed and updated at intervals that are specified in the plan by the person who established the plan. The review must be documented in writing.
(Added to NAC by Bd. of Health, eff. 7-20-90)
NAC 449.0187 Requirements for operation of facility for hospice care. (NRS 449.037) A facility for hospice care must comply with the following requirements:
1. A program of hospice care must be provided for each inpatient pursuant to a written plan of care established pursuant to NAC 449.0186.
2. Nursing services must be provided 24 hours per day in accordance with the plan of care for each patient.
3. Medication must be dispensed to each patient according to the instructions of the patient’s physician or the medical director.
4. Treatment must be administered to a patient pursuant to the instructions of the physician of the patient or the plan of care for the patient.
5. Each patient must be maintained in a clean and well-groomed manner.
6. Each patient must be protected from accidents, injuries and infections.
7. At least one registered nurse must be on duty for each work shift, providing direct care to patients.
8. A written plan of the procedures to be followed during a local disaster, a widespread disaster or a disaster which occurs within the facility for hospice care must be adopted. The plan must:
(a) Provide procedures designed to protect each patient and to care for any casualty which may arise from such a disaster;
(b) Be reviewed and the procedures set forth therein rehearsed by all members of the staff at least once in each quarter of the year; and
(c) Be approved by the Health Division.
9. A private room with an adjoining bath must be provided for each patient.
10. An anteroom, a room adjoining the room of each patient or a private area must be provided and furnished with a bed and chairs for use by the members of the patient’s family.
(Added to NAC by Bd. of Health, eff. 7-20-90; A by R123-99, 11-29-99)
NAC 449.0188 Continuity of service to patients required. (NRS 449.037) A person licensed to administer a program of hospice care or to operate a facility for hospice care shall maintain the continuity of service provided to each patient pursuant to NAC 449.017 to 449.0188, inclusive, during the term of his license.
(Added to NAC by Bd. of Health, eff. 7-20-90; A by R044-97, 10-30-97; R123-99, 11-29-99)
FACILITIES FOR TREATMENT OF ABUSE OF ALCOHOL OR DRUGS
General Provisions
NAC 449.019 Definitions. (NRS 449.037) As used in NAC 449.019 to 449.153, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.022 to 449.072, inclusive, have the meanings ascribed to them in those sections.
(Supplied in codification; A by Bd. of Health by R077-01, 10-18-2001)
NAC 449.022 “Administrator” defined. (NRS 449.037) “Administrator” means the person who is appointed by the governing body of a facility who has primary responsibility for the operations of the overall program of the facility.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.4, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)
NAC 449.025 “Alcohol and drug abuse treatment” defined. (NRS 449.037) “Alcohol and drug abuse treatment” means a program concerned with substance abuse treatment directed towards achieving the mental and physical restoration of alcohol and drug abusers.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.9, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)
NAC 449.030 “Case management services” defined. (NRS 449.037) “Case management services” means a multistep process by which clients may receive assistance in accessing services, including, without limitation, services concerning health, mental health, education, vocation, employment, legal issues, child care, housing and aftercare for recovery from alcohol and drug abuse.
(Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001)
NAC 449.031 “Client” defined. (NRS 449.037) “Client” means a resident or patient of a facility.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.8, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)
NAC 449.034 “Detoxification” defined. (NRS 449.037) “Detoxification” means the process of eliminating the toxic effects of alcohol and drugs from the body.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.1.3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001)
NAC 449.043 “Facility” defined. (NRS 449.037) “Facility” means a facility for the treatment of abuse of alcohol or drugs as defined in NRS 449.00455.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.1, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001)
NAC 449.044 “Facility for modified medical detoxification” defined. (NRS 449.037) “Facility for modified medical detoxification” has the meaning ascribed to it in NRS 449.00385.
(Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001)
NAC 449.046 “Governing body” defined. (NRS 449.037) “Governing body” means a body that has the ultimate authority for the administration of the overall program at a facility pursuant to NAC 449.085.
(Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001)
NAC 449.060 “Medically managed intensive detoxification program” defined. (NRS 449.037) “Medically managed intensive detoxification program” means a program which provides 24-hour medical monitoring of treatment and detoxification services in a licensed hospital pursuant to NAC 449.279 to 449.394, inclusive, and which has life support systems in place.
(Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001)
NAC 449.064 “Overall program” defined. (NRS 449.037) “Overall program” means all aspects of alcohol and drug abuse treatment, including general fiscal management, fund-raising projects and the general long-term goals of a facility which are defined in writing.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.10, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)
NAC 449.068 “Qualified social worker” defined. (NRS 449.037) “Qualified social worker” means a person who is licensed by the Board of Examiners for Social Workers to practice as a social worker.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.11, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)—(Substituted in revision for NAC 449.073)
NAC 449.069 “Residential program” defined. (NRS 449.037) “Residential program” means a treatment program for alcohol and drug abuse which takes place in a 24-hour residential setting and which encompasses organized services staffed by designated addiction treatment personnel who provide a planned regimen of client care.
(Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001)
NAC 449.072 “Social model detoxification program” defined. (NRS 449.037) “Social model detoxification program” means a treatment program that concentrates on providing psychosocial services and nonmedical detoxification.
(Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001)
Licensing
NAC 449.079 Denial, revocation or suspension of license if facility not certified by Health Division; appeal. (NRS 449.037)
1. If a facility is not certified by the Health Division pursuant to subsection 4 of NRS 458.025, the Health Division shall deny an application for a license or suspend or revoke the license of the facility.
2. An applicant or licensee who wishes to appeal an action of the Health Division relating to the denial, suspension or revocation of a license may appeal the action pursuant to the procedures set forth in NAC 439.300 to 439.395, inclusive.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 2 §§ 2.7-2.12, eff. 3-27-76; A and renumbered as §§ 2.7-2.11, 12-27-77]—(NAC A by R035-97 & R044-97, 10-30-97; R077-01, 10-18-2001)
NAC 449.081 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of licensing. (NRS 449.037)
1. Building plans for new construction or remodeling must be submitted to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115. Before the construction or remodeling may begin, the plans for the construction or remodeling must be approved by the Health Division.
2. The Health Division shall not approve the licensing of a facility until all construction has been completed and a survey is conducted at the site.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 16, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R076-01 & R077-01, 10-18-2001; R073-04, 8-4-2004)
Administration and Personnel
NAC 449.085 Governing body; bylaws. (NRS 449.037)
1. Every facility must have a governing body which has the ultimate authority for the administration of the overall program.
2. The governing body shall adopt written bylaws and policies that define the powers and duties of the governing body, its committees, the administrator and any advisory group.
3. The bylaws and policies must:
(a) Identify the overall goals.
(b) Include an organizational chart.
(c) Define the major lines of authority and areas of responsibility within the treatment program.
(d) Define the membership of the governing body, the types of membership, the method of selection or appointment of members, offices or committees and their terms of office.
(e) Define the frequency of meetings of the governing body and attendance requirements.
4. The duties of the governing body include, but are not limited to, the following items:
(a) Appointment of a qualified administrator with authority and responsibilities appropriate to the requirements of the program;
(b) Adoption, review and revision of the governing body’s bylaws and policies;
(c) Adoption of controls designed to achieve and maintain maximum standards of service; and
(d) Review and approval of an annual budget to carry out the objectives of the program.
5. New facilities must show sufficient resources to operate for 120 days.
6. The governing body shall retain the ultimate responsibility for the overall program and its objectives.
7. The governing body shall meet at least semiannually. Minutes must be kept of the meetings, including the date of the meeting, those in attendance, topics discussed, decisions made and actions taken, target dates for the implementation of recommendations and all program reports.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R044-97, 10-30-97; R077-01, 10-18-2001)
NAC 449.088 Policies and procedures. (NRS 449.037)
1. A facility must have written policies and procedures available to members of the staff, clients and the public which govern the operation of the facility and services provided by the facility.
2. The policies must:
(a) Ensure that only those persons are accepted as clients whose needs can be met by the facility directly or in cooperation with community resources or other providers of treatment with which it is affiliated.
(b) Ensure that a client whose physical or mental condition has changed to such an extent that he can no longer be adequately served by the facility will be transferred promptly to an appropriate facility.
(c) Set forth the rights of clients and members of the staff and provide for the registration and disposition of complaints without threat of discharge or reprisal against any employee or client.
(d) Ensure that the admission agreement between the administrator and the client does not permit the administrator or his designee a power of attorney.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001)
NAC 449.091 Transfer of client to another facility. (NRS 449.037)
1. Except in the case of an emergency, the transfer of a client to another facility must not be effected until the client, attending physician, if any, and responsible agency are notified in advance.
2. If a client is transferred to another facility, information required for appropriate continuation of care must be released to the receiving facility in compliance with the standards set forth in 42 C.F.R. Part 2, which are hereby adopted by reference. A copy of the standards may be obtained from the Health Division, free of charge, upon request.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001)
NAC 449.094 Money of clients. (NRS 449.037)
1. If a facility handles a client’s money, a written ledger account of all deposits, disbursements or other transactions must be maintained. A record must be made available to the client at least quarterly.
2. A client’s money must be given to him within 24 hours of his exit from the facility.
3. Large sums of money must be maintained in a financial institution in the community where the facility is located in a separate trustee account apart from the facility’s operational accounts and must be clearly designated.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001)
NAC 449.098 Preparations for disasters; reporting of fire or disaster. (NRS 449.037)
1. Each facility shall develop a written plan for disasters which outlines procedures for members of the staff and clients to follow in case of fire or another emergency and which provides for meeting the needs of clients if the facility must be evacuated or is destroyed.
2. A simple floor plan showing the routes for evacuating must be posted in prominent locations on each floor of each facility.
3. Each facility shall conduct a disaster drill at least annually, and a written record of each drill must be retained in the facility for not less than 12 months after the drill is conducted.
4. The facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001; R073-04, 8-4-2004)
NAC 449.102 Inventory and return of client’s belongings. (NRS 449.037) If a facility holds or stores a client’s belongings, there must be an inventory of the belongings on admission, made a part of the client’s record, and updated as needed. These belongings must be returned to the client upon his exit.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001)
NAC 449.105 Insurance. (NRS 449.037) Liability insurance in a sufficient amount to protect clients, members of the staff, volunteers, and visitors, must be maintained. A certificate of insurance must be furnished to the Health Division. The certificate must include provision for 30 days notice to the Division of cancellation or the nonrenewal of the policies.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]
NAC 449.108 General requirements for programs. (NRS 449.037)
1. A residential program must be certified by the Health Division pursuant to NAC 458.108 and must comply with any applicable regulations adopted pursuant to subsection 4 of NRS 458.025.
2. At the time of admission into a residential program, there must be documentation indicating that the client has been informed of:
(a) The general nature and goal of the program;
(b) The rules governing client conduct and the infractions that can lead to disciplinary action or discharge from the program;
(c) The treatment costs, if any, to be borne by the client;
(d) The client’s rights and responsibilities; and
(e) Confidentiality laws, rules and regulations.
3. The program must be periodically evaluated to ensure compliance with any applicable regulations adopted pursuant to subsection 4 of NRS 458.025.
4. The facility must provide access to medical, dental, psychological and rehabilitative services to meet the needs of all its clients, to the extent possible, with assistance from available community resources.
5. If a facility provides services through outside sources, written arrangements must be made ensuring that the services are supplied directly by, or under the supervision of, qualified persons.
6. The facility must provide case management services as needed by the client either directly or by written agreement with a qualified social worker, a registered nurse or a counselor certified or licensed by the Board of Examiners for Alcohol, Drug and Gambling Counselors.
7. A plan for case management services must be recorded in the client’s record and must be periodically evaluated in conjunction with the client’s treatment plan.
8. Each facility shall review the program at least annually. Areas reviewed must include, but need not be limited to, appropriateness of admissions, lengths of stay, discharge planning, use of services, and utilization of the components of the program and outside services. Written reports of the reviews must be evaluated by the governing body, administrator and such committees as they designate. Documentation of the evaluation process must be maintained at the facility.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 4, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001; R073-04, 8-4-2004; R098-06, 7-14-2006)
NAC 449.111 Administrator: Duties. (NRS 449.037)
1. The administrator is responsible to the governing body for the operation of the facility in accordance with established policy.
2. The administrator shall:
(a) Organize the administrative functions of the program, delegate duties and establish a formal means of accountability on the part of subordinates.
(b) Ensure that a written manual defining program policies and procedures is prepared, regularly revised and updated. The manual must:
(1) Contain all of the required written policies, procedures, definitions, lists and other documentation required by NAC 449.019 to 449.153, inclusive.
(2) Be available to members of the staff at all times at designated and convenient locations.
(c) Appoint a person of majority age to act for him during any absence.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 5, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)
NAC 449.114 Employees: General requirements. (NRS 449.037)
1. A facility must have on duty, all hours of each day, members of the staff sufficient in number and qualifications to carry out policies, responsibilities and program continuity.
2. Each member of the counseling staff must be:
(a) A registered intern;
(b) Certified or licensed by the Board of Examiners for Alcohol, Drug and Gambling Counselors; or
(c) A licensed mental health professional who has experience with alcohol and drug abuse counseling.
3. The administrator or his appointee must be present and responsible for the operations of the facility during normal hours.
4. A facility must have written policies and procedures for the recruitment, selection, promotion and termination of members of the staff.
5. The facility must have written policies and procedures covering wages and salaries, working hours, employee benefits, vacation and sick leave, rules of conduct, and training and the development of the staff.
6. The facility must provide an orientation session to new employees. Documentation of the sessions must be maintained in the employee’s personnel record.
7. There must be written policies and procedures governing disciplinary actions which clearly define the mechanism for suspension or dismissal of members of the staff as well as the procedures for appeal.
8. Written job descriptions must be maintained for all positions. A description must include:
(a) The title of the job;
(b) The tasks and responsibilities of the job;
(c) The skills, education and experience necessary for the job;
(d) The relationship of the job to other jobs within the program; and
(e) The working conditions, location, shift, materials and equipment to be used on the job.
Ê The job description must accurately reflect the actual job situation and must be reviewed annually or whenever a change in the job or qualifications occurs. Job descriptions must be available on request to all members of the staff.
9. A personnel record must be maintained for each employee. The record must contain:
(a) The employment application;
(b) Letters of recommendation;
(c) Reference investigation records;
(d) Verification of training, experience and, if applicable, certification;
(e) Documentation of attendance at the orientation session for new employees;
(f ) Job performance evaluations;
(g) Incident reports; and
(h) Disciplinary actions taken.
10. Personnel records must be maintained in a secure manner and must be available only to those persons authorized in written policies and procedures. An employee must have access to his own records upon request.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 6, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001; R098-06, 7-14-2006)
NAC 449.117 Employees: Proof of compliance with provisions concerning tuberculosis. (NRS 449.037) All persons employed in a facility must have documentation showing that they are in compliance with any applicable provisions of chapter 441A of NAC concerning tuberculosis.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 12, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)
Social Model Detoxification Programs
NAC 449.121 Certain facilities authorized to offer program. (NRS 449.037) A social model detoxification program may be offered to clients in:
1. Residential programs that offer detoxification services;
2. A licensed facility for modified medical detoxification pursuant to NAC 449.15311 to 449.15369, inclusive; or
3. A medically managed intensive detoxification program.
(Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001)
NAC 449.1214 General requirements. (NRS 449.037)
1. A facility that offers a social model detoxification program:
(a) Must have a physician, nurse practitioner, registered nurse or physician assistant conduct a physical assessment and a review of the general medical and drug history of a client within 24 hours after the client is admitted to the facility to ensure that a social model detoxification program is appropriate for the client.
(b) Must not provide detoxification services for clients who exhibit life-threatening symptoms of withdrawal from alcohol and drug abuse.
(c) Must develop and implement policies and procedures that protect the safety and health of clients. The facility must have these policies and procedures reviewed annually by a licensed physician who is familiar with the symptoms of withdrawal from alcohol and drug abuse.
(d) Must ensure that the observation of a client during his treatment in the social model detoxification program is reflected in the records of the client as deemed necessary by the policies and procedures of that facility.
2. The staff of a facility that offers a social model detoxification program must complete at least 6 hours of additional education in the detoxification of alcohol and drug abusers, as approved by the program of ongoing quality improvement pursuant to NAC 449.1218, every 2 years. Such education must include instruction in:
(a) Acute withdrawal symptoms from alcohol and drug abuse; and
(b) First-aid procedures for clients with seizures.
(Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001)
NAC 449.1218 Program of ongoing quality improvement. (NRS 449.037)
1. A social model detoxification program must have a program of ongoing quality improvement designed to:
(a) Monitor and evaluate, objectively and systematically, the quality and appropriateness of client care;
(b) Pursue opportunities to improve client care; and
(c) Resolve identified problems.
2. The program of ongoing quality improvement must:
(a) Establish written policies and procedures to describe and document the monitoring and evaluation activities of the program of ongoing quality improvement.
(b) Include the participation of a medical professional who is not required to be a member of the staff. For the purposes of this paragraph, “medical professional” means a licensed physician, nurse practitioner, physician assistant or registered nurse who is familiar with clients suffering from acute withdrawal symptoms from alcohol and drug abuse.
(c) In addition to the participation of a medical professional pursuant to paragraph (b), include the participation of the administrator and two staff members of the social model detoxification program.
(d) Approve the 6 hours of additional education required pursuant to NAC 449.1214 to ensure that the additional education is appropriate.
3. The findings of the program of ongoing quality improvement, including any conclusions, recommendations, actions taken and the results of the actions taken, must be documented. All documentation must be reported to the governing body and must be reflected in the minutes annually.
(Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001)
Operation of Facility
NAC 449.123 General sanitary requirements. (NRS 449.037)
1. Each facility must meet all state and local environmental health standards.
2. A facility which provides dietary services must have food service equipment of appropriate quality and type for the type of food service program used by the facility. The equipment must comply with all applicable provisions in chapter 446 of NAC.
3. All environmental health inspection reports must be on file in the facility. Any deficiencies must be corrected within 90 days and documented in the file.
4. Premises and equipment must be maintained in a sanitary condition:
(a) The facility must have the necessary cleaning and maintenance equipment with sufficient storage areas and appropriate procedures to maintain a clean and orderly establishment.
(b) Janitorial supplies, including aerosols, must be stored in areas separate from clean linen, food and other supplies.
(c) The storage of dirty linen must be separate from the storage of clean linen, food and other supplies.
5. The facility shall establish a policy that prohibits clients from sharing items for personal use, such as combs, toothbrushes, towels or bar soap.
6. Restrooms or lavatories for the staff must be provided with soap dispensers and individual disposable towels.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 11, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)
NAC 449.126 Laundry requirements. (NRS 449.037)
1. A facility must maintain:
(a) A laundry with equipment which is adequate for the sanitary washing and finishing of linen and other washable goods; or
(b) A written agreement with a commercial establishment to provide laundry services for the facility.
2. The laundry must be situated in an area which is separate from any area where food is stored, prepared or served. The laundry must be well-lighted, ventilated, adequate in size to house the equipment and maintained in a sanitary manner. The equipment must be kept in good repair.
3. Soiled linen must be collected and transported to the laundry in washable or disposable covered containers in a sanitary manner.
4. Clean linen to be dried, ironed, folded, transferred or distributed must be handled in a sanitary manner, specified in writing.
5. Closets for storing linen and laundry supplies must be provided and must not be used for any other purpose.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 11, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R077-01, 10-18-2001)
NAC 449.129 Design, construction, equipment and maintenance. (NRS 449.037)
1. A facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the clients and personnel of the facility and members of the general public.
2. Each facility must comply with all currently adopted life safety, fire, Health Division, local building and zoning codes. If there is a difference between state and local codes, the more stringent standards apply.
3. Facilities housing 17 or more clients must meet the requirements of the chapter entitled “New Hotels and Dormitories,” of the edition of NFPA 101: Life Safety Code, adopted by reference pursuant to NAC 449.0105. Those facilities housing not more than 16 clients must meet the requirements of the chapter entitled “Lodging or Rooming Houses,” of the edition of NFPA 101: Life Safety Code, adopted by reference pursuant to NAC 449.0105.
4. A facility is deemed to be in compliance with the provisions of this section if:
(a) The facility is licensed by May 30, 2001, and:
(1) The use of the physical space in the facility is not changed; and
(2) There are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the health and welfare of the public; or
(b) Before May 30, 2001, the facility has submitted building plans to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115 and:
(1) The Health Division determines that the plans comply with standards for construction in effect before May 30, 2001;
(2) Construction of the facility is begun before February 1, 2002;
(3) The facility is constructed in accordance with those standards; and
(4) There are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the health and welfare of the public.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 13, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R077-01, 10-18-2001; R073-04, 8-4-2004; R098-06, 7-14-2006)
NAC 449.132 Accommodations for clients. (NRS 449.037)
1. No room or space in a facility may be occupied for sleeping, living or dining which is accessible only by a ladder, by folding stairs or through a trapdoor.
2. If a basement is used for living and dining, at least one exit must be provided directly to the outside at ground level. No facility may:
(a) Be situated more than one story below the ground.
(b) Use any basement or space in a basement for sleeping.
3. Each room of a facility used by clients for sleeping must:
(a) Be furnished with a bed, clean linen and blankets; and
(b) Not be less than 50 square feet per bed.
4. Toilet and bathing facilities must be provided to clients in a manner that ensures their privacy during use and in an adequate number to meet the needs of the clients.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 13, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R077-01, 10-18-2001)
NAC 449.135 Safety from fire. (NRS 449.037)
1. Portable fire extinguishers must be installed throughout each facility at the direction of the fire authority having jurisdiction. Each portable fire extinguisher available at a facility must be inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections.
2. Any facility with a kitchen range with an upper surface of more than 15 square feet must provide the range with an exhaust hood having an automatic fire protection system in accordance with the chapter titled “Standards for Ventilation Control and Fire Protection of Commercial Cooking Operations,” of the edition of NFPA 101: Life Safety Code, adopted by reference pursuant to NAC 449.0105.
3. A portable room-heating device may be used at a facility if the device:
(a) Is located at least 2 feet from any combustible material;
(b) Is plugged directly into a wall socket;
(c) Turns off automatically if it is tipped over; and
(d) Has no exposed heating elements.
4. Receptacles or outlets serviced by extension cords are prohibited.
5. Rooms in which smoking is allowed by direction of the facility or the fire authority must be provided with plainly visible “Smoking Area” signs.
6. A facility must conduct fire drills at least monthly and a written record of each drill conducted must be retained in the facility for not less than 12 months after the drill is conducted.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 13, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R077-01, 10-18-2001; R073-04, 8-4-2004)
NAC 449.141 Health services. (NRS 449.037)
1. Facilities must provide access to health services which ensure that each client receives treatment, prescribed medication, adequate diets and other health services consistent with the program administered by the facility.
2. Facilities must implement policies and procedures designed to ensure the early detection of complications or conditions considered to be common among drug abusers. These policies and procedures must be developed in conjunction with and approved by a licensed physician.
3. Before a client’s admission to a program or facility, a general medical and drug history must be taken by a designated member of the staff who is certified or licensed by the Board of Examiners for Alcohol, Drug and Gambling Counselors or who is a licensed mental health professional who has experience with alcohol and drug abuse counseling. Current medical information must be provided on a form that has been approved by a physician. The history must include, but is not limited to:
(a) Drugs used in the past;
(b) Drugs used recently;
(c) Drugs of preference;
(d) Frequently used drugs;
(e) Drugs used in combination;
(f ) Dosages used;
(g) Date of first usage;
(h) Incidents of overdose, withdrawal or adverse drug reactions; and
(i) Previous history of treatment.
4. A program may accept medical history and physical examination results from referral sources which were conducted not more than 30 days before admission in lieu of personally taking a general medical and drug history as required pursuant to subsection 3.
5. Each facility must be able to provide directly, or through written arrangements, laboratory tests as requested by a physician or federal regulations.
6. Facilities must implement written policies and procedures that are reviewed by a licensed physician defining the appropriate action to be taken when a medical emergency arises.
7. There must be one staff person in the facility who is capable of providing cardiopulmonary resuscitation at all times. Staff members providing cardiopulmonary resuscitation must be qualified by the American Red Cross or another recognized agency.
8. Clients of residential programs must undergo a tuberculin skin test that meets the requirements specified in chapter 441A of NAC.
9. Each facility shall maintain and have readily available first-aid supplies. Staff members shall have evidence that they have received training on the use of first-aid supplies.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 7, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001; R098-06, 7-14-2006)
NAC 449.144 Medication. (NRS 449.037)
1. In programs that permit the self-administration of medication, there must be written policies and procedures governing this activity. The policies must require that:
(a) The decisions to permit self-administration be based on individual needs.
(b) The reasons for the permission be clearly documented in the client’s case record.
(c) All medications that are to be self-administered be packaged in a manner complying with the Poison Prevention Packaging Act of 1970, 15 U.S.C. §§ 1471 et seq., and all current regulations stemming from that act.
(d) The self-administration of prescription medication be observed by a staff member who has been oriented to the program’s policies and procedures on self-administration of prescription medication.
(e) The self-administration of prescription medication be permitted only when the medication is clearly labeled.
(f ) There be documentation in the client’s record of the name of the medication, dose, route of administration, time and name of the person observing the self-administration or the licensed staff member who administered the medication.
(g) Clients who receive medication for self-administration be given instructions concerning the safe storage and usage of the drugs and the appropriate emergency procedures to be followed if adverse reactions occur.
2. Any unusual reaction to a medication by a client must be documented in the client’s record and reported to the appropriate physician as outlined in the policies of the facility.
3. Facilities must provide a locked storage area for prescription medication that is to be self-administered by clients. Such medication must be made available to clients at appropriate times and may be dispensed only from a licensed pharmacy in accordance with all applicable provisions of NRS and NAC.
4. Members of the staff may not administer any medication unless licensed to do so.
5. All medication must be maintained in locked storage. Controlled substances must be maintained in a locked box within the locked storage. Medications requiring refrigeration must be kept in a locked box inside the refrigerator separated from food and other items. Disinfectants and medication for external use must be stored separately from medications for internal use and from medications that can be injected. All potent, poisonous or caustic drugs must be plainly labeled, stored and made accessible only to authorized persons. All medication storage must be maintained in accordance with the security requirements of federal, state and local laws.
6. Narcotic treatment facilities may issue methadone “takeouts” to a client in a facility without listing the strength of the drug if the label shows:
(a) The client’s name or other identifying code; and
(b) The 24-hour emergency telephone number for the narcotic treatment facility.
7. Medication prescribed for a client must not be allowed to be in the possession of another client.
8. Any unused prescription medication left behind at a facility by a client must be destroyed by the administrator or his designee in the presence of a witness, and a notation indicating that the medication was destroyed must be made on the client’s record. At the time a client is discharged or leaves the facility, medications that are currently being self-administered must be sent, in the original container, with the client or a responsible agent of the client.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 9, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)
NAC 449.147 Dietary services. (NRS 449.037)
1. Facilities must serve at least three meals or their equivalent daily, at regular times, with not more than 14 hours between a substantial evening meal and breakfast. A second serving must be provided for those clients who desire one.
2. Menus must be planned and followed to meet the nutritional needs of the clients in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences.
3. Therapeutic menus must be planned by a registered dietitian or must be reviewed and approved by the client’s attending or staff physician.
4. Menus must be in writing, planned in advance, dated and posted, and kept on file for 90 days. Any substitution must be noted on the written menus so that the menu on file reflects what was actually served.
5. Adequate facilities and equipment for the preparation, serving, refrigeration and storage of food in a sanitary manner must be provided.
6. A facility with more than 10 clients must:
(a) Comply with all applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto;
(b) Obtain the necessary permits from the Bureau of Health Protection Services of the Health Division;
(c) Maintain a report of each inspection concerning the sanitation of the facility for at least 1 year after the date of the inspection; and
(d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action.
7. Clients needing special equipment, implements or utensils to assist them while eating must have such items provided.
8. If a facility operates on the cottage plan, provision must be made for food service that assures hot, palatable meals.
9. A qualified person must be used as a consultant on planning meals and serving food. Consultation each month is required. A qualified person may be a person meeting the requirements for registration with the Commission on Dietetic Registration as either a registered dietitian or a registered dietetic technician.
10. All facilities that contract with food management companies must comply with the applicable regulations of the Health Division as provided in chapter 446 of NAC.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 8, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001; R073-04, 8-4-2004)
NAC 449.150 Records of clients. (NRS 449.037)
1. Each facility must maintain an organized system for clients’ records.
2. Clients’ records must be available to members of the staff who have authority to review such records.
3. Clients’ records must be available to representatives of the Health Division.
4. Clients’ records must contain:
(a) Identification information;
(b) Past medical and social history;
(c) Copies of initial and periodic examinations;
(d) Evaluations and progress notes; and
(e) A review and any revisions of each plan of treatment.
5. There must be an overall plan of treatment stated in quantifiable terms which outlines goals to be accomplished through individually designed activities, therapies and treatments.
6. The plan of treatment must state what service or person is responsible for treatment or services to the client.
7. Entries must be made describing treatments and services rendered, medications administered, including those that are self-administered, and any symptoms or other indications of illness or injury, including the date, time and action taken regarding each incident.
8. Records must be adequately safeguarded against destruction, loss or unauthorized use.
9. Records must be retained for at least 5 years following a client’s discharge.
10. A discharge plan, as determined by a case management services assessment of the client, must be documented for each client discharged from the facility. The discharge plan must be formulated upon a client’s admission to the facility.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 10, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)
NAC 449.153 Discrimination prohibited. (NRS 449.037)
1. No facility may deny treatment to a prospective client on the grounds of race, color, age, disability or national origin.
2. No resident may be segregated, given separate treatment, restricted in the employment of any advantage or privilege enjoyed by others under the program or provided with any aid, treatment, services or other benefits which are different or provided in a different manner from that provided to others under the program, on the grounds of race, color, age, disability or national origin.
[Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 15, eff. 3-27-76]—(NAC A 8-1-91; R077-01, 10-18-2001)
FACILITIES FOR MODIFIED MEDICAL DETOXIFICATION
NAC 449.15311 Definitions. (NRS 449.037) As used in NAC 449.15311 to 449.15369, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.15313 to 449.15321, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15313 “Administrator” defined. (NRS 449.037) “Administrator” means the person who is appointed by the governing body of a facility who has primary responsibility for the overall operations of the program of the facility.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15315 “Client” defined. (NRS 449.037) “Client” means a resident or patient of a facility.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15317 “Facility” defined. (NRS 449.037) “Facility” means a facility for modified medical detoxification as defined in NRS 449.00385.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15319 “Overall program” defined. (NRS 449.037) “Overall program” means tasks that are commonly undertaken by a board of directors, including, without limitation, general fiscal management, fund-raising projects and establishing the general long-term goals of a facility.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15321 “Program” defined. (NRS 449.037) “Program” means the program established pursuant to NAC 449.15337.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15323 Proof of certification required; revocation of license. (NRS 449.037)
1. As a condition of the issuance of a license to a facility, the facility shall provide proof that it is certified by the Health Division.
2. If the Health Division revokes or does not renew the certification of a facility, the Health Division shall revoke the license of the facility subject to the appeals procedure set forth in NAC 439.300 to 439.395, inclusive.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15325 Governing body; bylaws and policies. (NRS 449.037)
1. Each facility shall have a governing body that has the ultimate authority for the administration of the overall program of the facility.
2. The governing body shall adopt written bylaws and policies that define the powers and duties of the governing body, its committees, the administrator and any advisory group.
3. The bylaws and policies must:
(a) Identify the overall goals of the facility;
(b) Include, without limitation, an organizational chart of the facility;
(c) Define the major lines of authority and areas of responsibility within the program of treatment provided by the facility;
(d) Define the membership of the governing body, the types of membership, the method of selection or appointment of members, offices or committees and their terms of office; and
(e) Define the frequency of meetings of the governing body and attendance requirements.
4. The governing body shall:
(a) Appoint a qualified administrator of the facility with authority and responsibilities appropriate to the requirements of the program;
(b) Establish policies governing the responsibilities, authority and duties of the administrator that are designed to enable the administrator to perform the administrative and treatment functions of the facility;
(c) Appoint a medical director of the facility who is responsible for the medical services provided at the facility;
(d) Determine, in accordance with state law, which categories of practitioners are eligible to be appointed to the medical staff of the facility;
(e) Appoint members to the medical staff of the facility who are accountable to the governing body for the quality of medical care provided to clients of the facility, taking into consideration any recommendations of the existing members of the medical staff;
(f ) Review and revise the bylaws and policies of the governing body;
(g) Adopt controls designed to achieve and maintain maximum standards of service; and
(h) Review and approve an annual budget to carry out the objectives of the program.
5. The governing body shall retain the ultimate responsibility for the overall program and its objectives.
6. The governing body shall meet at least semiannually. Minutes must be kept of the meetings, including, without limitation, the date of each meeting, those in attendance, topics discussed, decisions made and actions taken, and all program reports.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15327 Policies and procedures for services and operation of facility. (NRS 449.037)
1. Each facility shall have written policies and procedures available to members of the staff, clients and the public that govern the operation of the facility and services provided by the facility.
2. The policies must:
(a) Ensure that only those persons are accepted as clients whose needs can be met by the facility directly or in cooperation with community resources or other providers of treatment with which it is affiliated or has contacts.
(b) Ensure that a client whose physical or mental condition has changed to such an extent that he can no longer be adequately served by the facility will be transferred promptly to an appropriate facility. Written transfer agreements or other written provisions with such other facilities must be maintained by the facility.
(c) Set forth the rights of clients and members of the staff and provide for the registration and disposition of complaints without threat of discharge or reprisal against any employee or client.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15329 Transfer of client. (NRS 449.037)
1. Except in the case of an emergency, the transfer of a client must not be effected until the client, attending physician of the client, if any, and responsible agency are consulted in advance.
2. Except as otherwise provided in subsection 3, if a client is transferred to a hospital or other medical facility, a summary of discharge containing a plan for continuation of care must be prepared and forwarded to the receiving facility if the client or his guardian consents to release such information to the receiving facility.
3. If a client is transferred to a hospital or other medical facility as a result of a medical emergency, information required for appropriate continuation of care must be released to the receiving facility in compliance with the standards set forth in 42 C.F.R. Part 2.
4. The admission agreement must not allow the licensee or his designee to be given power of attorney.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15331 Handling of money of client. (NRS 449.037)
1. If a facility handles the money of a client, a written ledger account of all deposits, disbursements or other transactions must be maintained. A record must be made available to the client at least quarterly.
2. The money of a client must be given to him within 24 hours after his exit from the facility.
3. Large sums of money must be maintained in a financial institution in the community where the facility is located in a separate trustee account apart from the operational accounts of the facility and must be clearly designated.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15333 Inventory of belongings of client. (NRS 449.037) If a facility holds or stores the belongings of a client, there must be an inventory of the belongings on admission, made a part of the record of the client and updated as needed. These belongings must be returned to the client upon his exit.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15335 Liability insurance. (NRS 449.037) Liability insurance in a sufficient amount to protect clients, members of the staff, volunteers and visitors, must be maintained by each facility. A certificate of insurance must be furnished to the Health Division. The certificate must include, without limitation, provision for 30 days’ notice to the Health Division of cancellation or the nonrenewal of a policy of insurance.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15337 Program: Requirements; review. (NRS 449.037)
1. Each facility shall have a written program outlining short-term and long-term objectives and goals. These goals must be realistic, attainable, and clearly and operationally defined.
2. Each component of the program must develop objectives that complement the goals of the program.
3. The Health Division shall:
(a) Periodically evaluate the program;
(b) Prepare a report of the evaluation; and
(c) Distribute the report to the persons who manage the program and make the report available to the members of the staff of the facility and the Bureau of Licensure and Certification of the Health Division.
4. The facility shall provide for the medical, dental and psychological services needed to fulfill the goals of the program and meet the needs of all its clients to the extent that is possible, with assistance from available community resources.
5. If a facility provides services through outside sources, formal, written arrangements must be made ensuring that the services are supplied directly by, or under the supervision of, qualified persons.
6. Each facility shall provide case management services as needed by a client through a social worker or a registered nurse or by written agreement with a social worker or a registered nurse.
7. A plan for case management must be recorded in the records of a client and must be periodically evaluated in conjunction with the treatment plan of the client.
8. Each facility shall review its general program at least annually. Areas reviewed must include, without limitation, appropriateness of admissions, lengths of stay, discharge planning, use of services and utilization of the components of the program and outside services. Written reports of the reviews must be evaluated by the governing body, administrator and such committees as they designate. Documentation of the evaluation process must be maintained at the facility.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15339 Responsibilities and duties of administrator. (NRS 449.037)
1. The administrator of a facility is responsible to the governing body of the facility for the operation of the facility in accordance with the policies and procedures of the facility.
2. The administrator shall:
(a) Organize the administrative functions of the program, delegate duties and establish a formal means of accountability on the part of subordinates.
(b) Ensure that a written manual defining the policies and procedures of the program is prepared, regularly revised and updated. The manual must:
(1) Contain all policies and procedures of the facility, including, without limitation, definitions and other documentation required by NAC 449.15311 to 449.15369; and
(2) Be available to members of the staff of the facility at all times at designated and convenient locations.
(c) Appoint a person who has attained the age of majority to act for him during any extended absence.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15341 Policies and procedures concerning employees. (NRS 449.037)
1. Each facility shall have on duty, all hours of each day, members of the staff sufficient in number and qualifications to carry out policies, responsibilities and program continuity.
2. All members of the counseling staff of a facility shall be authorized by state law to provide alcohol and drug counseling.
3. The administrator or his appointee shall be present and responsible for the operations of the facility during normal hours.
4. Each facility shall have written policies and procedures for the recruitment, selection, promotion and termination of members of the staff.
5. Each facility shall have written policies and procedures concerning wages and salaries, working hours, employee benefits, vacation and sick leave, rules of conduct, and training and development of the staff.
6. Each facility shall provide an orientation session to new employees. Documentation of the session must be maintained in the personnel file of the employee.
7. Each facility shall have written policies and procedures governing disciplinary actions that clearly define the mechanism for the suspension or dismissal of members of the staff as well as the procedures for appeal.
8. Each facility shall maintain a written job description for each position at the facility. The job description must accurately reflect the actual job situation and must be reviewed annually or whenever a change in the responsibilities of the job or qualifications occurs. Job descriptions must be available on request to all members of the staff. A job description must include, without limitation:
(a) The title of the job;
(b) The tasks and responsibilities of the job;
(c) The skills, education and experience necessary for the job;
(d) The relationship of the job to other jobs within the program; and
(e) The working conditions, location and shift of the job, and the materials and equipment to be used on the job.
9. Each facility shall maintain a personnel record for each employee of the facility. The record must include, without limitation:
(a) The employment application;
(b) Letters of recommendation;
(c) Records from any investigation of the employee;
(d) Verification of training, experience and certification;
(e) Job performance evaluations;
(f ) Incident reports; and
(g) Disciplinary actions taken.
10. Each facility shall maintain personnel records in a secure manner and make them available only to those persons authorized to receive personnel records in the written policies and procedures of the facility. An employee must have access to his own file upon request.
11. Each person employed in a facility shall have a preemployment physical examination or certification of a 3-year health record from a physician, and be tested for tuberculosis as required in chapter 441A of NAC.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15343 Nursing services. (NRS 449.037)
1. Each facility shall have an organized plan for nursing service that provides nursing services 24 hours per day. The nursing services must be provided or supervised by a registered nurse in compliance with state law, including, without limitation, chapter 632 of NRS and chapter 632 of NAC.
2. The nursing service shall have a sufficient number of registered nurses, licensed practical nurses and other personnel to provide nursing care to all clients as needed.
3. The facility shall ensure that the nursing staff develops and keeps current a plan for nursing care for each client.
4. The administrator shall appoint a chief administrative nurse to direct the nursing service. The chief administrative nurse must:
(a) Be a registered nurse;
(b) Be knowledgeable, skilled and competent in clinical practice and the management of nurses;
(c) Be authorized by state law to provide alcohol and drug counseling; and
(d) Comply with the provisions of chapter 632 of NRS and chapter 632 of NAC and follow professional standards established for organized nursing services.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15345 Health services. (NRS 449.037)
1. Each facility shall provide health services which ensure that each client receives treatment, prescribed medication, adequate diets and other health services consistent with the program administered by the facility.
2. There must be policies and procedures designed to ensure the early detection of complications or conditions considered to be common among alcohol and drug abusers. The policies and procedures must be developed with assistance from and approved by the medical director of the facility.
3. Before a client is admitted to a facility, a general medical and drug history of the client must be taken by a physician or designated member of the nursing staff of the facility. The history must include, without limitation:
(a) Drugs used in the past;
(b) Drugs used recently;
(c) Drugs of preference;
(d) Frequently used drugs;
(e) Drugs used in combination;
(f ) Dosages used;
(g) Date of first usage;
(h) Incidents of overdose, withdrawal or adverse drugs reactions; and
(i) Previous history of treatment.
4. Except as otherwise provided in this subsection, a physical examination and review of the medical and drug history of a client must be conducted by a physician, registered nurse or physician assistant within 48 hours after the client is admitted to a facility. If the assessment performed by a physician or a member of the nursing staff before a client is admitted to the facility concludes that a physical examination of the client should be completed within less than 48 hours after the client is admitted to the facility to ensure that the needs of the client are met, the physical examination must be conducted within the time recommended in the assessment.
5. Each facility must be able to provide directly, or through written arrangements, laboratory tests as requested by a physician or federal regulations.
6. Referral to an outside health resource must be made only if the resource is able to accept the client. Any records that accompany the client must be either expurgated of any sensitive material or be available only to persons authorized to receive the information under the direction of the physician or administrator. Except where an emergency that threatens a life exists and except as otherwise provided in NAC 449.15329, no information may be released without the prior consent of the client or his guardian.
7. Each facility shall have written policies and procedures defining the appropriate action to be taken when a medical emergency arises. The policies and procedures must be reviewed and approved by the medical director of the facility.
8. Each member of the staff of a facility must be qualified by the American Red Cross or another similar nationally recognized agency to administer cardiopulmonary resuscitation.
9. Each client of a facility shall, within 5 days after admission, undergo a Mantoux tuberculin skin test. If the client has no documented history of a two-step Mantoux tuberculin skin test and has not had a single Mantoux tuberculin skin test within the 12 months preceding admission to the facility, the client shall undergo a two-step Mantoux tuberculin skin test.
10. First-aid supplies must be maintained and readily available at each facility.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15347 Pharmaceutical services. (NRS 449.037)
1. Each facility shall have a pharmacy directed by a registered pharmacist or a drug room supervised by no less than a currently licensed professional nurse. The pharmacy or drug room must be administered in accordance with all applicable state and federal laws. The facility shall have a full-time, part-time or consulting pharmacist who is responsible for developing, supervising and coordinating all of the activities of the pharmacy service.
2. Each facility shall have and implement policies and procedures that minimize errors in the administration of drugs. The medical director of the facility and the pharmacist who is responsible for the pharmacy service shall approve the policies and procedures.
3. Drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice and state and federal laws.
4. When a pharmacist is not available at the facility, drugs and biologicals may be removed from the pharmacy or drug area only by a member of the staff who is authorized to remove such substances by the policies and procedures of the facility, which must be established in accordance with state and federal laws.
5. Errors in administering a drug, adverse reactions by a client to a drug and incompatibilities between a drug and a client must be immediately reported to the attending physician of the client.
6. Abuses and losses of controlled substances must be reported to the pharmacist who is responsible for the pharmacy service, the administrator and the chief administrative nurse of the facility, in accordance with all applicable state and federal laws.
7. Information relating to drug interactions and information on drug therapy, side effects, toxicology, dosage indications for use and routes of administration must be available to the professional members of the staff of the facility.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15349 Medication and biologicals. (NRS 449.037)
1. Except as otherwise provided in subsection 2, an order for medication or biologicals for a client must be in writing and signed by the practitioner, or other appropriate professional person authorized by state or federal law to order the medication or biological, who is responsible for the care of the patient.
2. When a telephone or verbal order is used to order medications or biologicals, the order must be:
(a) Accepted only by a person who is authorized by the policies and procedures of the facility, which must be consistent with state law, to accept such an order; and
(b) Signed or initialed by the prescribing practitioner in accordance with the policies and procedures of the facility.
3. Each order for a medication or biological must include, without limitation, the name of the medication or biological, and the dosage, time or frequency of administration and route of administration of the medication or biological.
4. Only a member of the staff of the facility who is authorized by state law to administer medication or biologicals may administer medication or biologicals at the facility.
5. Each facility shall have a system to monitor and improve the process of administering medication and biologicals.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15351 Dietary services. (NRS 449.037)
1. Facilities shall serve at least three meals or their equivalent daily, at regular times, with not more than 14 hours between a substantial evening meal and breakfast. A second serving must be provided for those clients who desire one.
2. Menus must be planned and followed to meet the nutritional needs of the clients in accordance with the recommended dietary allowances recommended by the Food and Nutrition Board of the National Research Council, National Academy of Sciences.
3. Therapeutic menus must be planned by a registered dietitian or must be reviewed and approved by the attending physician of the client or a staff physician.
4. Menus must be in writing, planned in advance, dated and posted, and kept on file at the facility for at least 90 days. Any substitution must be noted on the written menu so that the menu on file reflects what was actually served.
5. Adequate facilities and equipment for the preparation, serving, refrigeration and storage of food in a sanitary manner must be provided.
6. A facility with more than 10 clients shall:
(a) Comply with all applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto;
(b) Obtain the necessary permits from the Bureau of Health Protection Services of the Health Division;
(c) Maintain a report of each inspection concerning the sanitation of the facility for at least 1 year after the date of the inspection; and
(d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action.
7. Clients needing special equipment, implements or utensils to assist them while eating must have such items provided.
8. If a facility operates on the cottage plan, provision must be made for food service that ensures hot, palatable meals.
9. A professional, qualified person must be used as a consultant on planning meals and serving food. At least 4 hours of consultation each month is required. A person is qualified only if he meets the requirements for registration with the Commission on Dietetic Registration as a dietitian or dietetic technician.
10. A facility that contracts with a food management company shall comply with all applicable regulations of the State Board of Health.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004)
NAC 449.15353 Records of clients. (NRS 449.037)
1. Each facility shall maintain an organized system for the records of clients.
2. The records of a client must be available to professional members of the staff of the facility who are directly involved with the client.
3. The records of clients must be available to representatives of the Health Division.
4. The records of clients must include, without limitation:
(a) Identification information;
(b) Past medical and social history;
(c) Copies of initial and periodic examinations;
(d) Evaluations and progress notes; and
(e) Assessments and goals of the plan of treatment of each client.
5. The plan of treatment must state what service or person is responsible for providing treatment or services to the client.
6. Entries must be made describing treatments and services rendered, medications administered, and any symptoms or other indications of illness or injury, including, without limitation, the date, time and action taken regarding each incident.
7. Records must be adequately safeguarded against destruction, loss or unauthorized use.
8. Records must be retained for at least 5 years after the discharge of a client from a facility.
9. A discharge plan, as determined by a case management assessment of the client, must be documented for each client discharged from the facility.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15355 Safety and sanitation; temperature. (NRS 449.037)
1. The premises and equipment of each facility must be maintained in a safe, functional and sanitary condition. Each facility shall have the necessary cleaning and maintenance equipment with sufficient storage areas and appropriate procedures to maintain a clean and orderly establishment. Janitorial supplies, including, without limitation, aerosols, must be stored in areas separate from clean linen, food and other supplies. The storage of dirty linen must be separate from the storage of clean linen, food and other supplies.
2. Items for personal use, including, without limitation, combs, toothbrushes, towels and bar soap, must not be shared by clients.
3. Restrooms or lavatories for the staff of a facility must be provided with soap dispensers and individual, disposable towels.
4. Each facility shall ensure that the environment of the facility is free of hazards that may cause accidents.
5. Each facility shall maintain an effective program to control pests and rodents in order to ensure that the facility is free from pests and rodents.
6. Each facility shall provide safe and comfortable levels of temperature in the facility. The temperature of the facility must be maintained at a level that is not less than 71 degrees Fahrenheit and not more than 81 degrees Fahrenheit.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004)
NAC 449.15357 Laundry requirements. (NRS 449.037)
1. Each facility shall have the proper equipment for the sanitary washing and finishing of linen and other washable goods or shall maintain a written agreement with a commercial establishment to provide laundry services.
2. The laundry area of a facility must be situated in an area of the facility that is separate and apart from any room where food is stored, prepared or served. The laundry area must be well-lighted, ventilated, adequate in size to house equipment, maintained in a sanitary manner and kept in good repair.
3. Soiled linen must be collected and transported to the laundry in washable or disposable containers in a sanitary manner. Soiled linen must not be transported through areas of the facility used for preparing or serving food.
4. Clean linen to be dried, ironed, folded, transferred or distributed must be handled in a sanitary manner in accordance with a written plan maintained by the facility.
5. Closets for storing linen and laundry supplies must be provided and must not be used for any other purpose.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15359 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of facility for licensure. (NRS 449.037)
1. Except as otherwise provided in subsection 4, before any new construction of a facility or any remodeling of an existing facility is begun:
(a) The facility must submit a copy of the building plans for the new construction or remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115. The entity’s review of those plans is advisory only and does not constitute approval for licensure of the facility.
(b) The building plans must be approved by the Health Division.
2. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility.
3. The Health Division shall not issue a license to operate a facility until the Bureau has approved the construction of the facility.
4. The provisions of subsection 1 do not apply to plans for remodeling a facility if the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting in the area, replacing flooring in the area, repairing windows in the area or replacing window and wall coverings in the area.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R076-01, 10-18-2001; R069-04, 8-4-2004)
NAC 449.15361 Design, construction, equipment and maintenance. (NRS 449.037)
1. Each facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the clients and personnel of the facility and members of the general public.
2. Each facility shall comply with all applicable:
(a) Federal and state laws;
(b) Local ordinances, including, without limitation, zoning ordinances; and
(c) Environmental, life safety, fire, health and local building codes,
Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply.
3. Each facility shall comply with the provisions of NFPA 101: Life Safety Code, as adopted by reference pursuant to NAC 449.0105. Facilities housing 17 or more clients shall meet the requirements of the chapter entitled “Hotel and Dormitories,” of the edition of NFPA 101: Life Safety Code adopted by reference pursuant to NAC 449.0105. Those facilities housing not more than 16 clients shall meet the requirements of the chapter entitled “Lodging or Rooming Houses,” of the edition of NFPA 101: Life Safety Code adopted by reference pursuant to NAC 449.0105.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004)
NAC 449.15363 Accommodations for clients. (NRS 449.037)
1. No room or space of a facility may be occupied for sleeping, living or dining that is accessible only by a ladder, by folding stairs or through a trapdoor.
2. If a basement of a facility is used for living and dining, at least one exit must be provided directly to the outside at ground level. No facility may:
(a) Be situated more than one story below the ground; and
(b) Use any basement or space in a basement for sleeping.
3. Each room of a facility used by clients for sleeping must:
(a) Be provided and furnished with a bed, clean linen and blankets;
(b) Not be less than 60 square feet per bed; and
(c) Not be used for sleeping by more than four clients.
4. Toilet facilities and bathing facilities must be provided to clients in a manner that ensures their privacy while bathing and in an adequate number to meet the needs of the clients.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
NAC 449.15365 Safety from fire. (NRS 449.037)
1. Devices for the detection of combustion other than heat detectors must be installed on the ceiling of each story of a facility, in front of doors to stairways in a facility, and at not more than 30 feet apart in the corridors of all floors of a facility, including, without limitation, the center. Smoke detectors must also be installed in the center of any lounge or recreational area of a facility. The smoke detectors may be single station units with an integral alarm.
2. Portable fire extinguishers must be installed throughout each facility at the direction of the fire authority having jurisdiction. Each portable fire extinguisher available at a facility must be inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections.
3. A portable room-heating device may be used if the device:
(a) Is located 2 feet or more from any combustible material;
(b) Is plugged directly into a wall socket;
(c) Turns off automatically if tipped over; and
(d) Has no exposed heating elements.
4. Receptacles or outlets serviced by extension cords are prohibited in facilities.
5. Rooms in which smoking is allowed by direction of the facility or the fire authority must be provided with plainly visible “Smoking Area” signs.
6. Each facility shall conduct fire drills at least monthly, and a written record of each drill conducted must be retained in the facility for not less than 12 months after the drill is conducted.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004)
NAC 449.15367 Preparations for disasters; reporting of fire or disaster. (NRS 449.037)
1. Each facility shall develop a written plan for disasters that outlines procedures for members of the staff and clients to follow in case of fire or another emergency and provides for meeting the needs of clients if the facility must be evacuated or is destroyed.
2. A simple floor plan showing the routes for evacuating must be posted in prominent locations on each floor of the facility.
3. The facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster.
4. Each facility shall conduct a disaster drill at least annually and retain a written record of the drill in the facility for not less than 12 months after the drill is conducted.
5. Each facility shall adopt procedures to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004)
NAC 449.15369 Discrimination prohibited. (NRS 449.037)
1. No facility that accepts a person for treatment for whom all or part of the payment for treatment is made from the money of the Division of Welfare and Supportive Services or any other agency funded in whole or in part by federal money may deny treatment to a prospective client on the grounds of race, color, national origin, age, gender or disability.
2. No client may be segregated, given separate treatment, restricted in the employment of any advantage or privilege enjoyed by others under the program or provided with any aid, treatment, services or other benefits which are different or provided in a different manner from that provided to others under the program on the grounds of race, color, national origin, age, gender or disability.
3. Employment practices of a facility, including, without limitation, hiring, firing, the rate of remuneration, assignments or work hours, may not be based on race, color, national origin, age, gender or disability.
(Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000)
FACILITIES FOR TREATMENT WITH NARCOTICS; MEDICATION UNITS
General Provisions
NAC 449.154 Definitions. (NRS 449.037, 449.038) As used in NAC 449.154 to 449.15485, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.15415 to 449.15438, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002)
NAC 449.15415 “DEA” defined. (NRS 449.037, 449.038) “DEA” means the Drug Enforcement Administration of the United States Department of Justice.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98)
NAC 449.1542 “Facility for treatment with narcotics” defined. (NRS 449.037, 449.038) “Facility for treatment with narcotics” means any person or any public or private facility that provides a narcotic treatment program described in 42 C.F.R. Part 8.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002)
NAC 449.1543 “Medical director” defined. (NRS 449.037, 449.038) “Medical director” means a physician who is licensed to practice medicine in this State and who is responsible for the administration of all medical services at a facility for treatment with narcotics or a medication unit and for ensuring that the facility or the medication unit complies with all applicable federal, state and local laws and regulations.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98)
NAC 449.15435 “Medication unit” defined. (NRS 449.037, 449.038) “Medication unit” means any person or any public or private facility that:
1. Is established as part of or operates in conjunction with a facility for treatment with narcotics but is separated geographically from the facility for treatment with narcotics; and
2. Is limited to:
(a) Administering or dispensing narcotics; and
(b) Collecting specimens in accordance with chapter 652 of NRS for drug testing or analysis relating to treatment with narcotics.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98)
NAC 449.15438 “SAMHSA” defined. (NRS 449.037, 449.038) “SAMHSA” means the Substance Abuse and Mental Health Services Administration of the United States Department of Health and Human Services.
(Added to NAC by Bd. of Health by R053-02, eff. 7-24-2002)
NAC 449.1544 Health Division is state authority for certain federal regulations. (NRS 449.037, 449.038) The Health Division is the state authority for the purposes of 42 C.F.R. Part 8.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002)
Licensing
NAC 449.15445 License and federal certification required to operate facility or unit. (NRS 449.037, 449.038)
1. A person or a public or private facility shall not operate or provide the services of a facility for treatment with narcotics or represent that it operates or provides the services of a facility for treatment with narcotics, unless the person or the public or private facility is:
(a) Licensed by the Health Division pursuant to NAC 449.154 to 449.15485, inclusive, to operate the facility for treatment with narcotics; and
(b) Certified by the SAMHSA pursuant to 42 C.F.R. Part 8 to operate the facility for treatment with narcotics.
2. A person or a public or private facility shall not operate or provide the services of a medication unit or represent that it operates or provides the services of a medication unit, unless the person or the public or private facility is:
(a) Licensed by the Health Division pursuant to NAC 449.154 to 449.15485, inclusive, to operate the medication unit and the facility for treatment with narcotics that is associated with the medication unit; and
(b) Certified by the SAMHSA pursuant to 42 C.F.R. Part 8 to operate the medication unit and the facility for treatment with narcotics that is associated with the medication unit.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002)
NAC 449.1545 Filing requirements; recommendation for certification. (NRS 449.037, 449.038)
1. If a person or a public or private facility wants to operate a facility for treatment with narcotics or a medication unit, the person or the public or private facility must:
(a) File with the SAMHSA an application for certification pursuant to 42 C.F.R. Part 8;
(b) File with the Bureau an application for a license pursuant to NAC 449.011 and include with the application:
(1) If there is an accreditation body that has been approved pursuant to 42 C.F.R. § 8.3, proof that the applicant has applied for accreditation from such accreditation body; and
(2) Any other information requested by the Bureau; and
(c) Demonstrate that the proposed facility for treatment with narcotics or the proposed medication unit is able to comply with the requirements set forth in NAC 449.1548.
2. A person or a public or private facility must file an application for a license for each facility for treatment with narcotics that it wants to operate, whether or not the person or the public or private facility is already licensed to operate one or more other facilities for treatment with narcotics.
3. A person or a public or private facility must file an application for a license for each medication unit that it wants to operate, whether or not the person or the public or private facility is already licensed to operate one or more other medication units.
4. The Health Division may make a recommendation to the SAMHSA that an applicant for certification of a facility for treatment with narcotics or a medication unit be certified, if the applicant has:
(a) Satisfied all the requirements for licensure by the Health Division pursuant to NAC 449.154 to 449.15485, inclusive;
(b) Submitted all items required pursuant to NAC 449.011; and
(c) Provided satisfactory evidence to the Health Division that the facility is in substantial compliance with the requirements of 42 C.F.R. Part 8.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002)
NAC 449.15455 Investigation and prelicensure survey. (NRS 449.037, 449.038)
1. If an application for a license is filed pursuant to NAC 449.1545, the Bureau shall conduct pursuant to NAC 449.0112:
(a) An investigation; and
(b) A prelicensure survey.
2. The investigation and any prelicensure survey conducted by the Bureau must include, but are not limited to, an evaluation of whether the proposed facility for treatment with narcotics or the proposed medication unit is able to comply with the requirements set forth in NAC 449.1548.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002)
NAC 449.1547 Suspension, revocation or cancellation of license; provisional license; denial of application. (NRS 449.037, 449.038)
1. The Health Division may suspend or revoke a license issued pursuant to NAC 449.154 to 449.15485, inclusive, or cancel such a license and issue a provisional license based upon any grounds for such action set forth in this chapter or chapter 449 of NRS.
2. The Health Division shall deny an application for a license pursuant to NAC 449.1545 if the SAMHSA denies an application for certification pursuant to 42 C.F.R. Part 8.
3. The Health Division shall suspend or revoke a license issued pursuant to NAC 449.154 to 449.15485, inclusive, if the facility for treatment with narcotics or the medication unit operates without certification from the SAMHSA pursuant to 42 C.F.R. Part 8.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002)
Operation
NAC 449.1548 General operational requirements. (NRS 449.037, 449.038) In addition to all other requirements set forth in NAC 449.154 to 449.15485, inclusive, each facility for treatment with narcotics and each medication unit shall:
1. Have a medical director who has a valid and current license to practice medicine in this State;
2. Employ, contract with or allow a person to act as an alcohol and drug abuse counselor only if the person is certified by the Board of Examiners for Alcohol, Drug and Gambling Counselors to be such a counselor;
3. Obtain and maintain with the State Board of Pharmacy a valid and current registration relating to the use of narcotics;
4. Be in full compliance with all applicable provisions of 42 C.F.R. Part 8, all other applicable federal laws and regulations and all other requirements of the SAMHSA and the DEA;
5. Be in full compliance with all applicable provisions of chapters 449 and 453 of NRS and in substantial compliance with all applicable provisions of this chapter and chapter 453 of NAC;
6. Maintain records and documentation of treatment pursuant to NRS 453.690;
7. Provide the Health Division and the State Board of Pharmacy with access to all records and documentation relating to the purchase, distribution and use of narcotics;
8. Comply with the rules of confidentiality and privilege set forth in NRS 453.720;
9. Develop and maintain a system to ensure that prospective and existing clients are not receiving narcotics from any other facility for treatment with narcotics or any other medication unit; and
10. Comply with all applicable local laws and regulations, including, but not limited to, zoning laws and regulations.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002; R098-06, 7-14-2006)
NAC 449.15485 Continuing review of operations; investigation of complaints. (NRS 449.037, 449.038)
1. The operation of a facility for treatment with narcotics or a medication unit is subject to continuing review by the Health Division.
2. The Health Division shall investigate all complaints against a facility for treatment with narcotics or a medication unit directly or in conjunction with other federal, state or local governmental agencies, including, but not limited to, the SAMHSA, the DEA, the State Board of Pharmacy or the Health Division.
(Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002)
HALFWAY HOUSES FOR RECOVERING ALCOHOL AND DRUG ABUSERS
NAC 449.1549 Definitions. (NRS 449.037) As used in NAC 449.1549 to 449.154945, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.154901, 449.154903 and 449.154905 have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154901 “Administrator” defined. (NRS 449.037) “Administrator” means a person:
1. Whose name appears on a license issued by the Bureau as administrator of record for a facility; and
2. Who is legally responsible for the management of the facility.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154903 “Client” defined. (NRS 449.037) “Client” means a person who is admitted to a facility.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154905 “Facility” defined. (NRS 449.037) “Facility” means a halfway house for recovering alcohol and drug abusers as defined in NRS 449.008.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.15491 Administrator: Qualifications. (NRS 449.037) An administrator must:
1. Be at least 21 years of age;
2. Have the tests and obtain the certifications required by NAC 441A.375 for a person employed in a facility for the dependent; and
3. Maintain evidence that he satisfies the requirements of this section in a file that is maintained on the premises of the facility.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154911 Administrator: General duties. (NRS 449.037) An administrator shall:
1. Post the license issued by the Bureau in a conspicuous place within the facility.
2. Organize and manage the facility.
3. Establish policies, procedures and rules for the operation of the facility, including, without limitation, the policies and procedures required to be established by NAC 449.154915.
4. Ensure that the records of the facility are maintained in accordance with the requirements of the policies, procedures and rules for the operation of the facility established pursuant to subsection 3.
5. Ensure that the facility complies with any applicable state statutes and regulations and local ordinances.
6. Ensure that the clients of the facility are afforded the opportunity to exercise their individual rights in a manner consistent with the rules of the facility.
7. Ensure that the facility is maintained in a safe and clean condition.
8. Review and approve changes in the policies and procedures established pursuant to subsection 3 at least annually. This review must be signed and dated.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154913 General operational guidelines. (NRS 449.037) An administrator shall ensure that:
1. Alcohol or drugs are not allowed on the premises of the facility;
2. The policies, procedures and rules established pursuant to NAC 449.154911 are carried out;
3. Each client complies with those policies, procedures and rules;
4. The facility provides an environment that will facilitate the reintegration of the clients of the facility into the community; and
5. The operation of the facility is not compromised by a client who violates the policies, procedures or rules of the facility.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154915 Policies and procedures: Establishment; maintenance of manual. (NRS 449.037)
1. An administrator shall establish written policies and procedures concerning:
(a) The manner in which records of clients will be maintained and protected against unauthorized use;
(b) The disclosure of confidential information about clients;
(c) The criteria the facility will use to determine whether to:
(1) Admit a client to the facility; and
(2) Discharge a client from the facility;
(d) The discharge of a client for a violation of the rules of the facility;
(e) The discharge of a client for the use of alcohol or drugs;
(f ) The rights and responsibilities of a client; and
(g) The evacuation of clients in case of fire or other emergency as required by NAC 449.154945.
2. The administrator shall maintain a manual of policies, procedures and rules of the facility that includes the policies and procedures established pursuant to subsection 1. The manual must be available on the premises of the facility at all times.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154917 Limitation on admissions. (NRS 449.037) An administrator shall ensure that the facility does not admit more clients to the facility than the number of beds for which it is licensed.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154919 Health and sanitation. (NRS 449.037)
1. An administrator shall ensure that the facility:
(a) Has a safe and sufficient supply of water, adequate drainage and an adequate system for the disposal of sewage; and
(b) Complies with all local ordinances and state and federal laws and regulations relating to zoning, sanitation, safety and accessibility to persons with disabilities.
2. A container used to store garbage outside of a facility must be kept reasonably clean and must be covered in such a manner that rodents are unable to get inside the container. At least once each week, the container must be emptied and the contents of the container must be removed from the premises of the facility.
3. To the extent practicable, the premises of the facility must be kept free from:
(a) Offensive odors;
(b) Hazards, including obstacles that impede the free movement of clients within and outside the facility;
(c) Insects and rodents; and
(d) Accumulations of dirt, garbage and other refuse.
4. The administrator shall ensure that the premises of the facility are clean and that the interior, exterior and landscaping of the facility are well maintained.
5. All windows that are capable of being opened in the facility and all doors that are left open to provide ventilation for the facility must be screened to prevent the entry of insects.
6. The administrator shall ensure that electrical lighting is maintained in the facility as necessary to ensure the comfort and safety of the clients of the facility.
7. The temperature in the facility must be maintained at a level that is not less than 68 degrees Fahrenheit and not more than 82 degrees Fahrenheit.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154921 Laundry facilities. (NRS 449.037)
1. An administrator shall ensure that laundry facilities are provided in the facility commensurate with the number of clients in the facility. At least one washer and at least one dryer must be provided in the facility.
2. The laundry area in a facility must be maintained in a sanitary manner. All the equipment in the laundry area must be maintained in good working condition. All dryers must be ventilated to the outside of the building.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154923 Kitchens; storage of food. (NRS 449.037)
1. The kitchen in a facility and the equipment in the kitchen must be clean and must allow for the sanitary preparation of food. The equipment must be in good working condition.
2. Perishable food must be refrigerated at a temperature of 40 degrees Fahrenheit or less. Frozen food must be kept at a temperature of 0 degrees Fahrenheit or less.
3. Food must not be stored in any area in which cleaning or pest control products are stored.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154925 Bedrooms; bedding. (NRS 449.037)
1. A bedroom in a facility that is used by more than one client must have at least 45 square feet of floor space for each client who resides in the bedroom. A bedroom that is occupied by only one client must have at least 80 square feet of floor space.
2. The arrangement of the beds and other furniture in the bedroom must accommodate the clients occupying the bedroom in comfort and safety.
3. A bed with a comfortable and clean mattress must be provided for each client. The bed must be made with two clean sheets, a blanket, a pillow and a bedspread. Linens must be changed at least once each week and more often if the linens become dirty.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154927 Use of certain areas as bedroom prohibited. (NRS 449.037) A hall, stairway, unfinished attic, garage, storage area or shed or other similar area of a facility must not be used as a bedroom. Any other room must not be used as a bedroom if it is used for any other purpose.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154929 Bathrooms and toilet facilities; toilet articles. (NRS 449.037)
1. All bathrooms and toilet facilities in the facility must be sufficiently lighted.
2. Each client must have his own towels and washcloths. Paper towels may be used for hand towels. The towels and washcloths must be changed as often as is necessary to maintain cleanliness, but in no event less often than once each week. A soap dispenser that provides liquid or granular soap may be used instead of individual bars of soap.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154931 Accommodations for residents with restricted mobility. (NRS 449.037) A facility that has a client who uses a wheelchair or a walker must:
1. Have hallways, doorways and exits wide enough to accommodate a wheelchair or walker; and
2. Have ramps at all primary exits.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154933 First aid. (NRS 449.037)
1. A first-aid kit must be available at the facility. The first-aid kit must include, without limitation:
(a) A germicide safe for use by humans;
(b) Sterile gauze pads;
(c) Adhesive bandages, rolls of gauze and adhesive tape;
(d) Disposable gloves;
(e) A shield or mask to be used by a person who is administering cardiopulmonary resuscitation; and
(f ) A thermometer or other device that may be used to determine the bodily temperature of a person.
2. Except for first aid in an emergency, no treatment or medication may be administered to a client.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154935 Medication. (NRS 449.037)
1. Except as otherwise provided in NAC 449.154933, an administrator or another client shall not administer or assist in the administration of medication to a client.
2. Medication for self-administration may be kept at the facility. That medication must:
(a) Be disposed of immediately when it expires or when a physician orders the medication to be discontinued;
(b) Be stored and controlled in a manner that protects the medication from unauthorized use; and
(c) Not be used by more than one of the clients.
3. The provisions of paragraph (a) of subsection 2 do not apply to over-the-counter medication.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154937 Telephones; telephone number. (NRS 449.037) An administrator shall ensure that:
1. The facility has at least one telephone that is in good working condition in the facility; and
2. The telephone number of the facility is listed in the telephone directory.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154939 Notification to Bureau under certain circumstances. (NRS 449.037) An administrator shall notify the Bureau within 24 hours after the occurrence of an incident that:
1. Involved significant harm to a client of the facility if the client of the facility required medical treatment as a result of the incident;
2. May cause imminent danger to the health or safety of a client of the facility; or
3. May jeopardize the integrity of the operation of the facility.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154941 Rights of clients. (NRS 449.037) An administrator shall ensure that:
1. A client of the facility is not abused, neglected or exploited by another client of the facility or any person who is visiting the facility;
2. A client is not prohibited from speaking to any person who advocates for the rights of the clients of the facility;
3. Each client is treated with respect and dignity;
4. The facility provides a safe and comfortable environment;
5. A client is not prohibited from interacting socially in a manner that is consistent with the rules of the facility;
6. To the extent practicable and in a manner that is consistent with the rules of the facility, each client is allowed to make his own decisions; and
7. The telephone number of the local office of the Bureau and the name and telephone number of the administrator is conspicuously posted on the premises of the facility.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154943 Client files: Maintenance; contents; confidentiality. (NRS 449.037)
1. An administrator shall ensure that the facility maintains a separate file for each client of the facility and retains the file for at least 5 years after the client permanently leaves the facility. The file must be kept locked in a location that is protected against unauthorized use. Each file must contain the information obtained by the facility that is related to the client, including, without limitation:
(a) The full name, address, date of birth and social security number of the client;
(b) The address and telephone number of the client’s physician and any next of kin or guardian of the client;
(c) A statement of the allergies of the client, if any, and any special diet or medication he requires;
(d) Evidence of compliance with the provisions of NAC 441A.380;
(e) A list of the rules of the facility that is signed by the client; and
(f ) The name and telephone number of the vendors and medical professionals that provide services for the client.
2. Except as otherwise provided in this subsection, the file of the client must be kept confidential. The file of a client must be made available upon request at any time to an employee of the Bureau who is acting in his capacity as an employee of the Bureau.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
NAC 449.154945 Safety from fire. (NRS 449.037)
1. An administrator shall ensure that the facility complies with the regulations adopted by the State Fire Marshal pursuant to chapter 477 of NRS and any local ordinances relating to safety from fire. The facility must be approved for occupancy by the State Fire Marshal.
2. The administrator shall ensure that the facility has a plan for the evacuation of clients in case of fire or other emergency. The plan must be:
(a) Understood by all clients;
(b) Posted in a common area of the facility; and
(c) Discussed with each client at the time of his admission.
3. At least one portable fire extinguisher must be available at the facility. Any portable fire extinguishers available at the facility must be inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections.
4. The administrator shall ensure that a written policy on smoking is developed and carried out by the facility. The policy must be:
(a) Developed with the purpose of preventing a fire caused by smoking in the facility; and
(b) Posted in a common area of the facility.
5. Smoke detectors installed in a facility must be maintained in proper operating condition at all times and must be tested monthly. The results of the tests conducted pursuant to this subsection must be recorded and maintained at the facility.
6. If a fire sprinkler system is installed in a facility, the system must be maintained in proper operating condition at all times and must be inspected in accordance with the provisions of NAC 477.460.
(Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002)
FACILITIES FOR TRANSITIONAL LIVING FOR RELEASED OFFENDERS
General Provisions
NAC 449.154951 Definitions. (NRS 449.037) As used in NAC 449.154951 to 449.154999, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.154953 to 449.154959, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154953 “Administrator” defined. (NRS 449.037) “Administrator” means a person:
1. Whose name appears on a license issued by the Bureau as administrator of record for a facility; and
2. Who is legally responsible for the management of the facility.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154955 “Facility” defined. (NRS 449.037) “Facility” means a facility for transitional living for released offenders as defined in NRS 449.0055.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154957 “Resident” defined. (NRS 449.037) “Resident” means a person who:
1. Is a person who has been released from prison as that term is defined in subsection 2 of NRS 449.0055; and
2. Is admitted to a facility.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154959 “Supportive services” defined. (NRS 449.037)
1. “Supportive services” mean services provided by a facility, directly or indirectly through arrangements with other providers, which are intended to assist a resident with reintegration into the community.
2. Those services may include, without limitation:
(a) Referrals and the provision of information concerning:
(1) Health care, including mental health care;
(2) Access to housing, benefits or employment;
(3) Resume writing; and
(4) Required counseling for sex offenders.
(b) Training concerning:
(1) Life skills;
(2) Resume writing; and
(3) Any other topic pursuant to the policies of the facility.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
Administration
NAC 449.154961 Administrator: Qualifications. (NRS 449.037) An administrator must:
1. Be at least 21 years of age;
2. Have the physical examination or certification required by paragraph (a) of subsection 3 of NAC 441A.375 for a person employed in a facility for the dependent; and
3. Maintain evidence that he satisfies the requirements of this section in a file that is maintained on the premises of the facility.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154963 Administrator: General duties. (NRS 449.037) An administrator shall:
1. Post the license issued by the Bureau in a conspicuous place within the facility.
2. Organize and manage the facility.
3. Establish policies, procedures and rules for the operation of the facility, including, without limitation, the policies and procedures required to be established by NAC 449.154967.
4. Ensure that the records of the facility are maintained in accordance with the requirements of the policies, procedures and rules for the operation of the facility established pursuant to subsection 3.
5. Ensure that the facility complies with any applicable state statutes and regulations and local ordinances.
6. Ensure that the residents of the facility are afforded the opportunity to exercise their individual rights in a manner consistent with the rules of the facility.
7. Ensure that the facility is maintained in a safe and clean condition.
8. Review and approve changes in the policies and procedures established pursuant to subsection 3 at least annually. This review must be signed and dated.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154965 Operation of facility. (NRS 449.037) An administrator shall ensure that:
1. Alcohol or drugs are not allowed on the premises of the facility;
2. The policies, procedures and rules established pursuant to NAC 449.154963 are carried out;
3. Each resident complies with those policies, procedures and rules;
4. The facility provides an environment that will facilitate the reintegration of the residents of the facility into the community; and
5. The operation of the facility is not compromised by a resident who violates the policies, procedures or rules of the facility.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154967 Policies and procedures. (NRS 449.037)
1. An administrator shall establish written policies and procedures concerning:
(a) The manner in which records of residents will be maintained and protected against unauthorized use;
(b) The disclosure of confidential information about residents;
(c) The criteria the facility will use to determine whether to:
(1) Admit a resident to the facility; and
(2) Discharge a resident from the facility;
(d) The discharge of a resident for a violation of the rules of the facility;
(e) The discharge of a resident for the use of alcohol or drugs;
(f ) The rights and responsibilities of a resident; and
(g) The evacuation of residents in case of fire or other emergency as required by NAC 449.154999.
2. The administrator shall maintain a manual of policies, procedures and rules of the facility that includes, without limitation, the policies and procedures established pursuant to subsection 1. The manual must be available on the premises of the facility at all times.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154969 Preparations for disasters and other emergencies. (NRS 449.037)
1. An administrator shall develop a written plan for disasters that outlines procedures for members of the staff of the facility and residents of the facility to follow in case of a disaster or other emergency. The plan must include, without limitation, provisions outlining procedures to be followed with regard to:
(a) Workplace threats and violence, bomb threats, and the possession of firearms or explosives by a resident;
(b) Medical emergencies;
(c) Natural disasters typical of the particular geographic area in which the facility is located; and
(d) Other disasters, including, without limitation, a power failure, an interruption in the normal supply of water to the facility and threats by terrorists.
2. The plan must include, without limitation, provisions concerning the provision of temporary shelter and other services for residents of the facility who are required to evacuate the facility because of a disaster.
3. The provisions of the plan must be communicated to each member of the staff of the facility and each resident of the facility.
4. Each facility shall conduct a drill for evacuation of the facility at least once each quarter and shall ensure that each shift of the staff of the facility participates in such a drill at least annually.
5. Each facility shall retain a written record of each drill conducted pursuant to subsection 4 on file at the facility for not less than 12 months after the drill is conducted. The administrator shall make such records available for inspection by the Health Division upon request.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
Operation
NAC 449.154971 Limitation on number of admissions. (NRS 449.037) An administrator shall ensure that the facility does not admit more residents to the facility than the number of beds for which it is licensed.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154973 Prerequisites to provision of particular services. (NRS 449.037)
1. In addition to satisfying the requirements of NAC 449.011, an applicant for a license to operate a facility must include with his application a statement indicating whether he will be operating a facility:
(a) That only provides a housing and living environment;
(b) That provides or arranges for the provision of supportive services for residents of the facility to assist the residents with reintegration into the community, in addition to providing a housing and living environment; or
(c) That provides or arranges for the provision of alcohol and drug abuse programs, in addition to providing a housing and living environment and providing or arranging for the provision of other supportive services.
2. If the applicant wishes to operate a facility described in paragraph (c) of subsection 1, the applicant must:
(a) Obtain certification of its program pursuant to subsection 4 of NRS 458.025 and include evidence of that certification with his application; and
(b) Satisfy the requirements set forth in NAC 449.019 to 449.153, inclusive, for a facility for the treatment of abuse of alcohol or drugs.
3. If the applicant wishes to operate a facility described in paragraph (b) or (c) of subsection 1 which has residents who are under the supervision of a parole officer, the applicant must:
(a) Obtain the approval of the Division of Parole and Probation of the Department of Public Safety; and
(b) Include evidence of that approval with his application.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154975 Sanitation, safety and comfort. (NRS 449.037)
1. An administrator shall ensure that the facility:
(a) Has a safe and sufficient supply of water, adequate drainage and an adequate system for the disposal of sewage; and
(b) Complies with all local ordinances and state and federal laws and regulations relating to zoning, sanitation, safety and accessibility to persons with disabilities.
2. A container used to store garbage outside of a facility must be kept reasonably clean and must be covered in such a manner that rodents are unable to get inside the container. At least once each week, the container must be emptied and the contents of the container must be removed from the premises of the facility.
3. To the extent practicable, the premises of the facility must be kept free from:
(a) Offensive odors;
(b) Hazards, including obstacles that impede the free movement of residents within and outside the facility;
(c) Insects and rodents; and
(d) Accumulations of dirt, garbage and other refuse.
4. The administrator shall ensure that the premises of the facility are clean and that the interior, exterior and landscaping of the facility are well maintained.
5. All windows that are capable of being opened in the facility and all doors that are left open to provide ventilation for the facility must be screened to prevent the entry of insects.
6. The administrator shall ensure that electrical lighting is maintained in the facility as necessary to ensure the comfort and safety of the residents of the facility.
7. The temperature in the facility must be maintained at a level that is not less than 68 degrees Fahrenheit and not more than 82 degrees Fahrenheit.
8. The administrator shall ensure that any pest control work performed at the facility is performed by a person licensed to engage in pest control pursuant to chapter 555 of NRS.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154977 Laundry facilities. (NRS 449.037)
1. An administrator shall ensure that laundry facilities are provided in the facility commensurate with the number of residents in the facility. At least one washer and at least one dryer must be provided in the facility.
2. The laundry area in a facility must be maintained in a sanitary manner. All the equipment in the laundry area must be maintained in good working condition. All dryers must be ventilated to the outside of the building.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154979 Kitchens; preparation and storage of food. (NRS 449.037)
1. The kitchen in a facility and the equipment in the kitchen must be clean and must allow for the sanitary preparation of food. The equipment must be in good working condition.
2. Perishable food must be refrigerated at a temperature of 40 degrees Fahrenheit or less. Frozen food must be kept at a temperature of 0 degrees Fahrenheit or less.
3. Food must not be stored in any area in which cleaning or pest control products are stored.
4. A facility with more than 10 residents must:
(a) Comply with applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto; and
(b) Obtain the necessary permits from the Bureau of Health Protection Services of the Health Division.
5. The equipment used for cooking and storing food in a facility with more than 10 residents must be inspected and approved by the Bureau of Health Protection Services of the Health Division and the state and local fire safety authorities.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154981 Bedrooms and bedding. (NRS 449.037)
1. A bedroom in a facility that is used by more than one resident must have at least 50 square feet of floor space for each resident who resides in the bedroom. A bedroom that is occupied by only one resident must have at least 80 square feet of floor space.
2. The arrangement of the beds and other furniture in the bedroom must accommodate the residents occupying the bedroom in comfort and safety.
3. A bed with a comfortable and clean mattress must be provided for each resident. The bed must be made with a mattress cover, two clean sheets, a blanket, a pillow and a bedspread. Linens must be changed at least once each week and more often if the linens become dirty.
4. Each mattress used in a facility must comply with the provisions of NRS 444.010 to 444.040, inclusive, and the regulations adopted pursuant thereto.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154983 Use of certain areas as bedroom prohibited. (NRS 449.037) A hall, stairway, unfinished attic, garage, storage area or shed or other similar area of a facility must not be used as a bedroom. Any other room must not be used as a bedroom if it is used for any other purpose.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154985 Bathrooms and toilet facilities; toiletries. (NRS 449.037)
1. All bathrooms and toilet facilities in the facility must be sufficiently lighted.
2. Each facility must have:
(a) A flush toilet and lavatory for each four residents; and
(b) A tub or shower for each six residents.
3. Each resident must have his own towels and washcloths. Paper towels may be used for hand towels. The towels and washcloths must be changed as often as is necessary to maintain cleanliness, but in no event less often than once each week. A soap dispenser that provides liquid or granular soap may be used instead of individual bars of soap.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154987 First aid. (NRS 449.037)
1. A first-aid kit must be available at the facility. The first-aid kit must include, without limitation:
(a) A germicide safe for use by humans;
(b) Sterile gauze pads;
(c) Adhesive bandages, rolls of gauze and adhesive tape;
(d) Disposable gloves;
(e) A shield or mask to be used by a person who is administering cardiopulmonary resuscitation; and
(f ) A thermometer or other device that may be used to determine the bodily temperature of a person.
2. Except for first aid in an emergency, no treatment or medication may be administered to a resident.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154989 Medication. (NRS 449.037)
1. Medication for self-administration may be kept at the facility. That medication must:
(a) Except as otherwise provided in subsection 3, be disposed of immediately when it expires or when a physician orders the medication to be discontinued;
(b) Be stored and controlled in a manner that protects the medication from unauthorized use; and
(c) Not be used by more than one of the residents.
2. Medication kept at the facility must be controlled and distributed in a manner that is consistent with applicable state and federal law.
3. The provisions of paragraph (a) of subsection 1 do not apply to over-the-counter medication.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154991 Telephones. (NRS 449.037) An administrator shall ensure that:
1. The facility has at least one telephone that is in good working condition in the facility; and
2. The telephone number of the facility is listed in the telephone directory.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154993 Notification of occurrence of certain incidents. (NRS 449.037)
1. An administrator shall notify the Bureau within 24 hours after the occurrence of an incident that:
(a) Involved significant harm to a resident of the facility if the resident of the facility required medical treatment as a result of the incident;
(b) May cause imminent danger to the health or safety of a resident of the facility; or
(c) May jeopardize the integrity of the operation of the facility.
2. The administrator shall report to the Health Division any fire or other disaster that takes place in the facility within 24 hours after the fire or other disaster occurs.
3. The administrator shall notify the Division of Parole and Probation of the Department of Public Safety of the occurrence of any of the incidents described in this section.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154995 Rights of residents. (NRS 449.037) An administrator shall ensure that:
1. A resident of the facility is not abused, neglected or exploited by another resident of the facility or any person who is visiting the facility;
2. A resident is not prohibited from speaking to any person who advocates for the rights of the residents of the facility;
3. Each resident is treated with respect and dignity;
4. The facility provides a safe and comfortable environment;
5. A resident is not prohibited from interacting socially in a manner that is consistent with the rules of the facility;
6. To the extent practicable and in a manner that is consistent with the rules of the facility, each resident is allowed to make his own decisions;
7. The telephone number of the local office of the Bureau and the name and telephone number of the administrator is conspicuously posted on the premises of the facility; and
8. Each resident of the facility is allowed to exercise his right to vote.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154997 Files for residents. (NRS 449.037)
1. An administrator shall ensure that the facility maintains a separate file for each resident of the facility and retains the file for at least 5 years after the resident permanently leaves the facility. The file must be kept locked in a location that is protected against unauthorized use. Each file must contain the information obtained by the facility that is related to the resident, including, without limitation:
(a) The full name, address and date of birth of the resident;
(b) The address and telephone number of any next of kin or guardian of the resident;
(c) Evidence of compliance with the provisions of NAC 441A.380;
(d) A list of the rules of the facility that is signed by the resident; and
(e) The name and telephone number of the parole officer of the resident, if any.
2. Except as otherwise provided in this subsection, the file of the resident must be kept confidential. The file of a resident must be made available upon request at any time to an employee of the Bureau who is acting in his capacity as an employee of the Bureau.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
NAC 449.154999 Safety from fire. (NRS 449.037)
1. An administrator shall ensure that the facility complies with the regulations adopted by the State Fire Marshal pursuant to chapter 477 of NRS and any local ordinances relating to safety from fire.
2. A facility with more than 16 beds must be equipped with a sufficient number of sprinklers to cover the entire area of the facility.
3. The administrator shall ensure that the facility has a plan for the evacuation of residents in case of fire or other emergency. The plan must be:
(a) Understood by all residents;
(b) Posted in a common area of the facility; and
(c) Discussed with each resident at the time of his admission.
4. At least one portable fire extinguisher must be available at the facility. Any portable fire extinguishers available at the facility must be inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections.
5. The administrator shall ensure that a written policy on smoking is developed and carried out by the facility. The policy must be:
(a) Developed with the purpose of preventing a fire caused by smoking in the facility; and
(b) Posted in a common area of the facility.
6. Smoke detectors installed in a facility must be maintained in proper operating condition at all times and must be tested monthly. The results of the tests conducted pursuant to this subsection must be recorded and maintained at the facility.
7. If an automatic fire sprinkler system is installed in a facility, the system must be inspected:
(a) Not less than once each calendar quarter by a person who understands the manner in which the system operates and the manner in which the system must be maintained; and
(b) Not less than once each calendar year by a person who is licensed to inspect such a system pursuant to the provisions of chapter 477 of NAC.
(Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006)
HOMES FOR INDIVIDUAL RESIDENTIAL CARE
NAC 449.15511 Definitions. (NRS 449.249) As used in NAC 449.15511 to 449.15529, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.15513 to 449.15519, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.15513 “Caregiver” defined. (NRS 449.249) “Caregiver” means a person who provides care, assistance and protective supervision to a resident of a home.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.15515 “Director” defined. (NRS 449.249) “Director” means a person:
1. Whose name appears on a license issued by the Bureau as the director of record for a home; and
2. Who is legally responsible for the care of the residents and the daily operation of the home.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.15517 “Home” defined. (NRS 449.249) “Home” means a home for individual residential care.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.15519 “Protective supervision” defined. (NRS 449.249) “Protective supervision” means supervision that protects the residents of a home from potential danger to their physical and mental well-being.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.15521 Director: Qualifications. (NRS 449.249) The director of a home must:
1. Be at least 21 years of age and have a high school diploma or its equivalent. A person who proposes to act as the director of a home must provide the Bureau with evidence that he satisfies the requirements of this subsection.
2. Possess the appropriate knowledge, skills and abilities to meet the needs of the residents of the home.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.15523 Director: Duties. (NRS 449.249) The director of a home shall:
1. Post the license to operate the home in a conspicuous place within the home.
2. Ensure that the needs of each resident of the home are assessed upon admission of the resident to the home, and that the assessment is updated as the needs of the resident change. Such an assessment must include:
(a) Documentation of the abilities of the resident to function independently; and
(b) A complete list of the matters for which the resident requires assistance.
3. Ensure that the residents of the home:
(a) Are treated with dignity and respect and are not abused, neglected or exploited; and
(b) Receive:
(1) The personal care they require;
(2) A balanced daily diet that meets their nutritional needs;
(3) Protective supervision and adequate services to maintain and enhance their physical, mental and emotional well-being; and
(4) The names of, and the telephone numbers for the registration of complaints with, the Bureau and the Aging Services Division of the Department of Health and Human Services.
4. Ensure that a caregiver, who is capable of meeting the needs of the residents and has been trained in first aid and cardiopulmonary resuscitation, is on the premises of the home at all times when a resident is present.
5. Ensure that appropriate sanitary procedures are carried out for the handling, cleaning and storage of linens and personal laundry in the home.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.15525 Requirements for safety and sanitation of facility. (NRS 449.249)
1. The interior and exterior of a home must be clean and free of hazards and offensive odors.
2. A home must contain:
(a) Appropriate and well-maintained furnishings;
(b) At least one functional, portable fire extinguisher;
(c) A first-aid kit;
(d) Equipment that is sufficiently clean and adequate for the preparation, service and storage of food; and
(e) Adequate areas and equipment to carry out appropriate sanitary procedures for the handling, cleaning and storage of linens and personal laundry.
3. The temperature of a home must be maintained at levels that are comfortable and safe. Portable heaters are prohibited in a home.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.15527 Agreement between operator of home and resident concerning rates; maintenance of records of residents. (NRS 449.249) The operator of a home shall:
1. Enter into a written agreement with each resident of the home that sets forth the basic rate for the services of the home and the charges for any optional services.
2. Maintain a separate, organized file for each resident of the home and retain the file for 5 years after the resident permanently leaves the home. Each file must include:
(a) The full name, address, date of birth and social security number of the resident;
(b) The address and telephone number of the resident’s physician and a person who is responsible for the resident;
(c) A copy of the results of a general physical examination of the resident conducted by his physician; and
(d) A current copy of the assessment of the needs of the resident conducted pursuant to NAC 449.15523.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.15529 On-site survey of home by Bureau. (NRS 449.249) The Bureau shall conduct:
1. An initial on-site survey of a home:
(a) After the Bureau receives a completed application for a license to operate the home and the fee required pursuant to NAC 449.016; and
(b) Before the issuance of a license to operate the home.
2. Additional on-site surveys of a home not less than once every 3 years after conducting the survey of the home pursuant to subsection 1.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
RESIDENTIAL FACILITIES FOR GROUPS
General Provisions
NAC 449.156 Definitions. (NRS 449.037) As used in NAC 449.156 to 449.27706, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.1565 to 449.178, inclusive, have the meanings ascribed to them in those sections.
(Supplied in codification; A by Bd. of Health, 3-6-86; R003-97, 10-30-97; R204-99, 2-10-2000; R071-04, 8-4-2004; R122-05, 11-17-2005; R097-06, 7-14-2006)
NAC 449.1565 “Administer” defined. (NRS 449.037) “Administer” means the direct application of a drug or medicine referred to in NRS 454.181 to 454.371, inclusive, by injection, inhalation, ingestion or any other means, to the body of a resident of a residential facility.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.157 “Administrator” defined. (NRS 449.037) “Administrator” means a person:
1. Who is licensed by the Nevada State Board of Examiners for Administrators of Facilities for Long-Term Care pursuant to chapter 654 of NRS;
2. Whose name appears on a license issued by the Bureau as administrator of record for a residential facility; and
3. Who is legally responsible for the care of residents and the daily operation of the facility.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.1575 “Board” defined. (NRS 449.037) “Board” means the State Board of Health.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.1585 “Caregiver” defined. (NRS 449.037) “Caregiver” means an employee of a residential facility who provides care, assistance or protective supervision to a resident of the facility.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.1591 “Category 1 resident” defined. (NRS 449.037) “Category 1 resident” means:
1. In a residential facility with not more than 10 residents, a resident who, without the assistance of any other person, is physically and mentally capable of moving himself from the room in which he sleeps to outside the facility in 4 minutes or less; or
2. In a residential facility with more than 10 residents, a resident who, without the assistance of any other person, is physically and mentally capable of moving himself from the room in which he sleeps to the other side of a smoke or fire barrier or outside the facility, whichever is nearest, in 4 minutes or less.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.1595 “Category 2 resident” defined. (NRS 449.037) “Category 2 resident” means:
1. In a residential facility with not more than 10 residents, a resident who, without the assistance of any other person, is not physically or mentally capable of moving himself from the room in which he sleeps to outside the facility in 4 minutes or less.
2. In a residential facility with more than 10 residents, a resident who, without the assistance of any other person, is not physically or mentally capable of moving himself from the room in which he sleeps to the other side of a smoke or fire barrier or outside the facility, whichever is nearest, in 4 minutes or less.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.1597 “Dietary supplement” defined. (NRS 449.037) “Dietary supplement” has the meaning ascribed to it in 21 U.S.C. 321(ff ) as that section existed on August 17, 1999.
(Added to NAC by Bd. of Health by R204-99, eff. 2-10-2000)
NAC 449.1599 “Discharge” defined. (NRS 449.037) “Discharge” means the release of a resident from a residential facility which does not involve a transfer.
(Added to NAC by Bd. of Health by R071-04, eff. 8-4-2004)
NAC 449.160 “Division” defined. (NRS 449.037) “Division” means the Health Division of the Department of Health and Human Services.
(Added to NAC by Bd. of Health, eff. 3-6-86)
NAC 449.161 “Grade” defined. (NRS 449.037) “Grade” means a letter that is assigned to a residential facility by the Bureau based on the severity and scope scores of the facility as determined by the Bureau.
(Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005)
NAC 449.164 “Hospice care” defined. (NRS 449.037) “Hospice care” has the meaning ascribed to it in NRS 449.0115.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.169 “Medical professional” defined. (NRS 449.037) “Medical professional” means a physician or a physician assistant, nurse practitioner, registered nurse, physical therapist, occupational therapist, speech pathologist or practitioner of respiratory care who is trained and licensed to perform medical procedures and care prescribed by a physician.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.170 “Placard” defined. (NRS 449.037) “Placard” means a certificate issued to a residential facility by the Bureau that includes the grade assigned to the facility by the Bureau.
(Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005)
NAC 449.172 “Residential facility” defined. (NRS 449.037) “Residential facility” means a residential facility for groups as defined in NRS 449.017.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.173 “Residential facility which provides care to persons with Alzheimer’s disease” defined. (NRS 449.037) “Residential facility which provides care to persons with Alzheimer’s disease” means a residential facility that provides care and protective supervision for persons with Alzheimer’s disease or a related disease, including, without limitation, senile dementia, organic brain syndrome or other cognitive impairment.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.175 “Severity and scope score” defined. (NRS 449.037) “Severity and scope score” has the meaning ascribed to it in NAC 449.99839.
(Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005)
NAC 449.176 “Staff of a facility” defined. (NRS 449.037) “Staff of a facility” means the administrator, caregivers and other employees of a residential facility.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.178 “Transfer” defined. (NRS 449.037) “Transfer” means the movement of a resident from a residential facility to another facility for inpatient or residential care.
(Added to NAC by Bd. of Health by R071-04, eff. 8-4-2004)
Licensing
NAC 449.179 Submission and approval of plan for new construction or remodeling; inspection; evidence of compliance. (NRS 449.037)
1. Except for a residential facility with less than 11 beds, before a residential facility is constructed or an existing facility is remodeled, the facility must:
(a) Submit the plan for construction or remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115;
(b) Notify the Bureau of a tentative date for the completion of the construction or remodeling; and
(c) Obtain approval of the plan from the Health Division.
2. The plan for construction or remodeling must include a description of the materials that will be used to complete the project.
3. Before issuing a license to operate a residential facility, the Bureau shall inspect the facility to ensure that it complies with:
(a) The provisions of NAC 449.156 to 449.27706, inclusive; and
(b) The applicable zoning ordinances and regulations.
4. An applicant for a license to operate a residential facility must submit to the Bureau with his application evidence that the applicant and the facility are in compliance with the provisions of NRS 449.001 to 449.240, inclusive, and NAC 449.156 to 449.27706, inclusive.
5. The Bureau shall not perform the inspection required pursuant to subsection 3 until the applicant has submitted to the Bureau the application required pursuant to NRS 449.040, the fee required pursuant to NAC 449.016 and the evidence required pursuant to subsection 4.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R076-01, 10-18-2001; R071-04, 8-4-2004; R118-05, 11-17-2005)
NAC 449.180 Requirements for purchasing licensed facility. (NRS 449.037) If an applicant for a license to operate a residential facility desires to purchase a currently licensed facility, the facility must comply with all current state and local requirements relating to health and safety.
[Bd. of Health, Group Care Facilities Appendix §§ 1, 1.1 & 2-2.7, eff. 10-13-77]—(NAC A 3-6-86; R003-97, 10-30-97)
NAC 449.190 License: Contents; validity; transferability; issuance of more than one type. (NRS 449.037)
1. A license to operate a residential facility must include:
(a) The name of the administrator of the facility;
(b) The name and address of the facility;
(c) The type of facility;
(d) The maximum number of residents authorized to reside at the facility; and
(e) The category of residents who may reside at the facility.
2. The license becomes invalid if the facility is moved to a location other than the location stated on the license. The license may not be transferred to another owner.
3. A residential facility may be licensed as more than one type of residential facility if the facility provides evidence satisfactory to the Bureau that it complies with the requirements for each type of facility and can demonstrate that the residents will be protected and receive necessary care and services.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
Administration and Personnel
NAC 449.194 Responsibilities of administrator. (NRS 449.037) The administrator of a residential facility shall:
1. Provide oversight and direction for the members of the staff of the facility as necessary to ensure that residents receive needed services and protective supervision and that the facility is in compliance with the requirements of NAC 449.156 to 449.27706, inclusive, and chapter 449 of NRS.
2. Designate one or more employees to be in charge of the facility during those times when the administrator is absent. Except as otherwise provided in this subsection, employees designated to be in charge of the facility when the administrator is absent must have access to all areas of and records kept at the facility. Confidential information may be removed from the files to which the employees in charge of the facility have access if the confidential information is maintained by the administrator. The administrator or an employee who is designated to be in charge of the facility pursuant to this subsection shall be present at the facility at all times. The name of the employee in charge of the facility pursuant to this subsection must be posted in a public place within the facility during all times that the employee is in charge.
3. Maintain in the facility, and make available upon request, a copy of the provisions of NAC 449.156 to 449.27706, inclusive, and the report of the latest investigation of the facility conducted by the Bureau pursuant to NRS 449.150.
4. Ensure that the records of the facility are complete and accurate.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.196 Qualifications and training of caregivers. (NRS 449.037)
1. A caregiver of a residential facility must:
(a) Be at least 18 years of age;
(b) Be responsible and mature and have the personal qualities which will enable him to understand the problems of the aged and disabled;
(c) Understand the provisions of NAC 449.156 to 449.27706, inclusive, and sign a statement that he has read those provisions;
(d) Demonstrate the ability to read, write, speak and understand the English language;
(e) Possess the appropriate knowledge, skills and abilities to meet the needs of the residents of the facility; and
(f ) Receive annually not less than 8 hours of training related to providing for the needs of the residents of a residential facility.
2. If a resident of a residential facility uses prosthetic devices or dental, vision or hearing aids, the caregivers employed by the facility must be knowledgeable of the use of those devices.
3. If a caregiver assists a resident of a residential facility in the administration of any medication, including, without limitation, an over-the-counter medication or dietary supplement, the caregiver must:
(a) Receive, in addition to the training required pursuant to NRS 449.037, at least 3 hours of training in the management of medication. The caregiver must receive the training at least every 3 years and provide the residential facility with satisfactory evidence of the content of the training and his attendance at the training; and
(b) At least every 3 years, pass an examination relating to the management of medication approved by the Bureau.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004; R118-05, 11-17-2005)
NAC 449.197 Medical services may be provided only by medical professional. (NRS 449.037) A member of the staff of a residential facility shall not provide medical services to a resident of the facility unless the member of the staff is a medical professional.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.199 Staffing requirements; limitation on number of residents; written schedule for each shift; direct supervision of certain employees. (NRS 449.037)
1. The administrator of a residential facility shall ensure that a sufficient number of caregivers are present at the facility to conduct activities and provide care and protective supervision for the residents. There must be at least one caregiver on the premises of the facility if one or more residents are present at the facility.
2. Except as otherwise provided in NAC 449.2756, the administrator of a residential facility which has more than 20 residents shall ensure that at least one employee is awake and on duty at the facility at all times. An additional employee must be available to provide care within 10 minutes after he is informed that his services are needed.
3. A residential facility must not accept residents in excess of the number of residents specified on the license issued to the owner of the facility.
4. The administrator of a residential facility shall maintain monthly a written schedule that includes the number and type of members of the staff of the facility assigned for each shift. The schedule must be amended if any changes are made to the schedule. The schedule must be retained for at least 6 months after the schedule expires.
5. An employee of a residential facility who is less than 18 years of age must be under the direct supervision of an employee who is 18 years of age or older.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.200 Personnel files. (NRS 449.037)
1. Except as otherwise provided in subsection 2, a separate personnel file must be kept for each member of the staff of a facility and must include:
(a) The name, address, telephone number and social security number of the employee;
(b) The date on which the employee began his employment at the residential facility;
(c) Records relating to the training received by the employee;
(d) The health certificates required pursuant to chapter 441A of NAC for the employee;
(e) Evidence that the references supplied by the employee were checked by the residential facility; and
(f ) Evidence of compliance with NRS 449.176 to 449.185, inclusive.
2. The personnel file for a caregiver of a residential facility must include, in addition to the information required pursuant to subsection 1:
(a) A certificate stating that the caregiver is currently certified to perform first aid and cardiopulmonary resuscitation; and
(b) Proof that the caregiver is 18 years of age or older.
3. The administrator may keep the personnel files for the facility in a locked cabinet and may, except as otherwise provided in this subsection, restrict access to this cabinet by other employees of the facility. Copies of the documents which are evidence that an employee has been certified to perform first aid and cardiopulmonary resuscitation and that the employee has been tested for tuberculosis must be available for review at all times. The administrator shall make the personnel files available for inspection by the Bureau within 72 hours after the Bureau requests to review the files.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R204-99, 2-10-2000; R073-03, 1-22-2004)
NAC 449.202 Rights of staff members during investigation of facility; duties of investigator. (NRS 449.037)
1. Upon the request of the administrator of a residential facility or any other member of the staff of the facility, a person who is conducting an investigation of the facility pursuant to NRS 449.150 shall:
(a) Identify himself and provide the name and telephone number of his supervisor; and
(b) Inform the administrator or other member of the staff of the facility of the reason for the investigation.
2. The person who is conducting the investigation shall:
(a) Treat the members of the staff of the facility in a professional and respectful manner;
(b) Conduct an unbiased investigation; and
(c) Provide to the administrator of the facility an accurate report of the findings of the investigation, including a description of each deficiency found and a citation to the section of this chapter or chapter 449 of NRS which has been violated.
3. After the investigation has been completed, the person conducting the investigation shall, upon the request of a member of the staff of the facility:
(a) Provide the member of the staff of the facility with the opportunity to:
(1) Ask questions concerning the findings of the investigation; and
(2) Review with the person who conducted the investigation the provisions of this chapter and chapter 449 of NRS that the investigator believes were violated; and
(b) Provide to the member of the staff of the facility the details of any complaints received by the Division concerning the facility, other than details that may reveal the identity of the person who submitted the complaint.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
General Operational Requirements
NAC 449.204 System of financial accounting; insurance. (NRS 449.037)
1. A residential facility shall:
(a) Maintain a recognized system of financial accounting; and
(b) Maintain a contract of insurance for protection against liability to third persons in amounts appropriate for the protection of residents, employees, volunteers and visitors to the facility.
2. A certificate of insurance must be furnished to the Division as evidence that the contract required by subsection 1 is in force, and a license must not be issued until that certificate is furnished. Each contract of insurance must contain an endorsement providing for a notice of 30 days to the Bureau before the effective date of a cancellation or nonrenewal of the policy.
[Bd. of Health, Group Care Facilities §§ 5.1-5.4, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004)
NAC 449.205 Advertising and promotional materials. (NRS 449.037) Advertising and promotional materials for a residential facility must be accurate and not misrepresent accommodations, services or programs offered by the facility.
(Added to NAC by Bd. of Health, eff. 3-6-86; A by R003-97, 10-30-97)
NAC 449.208 Restrictions on conducting other businesses or providing other services on premises. (NRS 449.037) No other business may be conducted or other services may be provided on the premises of a residential facility if the business or services would interfere with the operation of the facility or the care provided to the residents of the facility.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.209 Health and sanitation. (NRS 449.037)
1. A residential facility must:
(a) Have a safe and sufficient supply of water, adequate drainage and an adequate system for the disposal of sewage; and
(b) Comply with all local ordinances and state and federal laws and regulations relating to zoning, sanitation, accessibility to persons with disabilities and safety.
2. Containers used to store garbage outside of the facility must be kept reasonably clean and must be covered in such a manner that rodents are unable to get inside the containers. At least once each week, the containers must be emptied and the contents of the containers must be removed from the premises of the facility.
3. Containers used to store garbage in the kitchen and laundry room of the facility must be covered with a lid unless the containers are kept in an enclosed cupboard that is clean and prevents infestation by rodents or insects. Containers used to store garbage in bedrooms and bathrooms are not required to be covered unless they are used for food, bodily waste or medical waste.
4. To the extent practicable, the premises of the facility must be kept free from:
(a) Offensive odors;
(b) Hazards, including obstacles that impede the free movement of residents within and outside the facility;
(c) Insects and rodents; and
(d) Accumulations of dirt, garbage and other refuse.
5. The administrator of a residential facility shall ensure that the premises are clean and that the interior, exterior and landscaping of the facility are well maintained.
6. All windows that are capable of being opened in the facility and all doors that are left open to provide ventilation for the facility must be screened to prevent the entry of insects.
7. The facility must maintain electrical lighting as necessary to ensure the comfort and safety of the residents of the facility.
8. The temperature in the facility must be maintained at a level that is not less than 68 degrees Fahrenheit and not more than 82 degrees Fahrenheit.
9. If the door of a bathroom opens into any room in which food or utensils for eating are handled or stored, the door must close automatically.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99)
NAC 449.211 Automatic sprinkler systems. (NRS 449.037)
1. After January 14, 1997, the Division shall withhold the issuance of an initial license to operate a residential facility that does not have an automatic sprinkler system which complies with the provisions of chapter 477 of NRS and any local ordinances relating to the installation of automatic sprinkler systems.
2. Except as otherwise provided in subsection 3, a residential facility with less than seven residents that is issued a license on or before January 14, 1997, shall install an automatic sprinkler system that complies with the provisions of chapter 477 of NRS and any local ordinances relating to the installation of automatic sprinkler systems if:
(a) The ownership of the facility is transferred to a new owner;
(b) The number of beds in the facility is increased;
(c) The facility is currently authorized to admit or retain category 1 residents only and wishes to apply for authorization to admit or retain category 2 residents; or
(d) The facility is not currently authorized to admit or retain residents who suffer from Alzheimer’s disease or other related dementia and the facility wishes to apply for authorization to admit or retain such residents.
3. A residential facility with less than seven residents that was issued its initial license on or before January 14, 1997, may not admit or retain a category 2 resident, unless an automatic sprinkler system that complies with the provisions of chapter 477 of NRS and any local ordinances relating to the installation of automatic sprinkler systems is installed in the facility. Not more than one resident who is confined to a wheelchair or who is required to use a walker may be admitted to such a facility at any time unless such an automatic sprinkler system is installed in the facility.
4. An automatic sprinkler system that has been installed in a residential facility must be inspected:
(a) Not less than once each calendar quarter by a person who understands the manner in which the system operates and the manner in which it should be maintained; and
(b) Not less than once each calendar year by a person who is licensed to inspect such a system pursuant to the provisions of chapter 477 of NAC.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.213 Laundry and linen services. (NRS 449.037)
1. A residential facility shall:
(a) Provide laundry and linen services on the premises of the facility; or
(b) Contract with a commercial laundry for the provision of those services.
2. A residential facility that provides its own laundry and linen services shall have accommodations which are adequate for the proper and sanitary washing and finishing of linen and other washable goods.
3. The laundry room in a residential facility must be situated in an area which is separate from an area where food is stored, prepared or served. The laundry must be adequate in size for the needs of the facility and maintained in a sanitary manner. The laundry room must contain at least one washer and at least one dryer. All the equipment must be kept in good repair. All dryers must be ventilated to outside the building. If a washer or dryer is located outside the residential facility, the washer or dryer must be in a room or enclosure.
4. Clothes, bedding, linens and any other materials laundered pursuant to subsection 1 must be made clean by the laundering process. If a residential facility provides its own laundry and linen services, the residential facility shall:
(a) Make appropriate use of detergents, soaps, heat or chemicals; and
(b) Take precautions to ensure that no resident, member of the staff of the facility or other person in the facility is harmed by exposure to the detergents, soaps, heat or chemicals used in the laundering process.
[Bd. of Health, Group Care Facilities § 14.8, eff. 12-18-75; A 5-7-82; §§ 14.8.1-14.10.2, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R204-99, 2-10-2000; R073-03, 1-22-2004)
NAC 449.216 Common areas; dining rooms. (NRS 449.037)
1. A residential facility must have at least one centrally located common area in which residents may socialize and participate in recreational activities. A common area may include, without limitation, a living room, dining room, enclosed porch or solarium.
2. The common areas must be large enough to accommodate those to be served without overcrowding the areas. A minimum area of 15 square feet of total common area space per person must be provided.
3. All common areas must be furnished and equipped with comfortable furniture.
4. The dining room must be of sufficient size to accommodate all the residents comfortably. A minimum area of 10 square feet per person must be provided.
5. The dining room must be conveniently located near the kitchen to ensure the rapid and efficient serving of food.
[Bd. of Health, Group Care Facilities §§ 15.1-15.2.3, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97)
NAC 449.217 Kitchens; storage of food; adequate supplies of food; permits; inspections. (NRS 449.037)
1. The equipment in a kitchen of a residential facility and the size of the kitchen must be adequate for the number of residents in the facility. The kitchen and the equipment must be clean and must allow for the sanitary preparation of food. The equipment must be in good working condition.
2. Perishable foods must be refrigerated at a temperature of 40 degrees Fahrenheit or less. Frozen foods must be kept at a temperature of 0 degrees Fahrenheit or less.
3. Sufficient storage must be available for all food and equipment used for cooking and storing food. Food that is stored must be appropriately packaged.
4. The administrator of a residential facility shall ensure that there is at least a 2-day supply of fresh food and at least a 1-week supply of canned food in the facility at all times.
5. Pesticides and other toxic substances must not be stored in any area in which food, kitchen equipment, utensils or paper products are stored. Soaps, detergents, cleaning compounds and similar substances must not be stored in any area in which food is stored.
6. A residential facility with more than 10 residents shall:
(a) Comply with the standards prescribed in chapter 446 of NAC; and
(b) Obtain the necessary permits from the Bureau of Health Protection Services of the Division.
7. The equipment used for cooking and storing food and for washing dishes in a residential facility with more than 10 residents must be inspected and approved by the Bureau of Health Protection Services of the Division and the state and local fire safety authorities.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.2175 Service of food; seating; menus; special diets; nutritional requirements; dietary consultants. (NRS 449.037)
1. A residential facility shall have adequate facilities and equipment for the preparation, service and storage of food.
2. Tables and chairs must be of proper height and of sufficient number to provide seating for the number of residents authorized for the facility. They must be sturdy and have easily washable surfaces. Chairs must be constructed so that they do not overturn easily.
3. Menus must be in writing, planned a week in advance, dated, posted and kept on file for 90 days.
4. A resident who has been placed on a special diet by a physician or dietitian must be provided a meal that complies with the diet. The administrator of the facility shall ensure that records of any modifications to the menu to accommodate for special diets prescribed by a physician or dietitian are kept on file for at least 90 days.
5. Any substitution for an item on the menu must be documented and kept on file with the menu for at least 90 days after the substitution occurs. A substitution must be posted in a conspicuous place during the serving of the meal.
6. Each meal must provide a reasonable portion of the daily dietary allowances recommended by the Food and Nutrition Board, National Academy of Sciences, National Research Council.
7. Meals must be nutritious, served in an appropriate manner, suitable for the residents and prepared with regard for individual preferences and religious requirements. At least three meals a day must be served at regular intervals. The times at which meals will be served must be posted. Not more than 14 hours may elapse between the meal in the evening and breakfast the next day. Snacks must be made available between meals for the residents who are not prohibited by their physicians from eating between meals.
8. A resident must be served meals in his bedroom for not more than 14 consecutive days if he is temporarily unable to eat in the dining room because of an injury or illness. The facility may serve meals to other residents in their rooms upon request. If a meal is served to a resident in his room because the resident is unable to eat in the dining room, the facility shall maintain a record of the times and reasons for serving meals to the resident in his room.
9. A residential facility with more than 10 residents shall employ or otherwise obtain the services of a person to serve as a consultant for the planning and serving of meals who:
(a) Is registered as a dietitian by the Commission on Dietetic Registration; or
(b) Is a graduate from an accredited college with a major in food and nutrition and has 2 years of supervisory experience in a medical facility or facility for the dependent or has participated in a course of training for a supervisor of the service of food.
10. The person providing services pursuant to subsection 9 shall provide those services not less than once each calendar quarter. The administrator of the facility shall keep a written record of the consultations on file at the facility. The consultations must include:
(a) The development and review of weekly menus;
(b) Training for the employees who work in the kitchen;
(c) Advice regarding compliance with the nutritional program of the facility; and
(d) Any observations of the person providing the services regarding the preparation and service of meals in the facility to ensure that the facility is in compliance with the nutritional program of the facility.
[Bd. of Health, Group Care Facilities §§ 12.1-12.8.1, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004)
NAC 449.218 Bedrooms: Floor space; windows and doors; privacy; storage space; bedding; personal furnishings; lighting. (NRS 449.037)
1. A bedroom in a residential facility that is shared by two or three residents must have at least 60 square feet of floor space for each resident who resides in the bedroom. A resident may not share a bedroom with more than two other residents. A bedroom that is occupied by only one resident must have at least 80 square feet of floor space.
2. Each bedroom in a residential facility must have one or more windows that can be opened from the inside without the use of tools or a door to the outside which is at least 36 inches wide and can be opened from the inside.
3. The combined size of the windows in a bedroom in a facility that was issued a license on or after January 14, 1997, must equal not less than 10 percent of the floor space in the room, and each bedroom window must:
(a) Be not less than:
(1) Twenty-four inches in height; and
(2) Twenty inches in width; and
(b) Have a sill that is not more than 44 inches above the floor.
4. The arrangement of the beds and other furniture in the bedroom must provide privacy for and promote the safety of the residents occupying the bedroom. Adjustable curtains, shades, blinds or similar devices must be provided for visual privacy.
5. Each resident must be provided:
(a) At least 10 square feet of space for storage in a bedroom for each bed in the bedroom; and
(b) At least 24 inches of space in a permanent or portable closet for hanging garments.
6. A separate bed with a comfortable and clean mattress must be made available for each resident. The bed must be at least 36 inches wide. Two clean sheets, a blanket, a pillow and a bedspread must be available for each bed. Linens must be changed at least once each week and more often if the linens become dirty. Additional bedding, including protective mattress covers, must be provided if necessary.
7. Upon the request of a resident, a residential facility may authorize the resident to use personal furniture and furnishings that comply with the requirements of subsection 6 if their use does not jeopardize the health and safety of any of the residents of the facility.
8. There must be a light outside the entrance to each bedroom to provide a resident with adequate lighting to reach safely a switch for turning on a light fixture inside the bedroom. Upon the request of a resident, bedside lighting must be provided.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.220 Bedroom doors. (NRS 449.037)
1. A bedroom door in a residential facility which is equipped with a lock must open with a single motion from the inside unless the lock provides security for the facility and can be operated without a key or any special knowledge.
2. A bedroom door must not be equipped with a deadbolt lock or chain stop unless the door opens directly to the outside of the facility. The doors of a bedroom and the doors of the closets in the bedroom may be equipped with locks for use by residents if:
(a) The doors may be unlocked with a single motion from inside the bedroom or closet without the use of a key; and
(b) The doors of the bedroom may be unlocked from outside the room and the keys are readily available at all times.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.221 Use of certain areas in facility as bedroom prohibited. (NRS 449.037) A hall, stairway, unfinished attic, garage, storage area or shed or other similar area of a residential facility must not be used as a bedroom. Any other room must not be used as a bedroom if it:
1. Can only be reached by passing through a bedroom occupied by another resident; or
2. Is used for any other purpose.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.222 Bathrooms and toilet facilities; toilet articles. (NRS 449.037)
1. Each residential facility with less than seven residents that was issued an initial license before January 14, 1997, must have bathroom facilities in sufficient number to accommodate the residents, the members of the staff of the facility and other persons at the facility.
2. Each residential facility that is issued an initial license on or after January 14, 1997, must have:
(a) A flush toilet and lavatory for each four residents; and
(b) A tub or shower for each six residents.
3. The bottoms of tubs and showers must have surfaces that inhibit falling and slipping. Cabinets that are attached to the floor or grab bars must be adjacent to the tubs, toilets and showers.
4. All bathrooms and toilet facilities must be located convenient to sleeping, recreational and living areas. A bathroom must have a window that can be opened or a vent to outside the facility.
5. Provision must be made for privacy in all bathrooms and toilet facilities in rooms intended for use by more than one person.
6. Bathroom doors that are equipped with locks must open with a single motion from the inside without the use of a key. If a key is required to open a lock from outside the bathroom, the key must be readily available at all times.
7. Each resident must have his own toilet articles and must be provided with toilet paper, individual towels and washcloths. Paper towels may be used for hand towels. The towels and washcloths must be changed as often as is necessary to maintain cleanliness, but in no event less often than once each week. A soap dispenser may be used instead of individual bars of soap.
8. All bathrooms and toilet facilities must be sufficiently lighted, and night-lights must be provided in hallways that lead from the bedrooms to the bathrooms and toilet facilities.
[Bd. of Health, Group Care Facilities §§ 15.4-15.4.6 & 15.6, eff. 12-18-75; § 15.5, eff. 12-18-75; A 5-7-82]—(NAC A by R003-97, 10-30-97)
NAC 449.224 Housing for staff members. (NRS 449.037)
1. Bedrooms must be provided for any members of the staff of a residential facility and their families who live at a residential facility. The bedrooms must comply with the provisions of subsections 2 to 8, inclusive, of NAC 449.218 and the provisions of NAC 449.220 and 449.221.
2. Members of the staff of the facility and their families who live at the facility shall be deemed residents of the facility for the purposes of determining the number of toilets, lavatories and tubs or showers the facility is required to have pursuant to NAC 449.222. All toilets, lavatories and tubs or showers used by the members of the staff of the facility or their families must comply with the provisions of NAC 449.222.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.226 Safety requirements for residents with restricted mobility or poor eyesight; water hazards; auditory systems for bathrooms and bedrooms; access by vehicles. (NRS 449.037)
1. A resident of a residential facility who uses a wheelchair or a walker must not be required to use a bedroom on a floor other than the first floor of the facility that is entirely above the level of the ground, unless the facility is designed and equipped in such a manner that the resident can move between floors without assistance.
2. Stairways, inclines, ramps, open porches and other areas that are potentially hazardous for residents who have poor eyesight must be adequately lighted.
3. If a residential facility with a resident who is mentally or physically disabled has a fishpond, pool, hot tub, jacuzzi or other body of water on the premises of the facility, the body of water must be fenced, covered or blocked in some other manner at all times when it is not being used by a resident.
4. In a residential facility with more than 10 residents:
(a) Each resident must be provided with, or the bedroom and bathroom of each resident must be equipped with, an auditory system that is monitored by a member of the staff of the facility.
(b) An auditory system must be available for use in the bathroom of each resident of the facility if the facility was issued its initial license on or after January 14, 1997, so that a resident needing assistance can alert a member of the staff of the facility of that fact from the toilet and the shower.
(c) A bathroom that is located in a common area of the facility must be equipped with an auditory system that is monitored by a member of the staff of the facility.
5. Residential facilities must be easily accessible by vehicle in the case of an emergency.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99)
NAC 449.227 Accommodations for residents with restricted mobility. (NRS 449.037) A residential facility with a resident who uses a wheelchair or a walker shall:
1. Have hallways, doorways and exits wide enough to accommodate a wheelchair or walker;
2. Have ramps to accommodate access to areas used by residents; and
3. Provide assistance to such a resident at all steps located inside the facility on the first floor that is entirely above grade.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.229 Requirements and precautions regarding safety from fire. (NRS 449.037)
1. The administrator of a residential facility shall ensure that the facility complies with the regulations adopted by the State Fire Marshal pursuant to chapter 477 of NRS and all local ordinances relating to safety from fire. The facility must be approved for residency by the State Fire Marshal.
2. A residential facility shall have a plan for the evacuation of residents in case of fire or other emergency. The plan must be:
(a) Understood by all employees;
(b) Posted in a common area of the facility; and
(c) Discussed with each resident at the time of his admission.
3. A drill for evacuation must be performed monthly on an irregular schedule, and a written record of each drill must be kept on file at the facility for not less than 12 months after the drill.
4. Portable fire extinguishers must be inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections.
5. A portable heater or space heater must not be used in a residential facility unless the heater:
(a) Is located 2 feet or more from any combustible material;
(b) Is plugged directly into a wall socket;
(c) Turns off automatically if tipped over; and
(d) Has no exposed heating elements.
6. A fireplace must be equipped with glass doors or a metal screen to prevent ashes or burning wood from falling outside the fireplace.
7. The administrator shall ensure that a written policy on smoking is developed and carried out by the facility. The policy must be:
(a) Developed with the purpose of preventing a fire caused by smoking in the facility; and
(b) Posted in a common area of the facility.
8. The windows and doors of a residential facility must not be covered with security bars.
9. Smoke detectors must be maintained in proper operating condition at all times and must be tested monthly. The results of the tests conducted pursuant to this subsection must be recorded and maintained at the facility.
10. An exit door in a residential facility must not be equipped with a lock that requires a key to open it from the inside unless approved by the State Fire Marshal or his designee.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004)
NAC 449.231 First aid and cardiopulmonary resuscitation. (NRS 449.037)
1. Within 30 days after an administrator or caregiver of a residential facility is employed at the facility, the administrator or caregiver must be trained in first aid and cardiopulmonary resuscitation. The advanced certificate in first aid and adult cardiopulmonary resuscitation issued by the American Red Cross or an equivalent certification will be accepted as proof of that training.
2. A first-aid kit must be available at the facility. The first-aid kit must include, without limitation:
(a) A germicide safe for use by humans;
(b) Sterile gauze pads;
(c) Adhesive bandages, rolls of gauze and adhesive tape;
(d) Disposable gloves;
(e) A shield or mask to be used by a person who is administering cardiopulmonary resuscitation; and
(f ) A thermometer or other device that may be used to determine the bodily temperature of a person.
3. Except for first aid in an emergency, no treatment or medication may be administered to a resident without the approval of a physician.
[Bd. of Health, Group Care Facilities §§ 16.9-16.12.3, eff. 12-18-75; § 16.13, eff. 5-7-82]—(NAC A 3-6-86; R003-97, 10-30-97)
NAC 449.232 Telephone; list of telephone numbers. (NRS 449.037)
1. Each residential facility shall have a telephone that the residents may use to make local calls.
2. A list of telephone numbers to be called in case of an emergency for each resident must be located near the telephone. The list must include the telephone number of the resident’s physician and the telephone number of a friend of the resident or one of the members of the resident’s family.
3. The telephone number of the facility must be listed in the telephone directory under the name of the facility.
(Added to NAC by Bd. of Health, eff. 3-6-86; A by R003-97, 10-30-97; R073-03, 1-22-2004)
NAC 449.241 Limitations on use of volunteers; requirements concerning residents who volunteer to assist staff or perform other duties. (NRS 449.037)
1. Volunteers may be used to supplement the services and programs of a residential facility, but may not be used to replace members of the staff of the facility.
2. A resident may volunteer to help the employees of the facility in a manner that does not create an unsafe condition for the resident, other residents or the members of the staff of the facility.
3. A resident must not be required to perform duties normally performed by the staff of the facility. If a resident volunteers to perform such duties, the administrator of the facility shall ensure that the resident’s records include a statement that the resident has volunteered to perform those duties.
4. A resident who is performing duties pursuant to this section must not be allowed access to confidential files.
(Added to NAC by Bd. of Health, eff. 3-6-86; A by R003-97, 10-30-97)
NAC 449.258 Written policies for facility; policy on visiting hours; residents’ mail; compliance with policies. (NRS 449.037)
1. Written policies for a residential facility that comply with the provisions of NAC 449.156 to 449.27706, inclusive, must be developed.
2. A policy on visiting hours must be established to promote contact by the residents with persons who are not residents of the facility. The policy regarding visits must be flexible to ensure that every resident has the opportunity to retain and strengthen ties with family and friends.
3. Assurances must be provided that incoming and outgoing mail for a resident will not be interfered with in any way, unless written permission is obtained from the resident or his representative. Permission obtained from the resident or his representative may specifically state the type of mail that may be interfered with by the members of the staff of the facility. Permission granted by a resident or his representative pursuant to this subsection may be revoked by the resident at any time.
4. The employees of the facility shall comply with the policies developed pursuant to this section.
[Bd. of Health, Group Care Facilities §§ 11.1-11.7.1, eff. 12-18-75]—(NAC A by R003-97, 10-30-97; R073-03, 1-22-2004)
NAC 449.259 Supervision and treatment of residents generally. (NRS 449.037)
1. A residential facility shall:
(a) Provide each resident with protective supervision as necessary;
(b) Inform all caregivers of the required supervision;
(c) Provide each resident with the opportunity to attend the religious service of his choice and participate in personal and private pastoral counseling;
(d) Permit a resident to rest in his room at any time;
(e) Permit a resident to enter or leave the facility at any time if the resident:
(1) Is physically and mentally capable of leaving the facility; and
(2) The resident complies with the rules established by the administrator of the facility for leaving the facility;
(f ) Provide laundry services for each resident unless a resident elects in writing to make other arrangements;
(g) Ensure that each resident’s clothes are clean, comfortable and presentable; and
(h) Inform each resident or his representative of the actions that the resident should take to protect his valuables.
2. The administrator of a residential facility may require a resident who leaves the facility to inform a member of the staff of the facility upon his departure and return.
3. The employees of a residential facility shall:
(a) Treat each resident in a kind and considerate manner; and
(b) Respect each resident’s independence and ability to make decisions on his own, whenever possible.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.260 Activities for residents. (NRS 449.037)
1. The caregivers employed by a residential facility shall:
(a) Ensure that the residents are afforded an opportunity to enjoy their privacy, participate in physical activities, relax and associate with other residents;
(b) Provide group activities that provide mental and physical stimulation and develop creative skills and interests;
(c) Plan recreational opportunities that are suited to the interests and capacities of the residents;
(d) Provide each resident with a written program of activities;
(e) Provide for the residents at least 10 hours each week of scheduled activities that are suited to their interests and capacities;
(f ) Encourage the residents to participate in the activities scheduled pursuant to paragraph (e); and
(g) Post, in a common area of the facility, a calendar of activities for each month that notifies residents of the major activities that will occur in the facility. The calendar must be:
(1) Prepared at least 1 month in advance; and
(2) Kept on file at the facility for not less than 6 months after it expires.
2. The administrator of a residential facility with at least 20 residents shall appoint a member of the staff of the facility who will be responsible for the organization, conduct and evaluation of activities for the residents. The person so appointed shall ensure that the activities are suited to the interests and capacities of the residents.
3. The administrator of a residential facility with 50 or more residents shall, in addition to appointing a member of the staff of the facility pursuant to subsection 2, appoint such other members of the staff as the administrator deems necessary to assist the person who is responsible for conducting the activities.
4. A residential facility shall have areas of sufficient size to conduct indoor and outdoor activities, including, without limitation:
(a) A common area that complies with the provisions of NAC 449.216; and
(b) An outdoor activity area that is easily accessible for the residents and is safe from vehicular traffic.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.262 Provision of dental, optical and hearing care and social services; report of suspected abuse, neglect, isolation or exploitation; restrictions on use of restraints, confinement or sedatives. (NRS 449.037)
1. The administrator of a residential facility shall ensure that residents are provided with or are assisted in obtaining dental and optical care, treatment for hearing and hearing impairment and social services. The employees of the facility shall maintain a record of the services or assistance provided pursuant to this subsection.
2. If an employee of the facility suspects that a resident is being abused, neglected, isolated or exploited, the employee shall report that fact in the manner prescribed in NRS 200.5093.
3. The members of the staff of a residential facility shall not:
(a) Use restraints on any resident;
(b) Lock a resident in a room inside the facility; or
(c) Provide sedatives to a resident unless that sedative has been prescribed for that resident by a physician to treat specific symptoms. A caregiver shall make a record of the behavior of a resident who has been prescribed a sedative.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.267 Money and property of residents. (NRS 449.037)
1. An employee of a residential facility shall not handle a resident’s money without first being requested to do so in writing by the resident or his representative.
2. An accurate record must be kept of all money deposited with the facility for use by the resident, including withdrawals. The record must include:
(a) A separate accounting of the money held by the facility on behalf of the resident;
(b) Receipts for expenditures made by the facility on behalf of the resident; and
(c) A written acknowledgment by the resident for each withdrawal of his money.
3. Unless a resident otherwise requests in writing, all money in excess of $400 held by the facility on behalf of the resident must be maintained in a financial institution in an account separate from the facility’s operating accounts and must be clearly designated as such.
4. Each resident must have access to his money held at the facility on his behalf during normal business hours on each business day.
5. If a member of the staff of a residential facility receives from a resident a request to make a withdrawal of money in such an amount that the member of the staff has reason to believe that the resident is being or has been exploited, the member of the staff shall report the transaction to:
(a) If the resident is 60 years of age or older:
(1) The local office of the Aging Services Division of the Department of Health and Human Services;
(2) The local law enforcement agency;
(3) The office for protective services for the county in which the facility is located if that county has such an office; or
(4) The toll-free telephone service designated by the Aging Services Division pursuant to NRS 200.5093.
(b) If the resident is less than 60 years of age:
(1) The office for protective services for the county in which the facility is located if that county has such an office; or
(2) The local law enforcement agency if the county in which the facility is located does not have an office for protective services.
6. Except as otherwise provided in subsection 7, an operator or employee of a residential facility shall not accept appointment as a guardian or conservator of the estate of any resident, become a substitute payee for any payments made to any resident or accept an appointment as an attorney in fact for any resident.
7. If a resident whose only source of income is in the form of monthly checks is legally determined to be unable to manage his money and documentary evidence can be produced showing that efforts to obtain a legal guardian have failed, the facility may be the substitute payee on the checks. Records of all checks received, deposited or dispersed by the facility must be maintained in the resident’s file.
8. Money that is held by a residential facility on behalf of a resident must be returned to the resident or his representative within 30 days after the resident is discharged from the facility.
9. An employee of a residential facility shall not borrow money from a resident.
[Bd. of Health, Group Care Facilities §§ 11.15-11.19.1, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004)
NAC 449.268 Rights of residents; procedure for filing grievance, complaint or report of incident; investigation and response. (NRS 449.037)
1. The administrator of a residential facility shall ensure that:
(a) The residents are not abused, neglected or exploited by a member of the staff of the facility, another resident of the facility or any person who is visiting the facility;
(b) A resident is not prohibited from speaking to any person who advocates for the rights of the residents of the facility;
(c) The residents are treated with respect and dignity;
(d) The facility is a safe and comfortable environment;
(e) Residents are not prohibited from interacting socially;
(f ) Residents are allowed to make their own decisions whenever possible;
(g) Residents are aware that they may file a complaint or grievance with the administrator and that a resident who files such a complaint receives a response in a timely manner;
(h) A resident is informed as soon as practicable that he is being moved to a new room or that he is receiving a new roommate; and
(i) Residents are afforded the opportunity to initiate an advance directive or power of attorney for health care and that the employees of the facility comply with the wishes contained in such a document.
2. The administrator of a residential facility shall provide a procedure to respond immediately to grievances, incidents and complaints. The procedure must include a method for ensuring that the administrator or a person designated by the administrator is notified of the grievance, incident or complaint. The administrator or a person designated by the administrator shall personally investigate the matter. A resident who files a grievance or complaint or reports an incident pursuant to this subsection must be notified of the action taken in response to the grievance, complaint or report or be given a reason why no action needs to be taken.
3. The employees of the facility shall comply with the procedures adopted pursuant to subsection 2.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.269 Discrimination prohibited. (NRS 449.037)
1. A resident of a residential facility shall not be segregated or restricted in the enjoyment of any advantage or privilege enjoyed by other residents, or provided with any assistance, service or other benefit which is different or provided in a different manner from that provided to other residents, on the ground of race, color, religion, national origin or disability.
2. The facility’s policy regarding nondiscrimination must be posted in a public area of the facility.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
Admitting, Transferring and Discharging Residents
NAC 449.2702 Written policy on admissions; eligibility for residency. (NRS 449.037)
1. Each residential facility shall have a written policy on admissions which includes:
(a) A statement of nondiscrimination regarding admission to the facility and treatment after admission; and
(b) The requirements for eligibility as a resident of that type of facility.
2. A person who wishes to reside in a residential facility with residents that require a higher category of care than he requires may reside in the facility if he is not otherwise prohibited from residing in the facility.
3. A person who is admitted to a residential facility must be at least 18 years of age.
4. Except as otherwise provided in NAC 449.275 and 449.2754, a residential facility shall not admit or allow to remain in the facility any person who:
(a) Is bedfast;
(b) Requires restraint;
(c) Requires confinement in locked quarters; or
(d) Requires skilled nursing or other medical supervision on a 24-hour basis.
5. A person may not reside in a residential facility if the person’s physician or the Bureau determines that the person does not comply with the requirements for eligibility.
6. As used in this section:
(a) “Bedfast” means a condition in which a person is:
(1) Incapable of changing his position in bed without the assistance of another person; or
(2) Immobile.
(b) “Restraint” means:
(1) A psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms;
(2) A manual method for restricting a resident’s freedom of movement or his normal access to his body; or
(3) A device or material or equipment which is attached to or adjacent to a resident’s body that cannot be removed easily by the resident and restricts the resident’s freedom of movement or his normal access to his body.
[Bd. of Health, Group Care Facilities § 7.1, eff. 12-18-75; §§ 7.2-7.4.2, eff. 12-18-75; A 5-7-82; §§ 7.5-7.6.4, eff. 12-18-75]—(NAC A 3-6-86; 8-1-91; R003-97, 10-30-97; R073-03, 1-22-2004; R118-05, 11-17-2005)
NAC 449.2704 Disclosure of information concerning rates and payment for services. (NRS 449.037) The administrator of a residential facility shall, upon request, make the following information available in writing:
1. The basic rate for the services provided by the facility;
2. The schedule for payment;
3. The services included in the basic rate;
4. The charges for optional services which are not included in the basic rate; and
5. The residential facility’s policy on refunds of amounts paid but not used.
(Added to NAC by Bd. of Health, eff. 3-6-86; A by R003-97, 10-30-97; R052-99, 9-27-99)
NAC 449.2706 Transfer of resident whose condition deteriorates. (NRS 449.037)
1. If a resident’s condition deteriorates to such an extent that:
(a) The residential facility is unable to provide the services necessary to treat the resident properly; or
(b) The resident no longer complies with the requirements for admission to the facility,
Ê the facility shall plan for the transfer of the resident pursuant to NRS 449.700 and 449.705 to another facility that is able to provide the services necessary to treat the resident properly.
2. A resident, his next of kin and the responsible agency, if any, must be consulted and adequate arrangements must be made to meet the resident’s needs through other means before he permanently leaves the facility.
[Bd. of Health, Group Care Facilities §§ 10.1-10.3, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004)
NAC 449.2707 Transfer of resident: Effective date. (NRS 449.037) The transfer of a resident from a residential facility occurs:
1. Except as otherwise provided in subsection 2, on the date that the resident is admitted to the facility to which he is moved; or
2. If the resident is moved to a unit or department of a hospital, other than the emergency department of the hospital, on the date that the resident is accepted at the hospital for care or observation.
(Added to NAC by Bd. of Health by R071-04, eff. 8-4-2004)
NAC 449.2708 Discharge of resident; notice of discharge; issuance of notice to quit to resident for improper or harmful behavior. (NRS 449.037)
1. A resident may be discharged from a residential facility without his approval if:
(a) He fails to pay his bill within 5 days after it is due;
(b) He fails to comply with the rules or policies of the facility; or
(c) The administrator of the facility or the Bureau determines that the facility is unable to provide the necessary care for the resident.
2. Except as otherwise provided in this section, before a resident may be discharged from a residential facility without his approval pursuant to this section, the facility must provide the resident, his representative and the person who pays the bill on behalf of the resident, if any, with written notice that the resident will be discharged.
3. A residential facility shall discharge a resident who is transferred pursuant to NRS 449.700 and 449.705 and admitted to another facility for a higher level of care. Written notice pursuant to subsection 2 that the resident will be discharged is not required if the condition of the resident necessitates immediate transfer to receive emergency care.
4. If the resident or any of his visitors are engaging in behavior which is a threat to the mental or physical health or safety of the resident or other persons in the facility, the facility may issue a notice to quit to the resident. The notice to quit must include:
(a) The reasons for its issuance, with specific facts relating to the date, time and place of the incidents that posed a threat to the physical or mental health or safety of the resident or other persons in the facility; and
(b) The names of persons who witnessed the incidents and the circumstances under which the incidents occurred.
Ê If the resident or his visitors do not comply with the notice to quit, the resident may be discharged from the facility without his approval pursuant to subsection 2.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004)
Restrictions on Admitting or Retaining Residents With Certain Medical Needs or Conditions
NAC 449.271 Residents requiring gastrostomy care or suffering from staphylococcus infection or other serious infection or medical condition. (NRS 449.037) Except as otherwise provided in NAC 449.2736, a person must not be admitted to a residential facility or permitted to remain as a resident of a residential facility if he:
1. Requires gastrostomy care;
2. Suffers from a staphylococcus infection or other serious infection; or
3. Suffers from any other serious medical condition that is not described in NAC 449.2712 to 449.2734, inclusive.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.2712 Residents requiring use of oxygen. (NRS 449.037)
1. A person who requires the use of oxygen must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless he:
(a) Is mentally and physically capable of operating the equipment that provides the oxygen; or
(b) Is capable of:
(1) Determining his need for oxygen; and
(2) Administering the oxygen to himself with assistance.
2. The caregivers employed by a residential facility with a resident who requires the use of oxygen shall:
(a) Monitor the ability of the resident to operate the equipment in accordance with the orders of a physician; and
(b) Ensure that:
(1) The resident’s physician evaluates periodically the condition of the resident which necessitates his use of oxygen;
(2) Signs which prohibit smoking and notify persons that oxygen is in use are posted in areas of the facility in which oxygen is in use or is being stored;
(3) Persons do not smoke in those areas where smoking is prohibited;
(4) All electrical equipment is inspected for defects which may cause sparks;
(5) All oxygen tanks kept in the facility are secured in a stand or to a wall;
(6) The equipment used to administer oxygen is in good working condition;
(7) A portable unit for the administration of oxygen in the event of a power outage is present in the facility at all times when a resident who requires oxygen is present in the facility; and
(8) The equipment used to administer oxygen is removed from the facility when it is no longer needed by the resident.
3. The administrator of a residential facility shall ensure that the caregivers who may be required to administer oxygen have demonstrated the ability to operate properly the equipment used to administer oxygen.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.2714 Residents requiring use of intermittent positive pressure breathing equipment. (NRS 449.037)
1. A person who requires the use of intermittent positive pressure breathing equipment must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless:
(a) The resident is mentally and physically capable of operating and disinfecting the equipment and is capable of determining when its use is required; or
(b) The equipment is operated by a medical professional who has been trained to operate the equipment.
2. The caregivers employed by a residential facility with a resident who requires the use of intermittent positive pressure breathing equipment shall:
(a) Monitor the ability of the resident to operate the equipment in accordance with the orders of a physician; and
(b) Ensure that:
(1) The resident’s physician evaluates periodically the condition of the resident which necessitates his use of the equipment;
(2) The equipment is operated by a medical professional trained in the operation of the equipment if the resident requires assistance;
(3) The equipment is in good working condition; and
(4) The equipment is removed from the facility when it is no longer needed by the resident.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.2716 Residents having colostomy or ileostomy. (NRS 449.037)
1. A person who has a colostomy or ileostomy must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless:
(a) The resident is mentally and physically capable of properly caring for his colostomy or ileostomy, with or without assistance, and the resident’s physician has stated in writing that the colostomy or ileostomy is completely healed; or
(b) The care for the colostomy or ileostomy is provided by a medical professional who is trained to provide that care.
2. The caregivers employed by a residential facility with a resident who has a colostomy or ileostomy shall ensure that:
(a) All bags used by the resident are discarded appropriately; and
(b) Privacy is afforded to the resident when care for the colostomy or ileostomy is being provided.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.2718 Residents requiring manual removal of fecal impactions or use of enemas or suppositories. (NRS 449.037)
1. A person who requires the manual removal of fecal impactions or the use of enemas or suppositories must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless:
(a) The resident is able to provide the care for himself; or
(b) The care is administered according to the written instructions of a physician by a medical professional who has been trained to provide that care.
2. The caregivers employed by a residential facility with a resident who requires the manual removal of fecal impactions or the use of enemas or suppositories shall ensure that privacy is afforded to the resident when that care is being provided.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R204-99, 2-10-2000)
NAC 449.272 Residents requiring use of indwelling catheter. (NRS 449.037)
1. A person who requires the use of an indwelling catheter must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless:
(a) The resident is physically and mentally capable of caring for all aspects of the condition, with or without the assistance of a caregiver;
(b) Irrigation of the catheter is performed in accordance with the physician’s orders by a medical professional who has been trained to provide that care; and
(c) The catheter is inserted and removed only in accordance with the orders of a physician by a medical professional who has been trained to insert and remove a catheter.
2. The caregivers employed by a residential facility with a resident who requires the use of an indwelling catheter shall ensure that:
(a) The bag and tubing of the catheter are changed by:
(1) The resident, with or without the assistance of a caregiver; or
(2) A medical professional who has been trained to provide that care;
(b) Waste from the use of the catheter is disposed of properly;
(c) Privacy is afforded to the resident while care is being provided; and
(d) The bag of the catheter is emptied by a caregiver who has received instruction in the handling of such waste and the signs and symptoms of urinary tract infections and dehydration.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.2722 Residents having unmanageable condition of bowel or bladder incontinence; residents having manageable condition of bowel or bladder incontinence. (NRS 449.037)
1. A person who has an unmanageable condition of bowel or bladder incontinence must not be admitted to a residential facility or permitted to remain as a resident of a residential facility.
2. A person who has a manageable condition of bowel or bladder incontinence must not be admitted to a residential facility or permitted to remain as a resident of a residential facility unless the condition can be managed by:
(a) The resident without the assistance of any other person;
(b) Requiring the resident to participate in a structured bowel or bladder retraining program to assist the resident in restoring a normal pattern of continence;
(c) A program which includes scheduled toileting at regular intervals; or
(d) Requiring the resident to use products that keep him clean and dry at all times.
3. The caregivers employed by a residential facility with a resident who has a manageable condition of bowel or bladder incontinence shall ensure that:
(a) If the resident can benefit from scheduled toileting, he is assisted or reminded to go to the bathroom at regular intervals;
(b) The resident is checked during those periods when he is known to be incontinent, including during the night;
(c) The resident is kept clean and dry;
(d) Retraining programs are designed by a medical professional with training and experience in the care of persons with bowel or bladder dysfunction;
(e) The retraining programs established for a resident are followed; and
(f ) Privacy is afforded to the resident when care is being provided.
4. The caregivers employed by the facility shall not:
(a) Withhold fluids from a resident to control incontinence; or
(b) Have a resident catheterized to control incontinence for the convenience of the employees of the facility.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.2724 Residents having contractures. (NRS 449.037)
1. A person who has contractures must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless the contractures do not adversely affect the ability of the resident to perform normal bodily functions and:
(a) The resident is able to care for the contractures without assistance; or
(b) Supervision in caring for the contractures is provided by a medical professional who is trained to provide such supervision.
2. The caregivers employed by a residential facility with a resident who has contractures shall ensure that the performance by the resident of any exercises to improve the resident’s range of motion or any other exercises prescribed by a physician is supervised by a medical professional who has been trained to provide such supervision.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.2726 Residents having diabetes. (NRS 449.037)
1. A person who has diabetes must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless:
(a) The resident’s glucose testing is performed by:
(1) The resident himself without assistance; or
(2) A medical laboratory licensed pursuant to chapter 652 of NRS; and
(b) The resident’s medication is administered:
(1) By the resident himself without assistance;
(2) By a medical professional, or licensed practical nurse, who is:
(I) Not employed by the residential facility;
(II) Acting within his authorized scope of practice and in accordance with all applicable statutes and regulations; and
(III) Trained to administer the medication; or
(3) If the conditions set forth in subsection 2 are satisfied, with the assistance of a caregiver employed by the residential facility.
2. A caregiver employed by a residential facility may assist a resident in the administration of the medication prescribed to the resident for his diabetes if:
(a) The resident’s physical and mental condition is stable and is following a predictable course.
(b) The amount of the medication prescribed to the resident for his diabetes is at a maintenance level and does not require a daily assessment.
(c) A written plan of care by a physician or registered nurse has been established that:
(1) Addresses possession and assistance in the administration of the medication for the resident’s diabetes; and
(2) Includes a plan, which has been prepared under the supervision of a registered nurse or licensed pharmacist, for emergency intervention if an adverse condition results.
(d) The medication prescribed to the resident for his diabetes is not administered by injection or intravenously.
(e) The caregiver has successfully completed training and examination approved by the Health Division regarding the administration of such medication.
3. The caregivers employed by a residential facility with a resident who has diabetes shall ensure that:
(a) Sufficient amounts of medicines, equipment to perform tests, syringes, needles and other supplies are maintained and stored in a secure place in the facility;
(b) Syringes and needles are disposed of appropriately in a sharps container which is stored in a safe place; and
(c) The caregivers responsible for the resident have received instruction in the recognition of the symptoms of hypoglycemia and hyperglycemia by a medical professional who has been trained in the recognition of those symptoms.
4. The caregivers employed by a residential facility with a resident who has diabetes and requires a special diet shall provide variations in the types of meals served and make available food substitutions in order to allow the resident to consume meals as prescribed by the resident’s physician. The substitutions must conform with the recommendations for food exchanges contained in the Exchange Lists For Meal Planning, published by the American Diabetes Association, Incorporated, and the American Dietetic Association, which is hereby adopted by reference. A copy of the publication may be obtained from the American Diabetes Association, Incorporated, Order Fulfillment Department, P.O. Box 930850, Atlanta, Georgia 31193-0850, at a cost of $2.50.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.2728 Residents requiring regular intramuscular, subcutaneous or intradermal injections. (NRS 449.037)
1. A person who requires regular intramuscular, subcutaneous or intradermal injections must not be admitted to a residential facility or be permitted to remain as a resident of the facility unless the injections are administered by:
(a) The resident; or
(b) A medical professional, or licensed practical nurse, acting within his authorized scope of practice and in accordance with all applicable statutes and regulations,
Ê who has been trained to administer those injections.
2. The caregivers employed by a residential facility with a resident who requires regular intramuscular, subcutaneous or intradermal injections shall ensure that:
(a) Sufficient amounts of medicines, equipment to perform tests, syringes, needles and other supplies are maintained and stored in a secure place in the facility; and
(b) Syringes and needles are disposed of appropriately in a sharps container which is stored in a safe place.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.2732 Residents requiring protective supervision. (NRS 449.037)
1. Except as otherwise provided in subsection 2, a person who requires protective supervision may not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless:
(a) The resident is able to follow instructions;
(b) The resident is able to make his needs known to the caregivers employed by the facility;
(c) The resident can be protected from harming himself and other persons; and
(d) The caregivers employed by the facility can meet the needs of the resident.
2. If a person who requires protective supervision is unable to follow instructions or has difficulty making his needs known to the employees of the facility, the person may be admitted to the facility or be permitted to remain as a resident of the facility if the facility complies with the provisions of NAC 449.2754 and 449.2756.
3. The administrator of a residential facility with a resident who requires protective services shall ensure that:
(a) The caregivers employed by the facility are capable of providing the supervision for that resident without neglecting the needs of the other residents of the facility; and
(b) There is a written plan for providing protective supervision for that resident.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97)
NAC 449.2734 Residents having tracheostomy or open wound requiring treatment by medical professional; residents having pressure or stasis ulcers. (NRS 449.037)
1. A person who has a tracheostomy or an open wound that requires treatment by a medical professional must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless:
(a) The wound is in the process of healing or the tracheostomy is stable or can be cared for by the resident without assistance;
(b) The care is provided by or under the supervision of a medical professional who has been trained to provide that care; or
(c) The wound is the result of surgical intervention and care is provided as directed by the surgeon.
2. If a person who has a pressure or stasis ulcer or who is at risk of developing a pressure or stasis ulcer is admitted to a residential facility or permitted to remain as a resident of a residential facility:
(a) The condition must have been diagnosed by a physician;
(b) The condition must be cared for by a medical professional who is trained to provide care for and reassessment of that condition; and
(c) Before a caregiver provides care to the person who has a pressure or stasis ulcer or who is at risk of developing a pressure or stasis ulcer, the caregiver must receive training related to the prevention and care of pressure sores from a medical professional who is trained to provide care for that condition.
3. The administrator of the facility shall ensure that records of the care provided to a person who has a pressure or stasis ulcer pursuant to subsection 2 are maintained at the facility. The records must include an explanation of the cause of the pressure or stasis ulcer.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R204-99, 2-10-2000; R073-03, 1-22-2004)
NAC 449.2736 Procedure to exempt certain residents from restrictions. (NRS 449.037)
1. The administrator of a residential facility may submit to the Division a written request for permission to admit or retain a resident who is prohibited from being admitted to a residential facility or remaining as a resident of the facility pursuant to NAC 449.271 to 449.2734, inclusive.
2. A written request submitted pursuant to this section must include, without limitation:
(a) Records concerning the resident’s current medical condition, including updated medical reports, other documentation of current health, a prognosis and the expected duration of the condition;
(b) A plan for ensuring that the resident’s medical needs can be met by the facility;
(c) A plan for ensuring that the level of care provided to the other residents of the facility will not suffer as a result of the admission or retention of the resident who is the subject of the request; and
(d) A statement signed by the administrator of the facility that the needs of the resident who is the subject of the written request will be met by the caregivers employed by the facility.
3. A written request submitted to the Division pursuant to this section must be received:
(a) Before the administrator admits a resident; or
(b) At the onset of a medical condition set forth in NAC 449.271 to 449.2734, inclusive.
4. A residential facility must receive the permission requested pursuant to subsection 1 before the facility admits a resident who is otherwise prohibited from being admitted to the facility pursuant to NAC 449.271 to 449.2734, inclusive.
5. A residential facility may retain a resident who is otherwise prohibited from remaining as a resident of the facility pursuant to NAC 449.271 to 449.2734, inclusive, for 10 days after the facility submits to the Division the written request required pursuant to subsection 1.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R204-99, 2-10-2000)
NAC 449.2738 Review of medical condition of resident; relocation or transfer of resident having certain medical needs or conditions. (NRS 449.037)
1. If, after conducting an inspection or investigation of a residential facility, the Bureau determines that it is necessary to review the medical condition of a resident, the Bureau shall inform the administrator of the facility of the need for the review and the information the facility is required to submit to the Bureau to assist in the performance of the review. The administrator shall, within a period prescribed by the Bureau, provide to the Bureau:
(a) The assessments made by physicians concerning the physical and mental condition of the resident; and
(b) Copies of prescriptions for medication or orders of physicians for services or equipment necessary to provide care for the resident.
2. If the Bureau or the resident’s physician determines that the facility is prohibited from caring for the resident pursuant to NAC 449.271 to 449.2734, inclusive, or is unable to care for the resident in the proper manner, the administrator of the facility must be notified of that determination. Upon receipt of such a notification, the administrator shall, within a period prescribed by the Bureau, submit a plan to the Bureau for the safe and appropriate relocation of the resident pursuant to NRS 449.700 to a place where the proper care will be provided.
3. If an inspection or investigation reveals that the conditions at a residential facility may immediately jeopardize the health and safety of a resident, the administrator of the facility shall, as soon as practicable, ensure that the resident is transferred to a facility which is capable of properly providing for his care.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
Medical Services, Medical Records and Other Records Concerning Residents
NAC 449.274 Medical care of resident after illness, injury or accident; periodic physical examination of resident; rejection of medical care by resident; written records. (NRS 449.037)
1. If a resident of a residential facility becomes ill or is injured, the resident’s physician and a member of the resident’s family must be notified at the onset of illness or at the time of the injury. The facility shall:
(a) Make all necessary arrangements to secure the services of a licensed physician to treat the resident if the resident’s physician is not available; and
(b) Request emergency services when such services are necessary.
2. A resident who is suffering from an illness or injury from which the resident is expected to recover within 14 days after the onset of the illness or the time of the injury may be cared for in the facility. The decision as to the period within which the resident is expected to recover from the illness or injury and the needs of the resident must be made by the resident’s physician or, if he is unavailable, by another licensed physician.
3. A written record of all accidents, injuries and illnesses of the resident which occur in the facility must be made by the caregiver who first discovers the accident, injury or illness. The record must include:
(a) The date and time of the accident or injury or the date and time that the illness was discovered;
(b) A description of the manner in which the accident or injury occurred or the manner in which the illness was discovered; and
(c) A description of the manner in which the members of the staff of the facility responded to the accident, injury or illness and the care provided to the resident.
Ê This record must accompany the resident if he is transferred to another facility.
4. The facility shall ensure that appropriate medical care is provided to the resident by:
(a) A caregiver who is trained to provide that care;
(b) An independent contractor who is trained to provide that care; or
(c) A medical professional.
5. Before admission and each year after admission, or more frequently if there is a significant change in the physical condition of a resident, the facility shall obtain the results of a general physical examination of the resident by his physician. The resident must be cared for pursuant to any instructions provided by the resident’s physician.
6. The members of the staff of the facility shall:
(a) Ensure that the resident receives the personal care that he requires.
(b) Monitor the ability of the resident to care for his own health conditions and document in writing any significant change in his ability to care for those conditions.
7. This section does not prohibit a resident from rejecting medical care. If a resident rejects medical care, an employee of the facility shall record the rejection in writing and request that the resident sign that record as a confirmation of his rejection of medical care. If the resident rejects medical care that a physician has directed the facility to provide, the facility shall inform the resident’s physician of that fact within 4 hours after the care is rejected. The facility shall maintain a record of the notice provided to the physician pursuant to this subsection.
8. As used in this section, “significant change” means a change in a resident’s condition that results in a category 1 resident becoming a category 2 resident or otherwise results in an increase in the level of care required by the resident.
[Bd. of Health, Group Care Facilities §§ 8.1-8.4, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004)
NAC 449.2742 Administration of medication: Responsibilities of administrator, caregiver and employee of facility. (NRS 449.037)
1. The administrator of a residential facility that provides assistance to residents in the administration of medications shall:
(a) Ensure that a physician, pharmacist or registered nurse who does not have a financial interest in the facility:
(1) Reviews for accuracy and appropriateness, at least once every 6 months, the regimen of drugs taken by each resident of the facility, including, without limitation, any over-the-counter medications and dietary supplements taken by a resident; and
(2) Provides a written report of that review to the administrator of the facility;
(b) Include a copy of each report submitted to the administrator pursuant to paragraph (a) in the file maintained pursuant to NAC 449.2749 for the resident who is the subject of the report; and
(c) Make and maintain a report of any actions that are taken by the caregivers employed by the facility in response to a report submitted pursuant to paragraph (a).
2. Within 72 hours after the administrator of the facility receives a report submitted pursuant to paragraph (a) of subsection 1, a member of the staff of the facility shall notify the resident’s physician of any concerns noted by the person who submitted the report. The report must be reviewed and initialed by the administrator.
3. Before assisting a resident in the administration of any medication, including, without limitation, any over-the-counter medication or dietary supplement, a caregiver must obtain written information describing the side effects, possible adverse reactions, contraindications and toxicity of the medication.
4. Except as otherwise provided in this subsection, a caregiver shall assist in the administration of medication to a resident if the resident needs the caregiver’s assistance. A caregiver may assist the ultimate user of controlled substances or dangerous drugs only if the conditions prescribed in subsection 6 of NRS 449.037 are met.
5. An over-the-counter medication or a dietary supplement may be given to a resident only if the resident’s physician has approved the administration of the medication or supplement in writing or the facility is ordered to do so by another physician. The over-the-counter medication or dietary supplement must be administered in accordance with the written instructions of the physician. The administration of over-the-counter medications and dietary supplements must be included in the record required pursuant to paragraph (b) of subsection 1 of NAC 449.2744.
6. Except as otherwise provided in this subsection, a medication prescribed by a physician must be administered as prescribed by the physician. If a physician orders a change in the amount or times medication is to be administered to a resident:
(a) The caregiver responsible for assisting in the administration of the medication shall:
(1) Comply with the order;
(2) Indicate on the container of the medication that a change has occurred; and
(3) Note the change in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744;
(b) Within 5 days after the change is ordered, a copy of the order or prescription signed by the physician must be included in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744; and
(c) If the label prepared by a pharmacist does not match the order or prescription written by a physician, the physician, registered nurse or pharmacist must interpret that order or prescription and, within 5 days after the change is ordered, the interpretation must be included in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744.
7. If a resident refuses, or otherwise misses, an administration of medication, a physician must be notified within 12 hours after the dose is refused or missed.
8. An employee of a residential facility shall not draw medication into a syringe or administer an injection unless authorized by law to do so.
9. If the medication of a resident is discontinued, the expiration date of the medication of a resident has passed, or a resident who has been discharged from the facility does not claim the medication, an employee of a residential facility shall destroy the medication, by an acceptable method of destruction, in the presence of a witness and note the destruction of the medication in the record maintained pursuant to NAC 449.2744. Flushing contents of vials, bottles or other containers into a toilet shall be deemed to be an acceptable method of destruction of medication.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R204-99, 2-10-2000; R073-03, 1-22-2004)
NAC 449.2744 Administration of medication: Maintenance and contents of logs and records. (NRS 449.037)
1. The administrator of a residential facility that provides assistance to residents in the administration of medications shall maintain:
(a) A log for each medication received by the facility for use by a resident of the facility. The log must include:
(1) The type and quantity of medication received by the facility;
(2) The date of its delivery;
(3) The name of the person who accepted the delivery;
(4) The name of the resident for whom the medication is prescribed; and
(5) The date on which any unused medication is removed from the facility or destroyed.
(b) A record of the medication administered to each resident. The record must include:
(1) The type of medication administered;
(2) The date and time that the medication was administered;
(3) The date and time that a resident refuses, or otherwise misses, an administration of medication; and
(4) Instructions for administering the medication to the resident that reflect each current order or prescription of the resident’s physician.
2. The administrator of the facility shall keep a log of caregivers assigned to administer medications that indicates the shifts during which each caregiver was responsible for assisting in the administration of medication to a resident. This requirement may be met by including on a resident’s medication sheet an indication of who assisted the resident in the administration of the medication, if the caregiver can be identified from this indication.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004)
NAC 449.2746 Administration of medication: Restrictions concerning medication taken as needed by resident; written records. (NRS 449.037)
1. A caregiver employed by a residential facility shall not assist a resident in the administration of a medication that is taken as needed unless:
(a) The resident is able to determine his need for the medication;
(b) The determination of the resident’s need for the medication is made by a medical professional qualified to make that determination; or
(c) The caregiver has received written instructions indicating the specific symptoms for which the medication is to be given, the exact amount of medication that may be given and the frequency with which the medication may be given.
2. A caregiver who administers medication to a resident as needed shall record the following information concerning the administration of the medication:
(a) The reason for the administration;
(b) The date and time of the administration;
(c) The dose administered;
(d) The results of the administration of the medication;
(e) The initials of the caregiver; and
(f ) Instructions for administering the medication to the resident that reflect each current order or prescription of the resident’s physician.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004)
NAC 449.2748 Medication: Storage; duties upon discharge, transfer and return of resident. (NRS 449.037)
1. Medication, including, without limitation, any over-the-counter medication, stored at a residential facility must be stored in a locked area that is cool and dry. The caregivers employed by the facility shall ensure that any medication or medical or diagnostic equipment that may be misused or appropriated by a resident or any other unauthorized person is protected. Medications for external use only must be kept in a locked area separate from other medications. A resident who is capable of administering medication to himself without supervision may keep his medication in his room if the medication is kept in a locked container for which the facility has been provided a key.
2. Medication stored in a refrigerator, including, without limitation, any over-the-counter medication, must be kept in a locked box unless the refrigerator is locked or is located in a locked room.
3. Medication, including, without limitation, any over-the-counter medication or dietary supplement, must be:
(a) Plainly labeled as to its contents, the name of the resident for whom it is prescribed and the name of the prescribing physician; and
(b) Kept in its original container until it is administered.
4. Except as otherwise provided in subsection 5, when a resident is discharged or transferred from a residential facility, all medications prescribed for the resident must be provided to the resident or to the facility to which he is transferred.
5. If a resident is transferred to a hospital or skilled nursing facility, the residential facility shall hold the resident’s medications until the resident returns or for 30 days after the transfer, whichever is less, unless the hospital or skilled nursing facility requests the residential facility to provide the hospital or skilled nursing facility with the medications. If the resident does not return within 30 days after the transfer, the residential facility shall promptly dispose of any remaining medications. Upon the return of the resident from the hospital or skilled nursing facility, the residential facility shall, if there has been any change in the resident’s medication regimen:
(a) Contact a physician, within 24 hours after the resident returns, to clarify the change; and
(b) Document the physician contact in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R204-99, 2-10-2000; R073-03, 1-22-2004)
NAC 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information. (NRS 449.037)
1. A separate file must be maintained for each resident of a residential facility and retained for at least 5 years after he permanently leaves the facility. The file must be kept locked in a place that is resistant to fire and is protected against unauthorized use. The file must contain all records, letters, assessments, medical information and any other information related to the resident, including, without limitation:
(a) The full name, address, date of birth and social security number of the resident.
(b) The address and telephone number of the resident’s physician and the next of kin or guardian of the resident or any other person responsible for him.
(c) A statement of the resident’s allergies, if any, and any special diet or medication he requires.
(d) A statement from the resident’s physician concerning the mental and physical condition of the resident that includes:
(1) A description of any medical conditions which require the performance of medical services;
(2) The method in which those services must be performed; and
(3) A statement of whether the resident is capable of performing the required medical services.
(e) Evidence of compliance with the provisions of chapter 441A of NRS and the regulations adopted pursuant thereto.
(f ) The types and amounts of protective supervision and personal services needed by the resident.
(g) An evaluation of the resident’s ability to perform the activities of daily living and a brief description of any assistance he needs to perform those activities. The facility shall prepare such an evaluation:
(1) Upon the admission of the resident;
(2) Each time there is a change in the mental or physical condition of the resident that may significantly affect his ability to perform the activities of daily living; and
(3) In any event, not less than once each year.
(h) A list of the rules for the facility that is signed by the administrator of the facility and the resident or a representative of the resident.
(i) The name and telephone number of the vendors and medical professionals that provide services for the resident.
( j) A document signed by the administrator of the facility when the resident permanently leaves the facility.
2. The document required pursuant to paragraph ( j) of subsection 1 must indicate the location to which the resident was transferred or the person in whose care the resident was discharged. If the resident dies while a resident of the facility, the document must include the time and date of the death and the dates on which the person responsible for the resident was contacted to inform him of the death.
3. Except as otherwise provided in this subsection, a resident’s file must be kept confidential. A resident’s file must be made available upon request at any time to an employee of the Bureau who is acting in his capacity as an employee of the Bureau.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004)
NAC 449.275 Residents receiving hospice care: Responsibilities of staff; retention of resident with special medical needs. (NRS 449.037)
1. A residential facility that provides services to a resident who elects to receive hospice care shall obtain a copy of the plan of care required pursuant to NAC 449.0186 for that resident.
2. The members of the staff of the facility shall:
(a) Maintain at the facility a written record of the care and services provided to a resident who receives hospice care; and
(b) Report any deviation from the established plan of care to the resident’s physician within 24 hours after the deviation occurs.
3. If the Division grants a request made pursuant to NAC 449.2736 by the administrator of a residential facility that provides hospice care, the residential facility may retain a resident who:
(a) Is bedfast, as defined in NAC 449.2702; or
(b) Requires skilled nursing or other medical care on a 24-hour basis.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004)
NAC 449.2751 Provision of assisted living services: Prerequisites and requirements. (NRS 449.037)
1. Each residential facility that wishes to provide assisted living services must apply to the Health Division to obtain an endorsement on its license authorizing the residential facility to provide assisted living services.
2. The Health Division may deny an application for an endorsement that is made pursuant to subsection 1 or revoke an existing endorsement granted pursuant to subsection 1 if the residential facility for which the applicant is applying or the residential facility which has an endorsement does not satisfy the requirements set forth in this section or subsections 7 and 8 of NRS 449.037.
3. If a residential facility provides assisted living services, the written policies that the residential facility is required to develop pursuant to NAC 449.258 must include, without limitation, procedures to be followed:
(a) To ensure that the residential facility complies with the requirements set forth in subsections 7 and 8 of NRS 449.037;
(b) By the administrator to ensure that residents of the residential facility whose physical or mental condition is significantly changing over time are identified;
(c) To obtain a medical professional to assess and monitor, as necessary, but not less than once every quarter in each calendar year, each resident of the residential facility whose physical or mental condition is declining over time; and
(d) To provide services to residents of the residential facility pursuant to the assessment and monitoring performed pursuant to paragraph (c).
4. The administrator of a residential facility that provides assisted living services shall ensure that:
(a) A medical professional is notified whenever there has been a significant change in the physical or mental condition of a resident of the residential facility whose physical or mental condition is declining over time; and
(b) The residential facility maintains a list of resources for financial assistance and other social services that may decrease the need for a resident of the residential facility whose physical or mental condition is declining over time to move out of the residential facility.
5. The services provided by a residential facility that provides assisted living services must include, without limitation, services that will enable the residential facility to retain residents who have the medical needs or conditions described in NAC 449.2712 to 449.2734, inclusive, and 449.275.
(Added to NAC by Bd. of Health by R097-06, eff. 7-14-2006)
Special Types of Facilities
NAC 449.2754 Residential facility which provides care to persons with Alzheimer’s disease: General requirements. (NRS 449.037)
1. A residential facility which offers or provides care for a resident with Alzheimer’s disease or related dementia must obtain an endorsement on its license authorizing it to operate as a residential facility which provides care to persons with Alzheimer’s disease.
2. If a residential facility is authorized to operate as a residential facility which provides care to persons with Alzheimer’s disease and as another type of facility, the entire facility must comply with the requirements of this section or the residents who suffer from Alzheimer’s disease or other related dementia must be located in a separate portion of the facility that complies with the provisions of this section.
3. A residential facility which provides care to persons with Alzheimer’s disease may admit or retain a resident who requires confinement in locked quarters.
4. A residential facility which provides care to persons with Alzheimer’s disease must be administered by a person who:
(a) Has not less than 3 years of experience in caring for residents with Alzheimer’s disease or related dementia in a licensed facility; or
(b) Has a combination of education and training that the Bureau determines is equivalent to the experience required pursuant to paragraph (a).
5. The administrator of such a facility shall prescribe and maintain on the premises of the facility a written statement which includes:
(a) The facility’s policies and procedures for providing care to its residents;
(b) Evidence that the facility has established interaction groups within the facility which consist of not more than six residents for each caregiver during those hours when the residents are awake;
(c) A description of:
(1) The basic services provided for the needs of residents who suffer from dementia;
(2) The activities developed for the residents by the members of the staff of the facility;
(3) The manner in which the behavioral problems will be managed;
(4) The manner in which the medication for residents will be managed;
(5) The activities that will be developed by the members of the staff of the facility to encourage the involvement of family members in the lives of the residents; and
(6) The steps the members of the staff of the facility will take to:
(I) Prevent residents from wandering from the facility; and
(II) Respond when a resident wanders from the facility; and
(d) The criteria for admission to and discharge and transfer from the facility.
6. The written statement required pursuant to subsection 5 must be available for review by members of the staff of the facility, visitors to the facility and the Bureau.
7. The administrator shall ensure that the facility complies with the provisions of the statement required pursuant to subsection 5.
8. The members of the staff of the facility shall develop a program of activities that promotes the mental and physical enhancement of the residents. The following activities must be conducted at least weekly:
(a) Activities to enhance the gross motor skills of the residents;
(b) Social activities;
(c) Activities to enhance the sensory abilities of the residents; and
(d) Outdoor activities.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.2756 Residential facility which provides care to persons with Alzheimer’s disease: Standards for safety; personnel required; training for employees. (NRS 449.037)
1. The administrator of a residential facility which provides care to persons with Alzheimer’s disease shall ensure that:
(a) Swimming pools and other bodies of water are fenced or protected by other acceptable means.
(b) Operational alarms, buzzers, horns or other audible devices which are activated when a door is opened are installed on all doors that may be used to exit the facility.
(c) At least one member of the staff is awake and on duty at the facility at all times.
(d) Each employee of the facility who has direct contact with and provides care to residents with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, successfully completes the training and continuing education required pursuant to NAC 449.2768.
(e) Knives, matches, firearms, tools and other items that could constitute a danger to the residents of the facility are inaccessible to the residents.
(f ) The facility has an area outside the facility or a yard adjacent to the facility that:
(1) May be used by the residents for outdoor activities;
(2) Has at least 40 square feet of space for each resident in the facility;
(3) Is fenced; and
(4) Is maintained in a manner that does not jeopardize the safety of the residents.
Ê All gates leading from the secured, fenced area or yard to an unsecured open area or yard must be locked and keys for gates must be readily available to the members of the staff of the facility at all times.
(g) All toxic substances are not accessible to the residents of the facility.
2. The training required pursuant to NAC 449.2768 may be used to satisfy the requirement of paragraph (f ) of subsection 1 of NAC 449.196 for the year in which the training is received.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004; R071-04, 8-4-2004)
NAC 449.2758 Residential facility for elderly or disabled persons: Training for caregivers. (NRS 449.037)
1. Within 60 days after being employed by a residential facility for elderly or disabled persons, a caregiver must receive not less than 4 hours of training related to the care of those residents.
2. As used in this section, “residential facility for elderly or disabled persons” means a residential facility that provides care to elderly or disabled persons who require assistance or protective supervision because they suffer from infirmities or disabilities.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.2762 Residential facility for mentally retarded adults: Training for caregivers; program to modify behavior of resident. (NRS 449.037)
1. Within 60 days after being employed by a residential facility for mentally retarded adults, a caregiver must receive not less than 4 hours of training related to the care of mentally retarded persons.
2. If a resident who is mentally retarded is referred to the facility by a referring agency, the members of the staff of the facility may conduct a program to modify the behavior of the resident if that program is developed by the agency that referred the resident to the facility.
3. As used in this section, “residential facility for mentally retarded adults” means a residential facility that provides care and protective supervision for persons with mental retardation or related disorders, including, without limitation, birth trauma, anoxia, brain trauma or other genetic or developmental disorders.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.2764 Residential facility for persons with mental illnesses: Training for employees. (NRS 449.037)
1. A person who provides care for a resident of a residential facility for persons with mental illnesses shall, within 60 days after he becomes employed at the facility, attend not less than 8 hours of training concerning care for residents who are suffering from mental illnesses.
2. As used in this section, “residential facility for persons with mental illnesses” means a residential facility that provides care and protective supervision for persons with mental illnesses, including, without limitation, schizophrenia, bipolar disorder, psychosis and other related disorders.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004)
NAC 449.2766 Residential facility for persons with chronic illnesses: Training for employees. (NRS 449.037)
1. Within 60 days after being employed by a residential facility for persons with chronic illnesses, an employee of the facility shall obtain at least 4 hours of in-service training relating to the care provided to such persons and in the actions necessary to control infections.
2. Evidence of training received pursuant to subsection 1 must be included in the employee’s personnel file.
3. As used in this section, “residential facility for persons with chronic illnesses” means a residential facility that provides care and protective supervision for persons with chronic illnesses or progressively debilitating diseases, including, without limitation, acquired immunodeficiency syndrome and cancer.
(Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004)
NAC 449.2768 Residential facility which provides care to persons with dementia: Training for employees. (NRS 449.0357, 449.037)
1. Except as otherwise provided in subsection 2, the administrator of a residential facility which provides care to persons with any form of dementia shall ensure that:
(a) Each employee of the facility who has direct contact with and provides care to residents with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, successfully completes:
(1) Within the first 40 hours that such an employee works at the facility after he is initially employed at the facility, at least 2 hours of training in providing care, including emergency care, to a resident with any form of dementia, including, without limitation, Alzheimer’s disease, and providing support for the members of the resident’s family.
(2) In addition to the training requirements set forth in subparagraph (1), within 3 months after such an employee is initially employed at the facility, at least 8 hours of training in providing care to a resident with any form of dementia, including, without limitation, Alzheimer’s disease.
(3) If such an employee is licensed or certified by an occupational licensing board, at least 3 hours of continuing education in providing care to a resident with dementia, which must be completed on or before the anniversary date of the first date the employee was initially employed at the facility. The requirements set forth in this subparagraph are in addition to those set forth in subparagraphs (1) and (2), may be used to satisfy any continuing education requirements of an occupational licensing board, and do not constitute additional hours or units of continuing education required by the occupational licensing board.
(4) If such an employee is a caregiver, other than a caregiver described in subparagraph (3), at least 3 hours of training in providing care to a resident with dementia, which must be completed on or before the anniversary date of the first date the employee was initially employed at the facility. The requirements set forth in this subparagraph are in addition to those set forth in subparagraphs (1) and (2).
(b) The facility maintains proof of completion of the hours of training and continuing education required pursuant to this section in the personnel file of each employee of the facility who is required to complete the training or continuing education.
2. A person employed by a facility which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, is not required to complete the hours of training or continuing education required pursuant to this section if he has completed that training within the previous 12 months.
(Added to NAC by Bd. of Health by R071-04, eff. 8-4-2004)
REVISER’S NOTE.
The regulation of the Board of Health filed with the Secretary of State on August 4, 2004 (LCB File No. R071-04), the source of this section (section 5 of the regulation), contains the following provisions not included in NAC:
“1. Each person who on August 4, 2004, is employed by a residential facility for groups which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, and who is required to complete the hours of training and continuing education related to dementia required pursuant to section 5 of this regulation [NAC 449.2768] shall complete at least 8 hours of training and continuing education related to dementia within 12 months after August 4, 2004, unless the person has completed the training or continuing education within the 12 months before August 4, 2004.
2. Evidence that such a person has completed the training or continuing education required pursuant to subsection 1 must be included in his personnel file and must be kept at the facility.”
Deficiencies
NAC 449.27702 Determination of severity and scope of deficiency; assignment of grade. (NRS 449.037)
1. The Bureau shall determine:
(a) The severity of a deficiency of a residential facility in accordance with the provisions of NAC 449.99861; and
(b) The scope of a deficiency of a residential facility in accordance with the provisions of NAC 449.9986.
2. After the Bureau conducts a survey of a residential facility, the Bureau shall add the severity and scope scores for all deficiencies of the facility indicated in the survey and assign a grade to the facility as follows:
|
Sum of Severity and Scope Scores |
Grade |
|
0 to 15 points |
A |
|
At least 16 points but not more than 24 points, or any deficiency with a severity level of 3 and a scope level of 3 |
B |
|
At least 25 points but not more than 34 points, or any deficiency with a severity level of 4 and a scope level of 1 |
C |
|
At least 35 points, or any deficiency with a severity level of 4 and a scope level of at least 2 |
D |
(Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005)
NAC 449.27704 Placard: Issuance and display; failure to comply. (NRS 449.037)
1. After the Bureau assigns a grade to a residential facility pursuant to NAC 449.27702, the Bureau shall issue a placard to the residential facility.
2. The administrator shall, within 24 hours after receipt of the placard, display or cause the placard to be displayed conspicuously in a public area of the residential facility.
3. If the placard is not displayed in accordance with the provisions of subsection 2, the Bureau will assess against the residential facility a deficiency with a severity and scope score equal to the highest severity and scope score indicated in the most recent survey of the facility conducted by the Bureau.
(Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005)
NAC 449.27706 Resurvey: Application and fee; failure to comply. (NRS 439.150, 439.200, 449.037)
1. If the Bureau issues a placard to a residential facility that includes a grade of “B,” the administrator may submit an application to the Bureau for a resurvey of the facility not later than 30 days after the facility receives the placard. The fee for an application for a resurvey is $300 and must accompany the application.
2. If the Bureau issues a placard to a residential facility that includes a grade of “C” or “D,” the administrator must submit an application to the Bureau for a resurvey of the facility not later than 30 days after the facility receives the placard. The fee for an application for a resurvey is $500 and must accompany the application.
3. The Bureau may revoke the license of a residential facility that is required to submit an application for a resurvey pursuant to subsection 2 if the facility fails to submit the application in accordance with the provisions of that subsection.
4. As used in this section, “resurvey” has the meaning ascribed to it in NAC 449.99838.
(Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005)
BUSINESSES THAT PROVIDE REFERRALS TO RESIDENTIAL FACILITIES FOR GROUPS
NAC 449.27811 Definitions. (NRS 449.0305, 449.037) As used in NAC 449.27811 to 449.27831, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.27813 to 449.27821, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99)
NAC 449.27813 “Client” defined. (NRS 449.0305, 449.037) “Client” means a person who is referred by a referral agency for compensation to a residential facility for groups.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99)
NAC 449.27817 “Financial assessment” defined. (NRS 449.0305, 449.037) “Financial assessment” means an assessment to determine the intended source of payment by a client for services which will be provided by a residential facility for groups for 6 months, including the eligibility status of the client for services as determined by Medicaid and Medicare.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99)
NAC 449.27819 “Needs assessment” defined. (NRS 449.0305, 449.037) “Needs assessment” means an assessment of a client to document the abilities of the client to function independently, including a complete list of the areas in which the client requires assistance.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99)
NAC 449.27821 “Residential facility for groups” defined. (NRS 449.0305, 449.037) “Residential facility for groups” has the meaning ascribed to it in NRS 449.017.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99)
NAC 449.27823 License not required by certain persons to make referrals; application for licensure. (NRS 449.0305, 449.037)
1. A licensed nurse or social worker working in a medical facility or a facility for the dependent licensed by the Bureau may make a referral for a client of the facility or program to a residential facility for groups without first obtaining a license to operate as a referral agency. A person employed by this State or the governing body of any county or city within this State, who is employed in a position in which his duties require him to make referrals for clients to residential facilities for groups, may make those referrals without first obtaining a license to operate as a referral agency.
2. An applicant for a license to operate as a referral agency must submit to the Division a completed application on a form provided by the Division. The application for the initial license must include, without limitation:
(a) Evidence that the applicant has obtained a contract of insurance for protection against liability to third persons which may be incurred while operating as a referral agency; and
(b) The physical address of the applicant where the records of the referral agency will be maintained.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99; A by R124-05, 11-17-2005)
NAC 449.27827 Requirements for employees. (NRS 449.0305, 449.037)
1. Employees of a referral agency must have a working knowledge of the provisions of NRS and NAC that govern the licensing of residential facilities for groups.
2. An employee of a referral agency who is not licensed as a nurse, social worker, physician or physician assistant shall not gather any information needed to complete a needs assessment or financial assessment of a client, or engage in the process of referring a client to a residential facility for groups.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99)
NAC 449.27829 Responsibilities of referral agency. (NRS 449.0305, 449.037)
1. A referral agency shall:
(a) Complete a needs assessment and financial assessment for each client and make referrals for the services that would best meet the physical, psychosocial and financial needs and wishes of the client; and
(b) Submit to the residential facility for groups to which a client is referred a copy of the needs assessment completed by the referral agency for the client.
2. A referral agency shall not:
(a) Accept any fee, inducement or incentive, for any reason, from a residential facility for groups, or from any person or entity associated with a residential facility for groups; or
(b) Give a discharge planner, case manager, social worker or any other person who has the responsibility of discharge planning, a fee or incentive for prospective clients.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99)
NAC 449.27831 Contract for services; fees; maintenance of client records. (NRS 449.0305, 449.037)
1. Before a referral agency may provide any services to a client, the referral agency must obtain a written contract from the client or his legal representative to provide the services. The contract must:
(a) Be signed by a representative of the referral agency and the person who is paying for the services or his representative; and
(b) Include, without limitation, a description of the services to be provided pursuant to the contract and all fees associated with the provision of those services.
2. If, within 30 days after a client is admitted to a residential facility for groups, the referral of the client to the residential facility for groups is determined by the facility, the Bureau or a physician to be inappropriate, the referral agency shall:
(a) Refund the full amount of the fee paid by the client or his representative; or
(b) Assist the client with an acceptable referral to another residential facility for groups for no additional fee.
3. A referral agency shall not receive more than one fee from a client within any 6-month period unless, during that period, the client or his representative requests another referral by the referral agency.
4. A referral agency shall maintain an organized file for each client that includes, without limitation:
(a) A copy of the needs assessment and financial assessment completed by the referral agency for the client;
(b) A copy of the completed contract to provide the services to the client; and
(c) Information outlining the process used by the referral agency for determining the appropriate referral of the client.
Ê A referral agency shall maintain its file of a client for at least 5 years at the place of business of the referral agency.
(Added to NAC by Bd. of Health by R132-99, eff. 11-29-99)
HOSPITALS
General Provisions
NAC 449.279 Definitions. (NRS 449.037) As used in NAC 449.279 to 449.394, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.285 to 449.300, inclusive, have the meanings ascribed to them in those sections.
(Supplied in codification; A by Bd. of Health by R050-99, 9-27-99)
NAC 449.285 “General hospital” defined. (NRS 449.037) “General hospital” means a hospital that is designated a general hospital pursuant to NRS 449.021.
[Bd. of Health, Health Facilities Reg. Part I part Ch. III, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.286 “Governing body” defined. (NRS 449.037) “Governing body” means the person or group of persons, including a board of trustees, board of directors or other body, in whom the final authority and responsibility is vested for conduct of a hospital.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.287 “Hospital” defined. (NRS 449.037) “Hospital” has the meaning ascribed to it in NRS 449.012.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.289 “Inpatient” defined. (NRS 449.037) “Inpatient” means a person who has been formally admitted into a hospital for diagnosis or treatment.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.297 “Outpatient” defined. (NRS 449.037) “Outpatient” means a person who has been registered or accepted for care in a hospital but who has not been formally admitted as an inpatient, and who does not remain in the hospital for more than 48 hours.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.298 “Outpatient department” defined. (NRS 449.037) “Outpatient department” means that part of a hospital used for the treatment and diagnosis of patients not residing in the hospital.
[Bd. of Health, Health Facilities Reg. Part I part Ch. III, eff. 10-9-69]
NAC 449.299 “Patient” defined. (NRS 449.037) “Patient” means a person who:
1. Is receiving diagnostic, therapeutic or preventive health services; or
2. Is under observation or treatment for an illness or injury, or under care during and after pregnancy.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.300 “Restraint” defined. (NRS 449.037) “Restraint” means the control of the activity of a patient to protect the patient or others from injury by the seclusion of the patient or the use of mechanical devices. The term does not include the control of the activity of a patient by the use of mechanical supports that are used in rehabilitative situations to achieve proper body alignment.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
Licensing and Administration
NAC 449.307 Applicability of license; coverage against certain liabilities. (NRS 449.037)
1. A hospital must be operated and conducted in the name designated on the license, with the name of the person responsible for its operation also appearing on the face of the license. The license is not transferable.
2. Each hospital must retain proof that it is adequately covered against liabilities resulting from claims incurred in the course of operation.
3. Except as otherwise provided in this subsection, separate licenses are required for hospitals which are maintained on separate premises even though the hospitals are under the same management. The provisions of this subsection do not apply to outpatient departments, clinics or separate buildings on the same grounds.
4. A separate license is not required for the provision of special services within a hospital. This subsection does not relieve a hospital to which a special service is being added from the requirement of obtaining the approval of the Division to amend its license pursuant to NRS 449.087 before providing that service.
[Bd. of Health, Health Facilities Reg. Part II Ch. II §§ 1-4, eff. 10-9-69; A 8-26-74]—(NAC A by R044-97, 10-30-97; R050-99, 9-27-99; R117-05, 11-17-2005)
NAC 449.310 Limitation on number of patients; annual on-site inspection not required under certain circumstances. (NRS 449.037)
1. A hospital shall not have more patients than the number of beds for which it is licensed, except in emergencies. If there is an emergency, the hospital shall notify the Bureau.
2. If a hospital is accredited by the Joint Commission on Accreditation of Healthcare Organizations or the American Osteopathic Association, the Bureau is not required to make an annual on-site inspection of the hospital.
[Bd. of Health, Health Facilities Reg. Part II Ch. II §§ 5-9, eff. 10-9-69; A 8-26-74]—(NAC A by R035-97, 10-30-97; R050-99, 9-27-99)
NAC 449.312 Change in ownership, use or construction; correction of deficiencies. (NRS 449.037)
1. Upon a change in ownership, change of use or change in construction, a hospital shall notify the Bureau of the changes and identify all areas of noncompliance with the guidelines specified in NAC 449.3154 before the change in ownership, use or construction may take place.
2. Upon a change of use or change in construction, a hospital must come into compliance with the guidelines before it may admit patients into the area in which the change is made.
3. The Bureau shall notify a hospital in writing of the existence of any deficiencies and the hospital shall correct those deficiencies within a reasonable amount of time. Except for major deficiencies, including deficiencies which require structural alterations of a building or a portion of a building, and except as otherwise provided in this subsection, reasonable time for the purposes of this subsection shall be deemed to be not more than 180 days. Upon written request and just cause shown, the Bureau may grant an extension of the time in which a deficiency must be corrected based on extenuating circumstances.
4. If the deficiencies are likely to cause serious injury, serious harm or impairment to public health and welfare, the hospital shall take immediate action to correct the deficiencies or the hospital will not be allowed to continue to operate.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XVI subsec. F, eff. 10-9-69; A 8-26-74; Ch. II part § XI, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.313 Responsibilities and duties of governing body; bylaws; appointment and duties of chief executive officer; protocol for organ donations; annual operating budget. (NRS 449.037)
1. A hospital shall have an effective governing body which is legally responsible for the conduct of the hospital.
2. The governing body of a hospital shall adopt a workable set of bylaws which must be in writing and available to all members. The governing body shall:
(a) Determine, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff of the hospital;
(b) Appoint members to the medical staff after considering the recommendations of the existing members of the medical staff;
(c) Ensure that the medical staff has bylaws;
(d) Approve the bylaws of the medical staff and any other rules and regulations adopted by the medical staff;
(e) Ensure that the medical staff is accountable to the governing body for the quality of care which the medical staff provides to patients; and
(f ) Ensure that the criteria for the selection of members to the medical staff include competence, training, experience and judgment.
3. The governing body shall appoint a qualified chief executive officer using as its criteria the actual experience, nature and duration of hospital administration and graduate work in hospital administration of the appointee. Following his selection, the chief executive officer is responsible for the management of the hospital and for providing liaisons among the governing body, medical staff, nursing staff and other departments, units and services within the hospital. The chief executive officer shall keep the governing body fully informed of the conduct of the hospital through regular written reports. The chief executive officer must be allowed sufficient freedom from other responsibilities to provide adequate attention to the administration and management of the hospital.
4. The governing body shall ensure, in accordance with hospital policy, that:
(a) Each patient is under the care of at least one of the following persons:
(1) A doctor of medicine or osteopathy.
(2) A doctor of dental surgery or dental medicine who is licensed to practice dentistry in this State and who is acting within the scope of his license.
(3) A doctor of podiatric medicine, but only with respect to those functions which he is licensed to perform in this State.
(4) A doctor of optometry who is licensed to practice optometry in this State.
(5) A chiropractor who is licensed to provide chiropractic services in this State, but only with respect to the treatment of the spine by means of manual manipulation to correct a subluxation which is demonstrated by X-ray to exist.
(b) A doctor of medicine or osteopathy is on duty or on call at all times.
(c) A doctor of medicine or osteopathy is responsible for the care of each patient with respect to any medical or psychiatric problem that:
(1) Is present when the patient is admitted into the hospital or develops after the patient is admitted; and
(2) Is not specifically within the scope of practice of a doctor of dental surgery, dental medicine, podiatric medicine or optometry, or of a chiropractor, as that scope of practice is defined by the bylaws, rules and regulations of the medical staff.
5. To identify potential organ donors, a hospital shall have written protocols that:
(a) Ensure that the family of each potential donor knows of its option to donate organs or tissues, or both, or to decline to make such a donation; and
(b) Encourage discretion and sensitivity with respect to the circumstances, views and beliefs of the families of potential donors.
6. A hospital in which organ transplants are performed:
(a) Must be a member of the Organ Procurement and Transplantation Network established and operated in accordance with section 372 of the Public Health Services Act, 42 U.S.C. § 274; and
(b) Shall abide by the rules and regulations of the Organ Procurement and Transplantation Network.
7. A hospital shall have an overall institutional plan which includes an annual operating budget that is prepared according to generally accepted accounting principles. The annual operating budget must include anticipated income and expenses, except that the hospital is not required to identify item-by-item the components of each anticipated income or expense.
8. The governing body is responsible for the services furnished in the hospital, regardless of whether the services are furnished by staff or pursuant to contracts. The hospital shall maintain a list of contracted services which includes the scope and nature of the services provided.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § 1, eff. 10-9-69; A 8-26-74; ch. II § I, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.314 Quality of care; scope of services. (NRS 449.037)
1. A hospital must be administered in a manner that enables the hospital to use its resources effectively and efficiently to meet the needs of and provide quality care to its patients. The governing body of a hospital shall develop and provide services for the care of its patients based on the identified needs of those patients.
2. The scope of services provided by each department, unit or service within a hospital must be defined in writing and must be approved by the administration and the medical staff of the hospital. Each department, unit or service within a hospital shall provide patient care in accordance with its scope of services. The policies and procedures of a hospital and of each department, unit or service within the hospital must, to the extent necessary, be integrated with the policies and procedures of the other departments, units and services within the hospital.
3. The governing body of a hospital shall:
(a) Ensure that the competence of all members of the hospital staff is assessed, maintained, demonstrated and improved;
(b) Provide an orientation process for persons hired to work at the hospital that includes initial job training and information; and
(c) Assess the ability of the members of the hospital staff to fulfill their specified responsibilities.
4. A hospital shall ensure that it is staffed by a sufficient number of personnel, whose qualifications are consistent with their job responsibilities, to provide care to the patients of the hospital.
5. The chief executive officer of a hospital is responsible for operating the hospital in accordance with the authority conferred on him by the governing body.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.3152 Quality improvement program. (NRS 449.037)
1. The governing body of a hospital shall ensure that the hospital has an effective, comprehensive quality improvement program to evaluate the provision of care to its patients.
2. The quality improvement program must:
(a) Be ongoing;
(b) Include a written plan for carrying out the program; and
(c) Provide for the creation of a committee to oversee the program.
3. All services related to patient care, including services furnished by a contractor, must be evaluated by the committee.
4. Nosocomial infections, medication therapy and deaths occurring in the hospital must be evaluated by the committee.
5. All medical and surgical services performed in the hospital must be evaluated by the committee as those services relate to the appropriateness of the diagnosis and treatment.
6. The committee shall initiate an assessment of a service or the provision of care when any statistical analysis detects an undesirable variation in performance.
7. The committee shall take and document appropriate remedial action to address deficiencies found through the quality improvement program. The committee shall document the outcome of any remedial action taken.
8. When the findings of an assessment relate to the performance of an individual licensed practitioner, the medical staff shall determine how such a finding will be used in any peer review, ongoing monitoring and periodic evaluations of the competence of the practitioner. If the findings of the assessment relate to the performance of a person who is not a licensed practitioner, the director of the department, unit or service in which that person works shall determine how the finding will be used in evaluating the competence of the person.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.3154 Construction, remodeling, maintenance and change of use: General requirements; prerequisites to approval of licensure. (NRS 449.037)
1. Except as otherwise provided in this section, a hospital shall comply with the provisions of NFPA 101: Life Safety Code, adopted by reference pursuant to NAC 449.0105.
2. Except as otherwise provided in this section, any new construction, remodeling or change in the use of a hospital must comply with the Guidelines for Design and Construction of Hospital and Health Care Facilities, adopted by reference pursuant to NAC 449.0105, unless the remodeling is limited to refurbishing an area of the hospital, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area and replacing window or wall coverings in the area.
3. Except as otherwise provided in subsection 4, a hospital shall meet all applicable:
(a) Federal and state laws;
(b) Local ordinances, including, without limitation, zoning ordinances; and
(c) Life safety, environmental, health, fire and local building codes,
Ê related to the construction and maintenance of the hospital. If there are any differences between the state and local codes, the more restrictive standards apply.
4. A hospital which is inspected and approved by the State Public Works Board in accordance with the provisions set forth in chapter 341 of NRS and chapter 341 of NAC is not required to comply with any applicable local building codes related to the construction and maintenance of the hospital.
5. A complete copy of the building plans for new construction and remodeling of a hospital, drawn to scale, must be submitted to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115. Before the construction or remodeling may begin, plans for the construction or remodeling must be approved by the Health Division.
6. The Bureau shall not approve the licensure of a hospital until all construction has been completed and a survey is conducted at the site. The plan review is only advisory and does not constitute prelicensing approval.
7. Notwithstanding any provision of this section to the contrary, a hospital which was licensed on January 1, 1999, shall be deemed to be in compliance with this section if the use of the physical space in the hospital does not change and the existing construction of the hospital does not have any deficiencies which are likely to cause serious injury, serious harm or impairment to public health and welfare.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R076-01, 10-18-2001; R068-04, 8-4-2004)
NAC 449.3156 Compliance with certain guidelines for design and construction; correction of deficiencies. (NRS 449.037)
1. Notwithstanding any provision of NAC 449.3154 to the contrary, a hospital shall be deemed to be in compliance with the provisions of the Guidelines for Design and Construction of Hospital and Health Care Facilities, adopted by reference pursuant to NAC 449.0105, if:
(a) The hospital submitted architectural plans to the Bureau on or before February 1, 1999;
(b) The hospital began construction on or before August 1, 1999;
(c) The plans were determined by the Bureau to be in compliance with the provisions of this chapter that were in effect on December 1, 1998;
(d) The hospital is built in accordance with those provisions;
(e) The use of the physical space in the hospital has not changed; and
(f ) There are no deficiencies in the construction of the hospital which are likely to cause serious injury, serious harm or impairment to public health and welfare.
2. If there are deficiencies that are likely to cause serious injury, serious harm or impairment to public health and welfare, the hospital shall take immediate action to correct the deficiencies or the hospital will not be allowed to continue to operate.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R068-04, 8-4-2004)
Policies and Procedures for Operation of Hospital
NAC 449.316 Physical environment: Safety and well-being of patients; plan for emergency preparedness; safety management. (NRS 449.037)
1. The buildings of a hospital must be solidly constructed with adequate space and safeguards for each patient. The condition of the physical plant and the overall hospital environment must be developed and maintained in a manner so that the safety and well-being of patients are ensured.
2. A hospital shall develop and carry out a comprehensive plan for emergency preparedness which:
(a) Addresses internal and external emergencies, both local and widespread; and
(b) Is based on current standards for disaster management and fire safety.
3. A hospital shall ensure that the hospital staff and patients are adequately protected from fire and other disasters. To ensure that it has adequate fire protection, a hospital shall provide for the installation of extinguishers, sprinkling devices, fire barriers and the elimination of fire hazards.
4. The governing body shall analyze identified issues relating to safety management within the environment of care and develop or approve recommendations for addressing those issues. The governing body shall carry out and monitor the effectiveness of the recommendations.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § II part subsec. A & subsec. E, eff. 10-9-69; A 8-26-74; Ch. II part § II, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.317 Risk management. (NRS 449.037) Each hospital shall have in effect a comprehensive program for risk management and shall designate one person to be responsible for the implementation and maintenance of the program for risk management.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.319 Requirements for personal needs of patients. (NRS 449.037)
1. A hospital shall provide patients access to their belongings as is appropriate based on the needs of the patients and the phase of treatment of the patients.
2. A hospital shall communicate and enforce a nonsmoking policy throughout the hospital.
3. A hospital shall provide a clean and comfortable bed and mattress for each patient. Bed linen, blankets, pillows, washcloths and towels that are clean and in good condition must be provided to each patient. A hospital shall have such systems as are necessary to ensure that an adequate supply of clean linen is provided to each patient.
4. A hospital shall provide each inpatient with necessary bedside equipment and supplies based on the needs of the inpatient. The necessary equipment and supplies must include, without limitation, a water pitcher and equipment for personal hygiene. The equipment and supplies must be maintained in a sanitary manner.
5. In public areas and in areas in which patient care is provided, a hospital shall:
(a) Provide adequate and comfortable lighting levels;
(b) Provide comfortable and safe temperature levels; and
(c) Maintain comfortable sound levels.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § II part subsec. A, eff. 10-9-69; A 8-26-74; Ch. II part § II, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.322 Housekeeping and laundry services. (NRS 449.037)
1. A hospital shall establish organized housekeeping services planned, operated and maintained to provide a pleasant, safe and sanitary environment. Adequate personnel, using accepted practices and procedures, shall keep the hospital free from offensive odors, accumulations of dirt, rubbish, dust and safety hazards.
2. Suitable equipment and supplies must be provided for cleaning all surfaces. The equipment must be maintained in a safe, sanitary condition. Storage areas, attics and cellars must be kept safe and free from accumulations of extraneous materials such as refuse, discarded furniture and equipment, and old newspapers. Combustibles such as cleaning rags and compounds and hazardous substances must be labeled properly and stored in safe places. Paper towels, tissues and similar supplies must be stored in a manner to prevent their contamination before use.
3. Cleaning must be performed in a manner to minimize the spread of pathogenic organisms. Floors must be cleaned regularly. Polishes on floors must provide a nonslip finish. Throw or scatter rugs must not be used except for nonslip entrance mats.
4. Housekeeping personnel must receive adequate supervision. Continuous in-service training programs must be established for housekeeping personnel.
5. A hospital shall develop and carry out standards and systems for the operation of laundry services. Laundry services, whether owned by the hospital or provided pursuant to a contract, must:
(a) Maintain standards for a safe work environment for employees;
(b) Address issues relating to the control of infections; and
(c) Be operated in a manner that does not disrupt the patient care provided by the hospital.
6. A hospital shall develop and carry out:
(a) Standards and systems for the storage and handling of clean linen and soiled linen; and
(b) Written policies relating to the handling, storage, transportation and processing of its linen.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § II part subsec. A, eff. 10-9-69; A 8-26-74; Ch. II part § II, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.325 Prevention, control and investigation of infections and communicable diseases. (NRS 449.037)
1. A hospital shall:
(a) Provide a sanitary environment to avoid sources and transmission of infections and communicable diseases; and
(b) Develop and carry out an active program for the prevention, control and investigation of infections and communicable diseases.
2. A hospital shall designate at least one person as an infection control officer, who shall develop and carry out policies governing the control of infections and communicable diseases.
3. The infection control officer of a hospital shall:
(a) Develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel of the hospital; and
(b) Maintain a record of incidents within the hospital related to infection and communicable disease.
4. The chief executive officer, the medical staff and the chief administrative nurse of a hospital:
(a) Shall ensure that the quality improvement program established pursuant to NAC 449.3152 and the training program for the entire hospital address those problems identified by the infection control officer of the hospital; and
(b) Are responsible for the implementation of successful corrective plans of action in affected problem areas.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § II part subsec. A & subsec. D, eff. 10-9-69; A 8-26-74; Ch. II part § II, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.327 Preparation, sterilization, storage and distribution of sterile supplies and medical and surgical equipment. (NRS 449.037)
1. To meet the ongoing needs of its patients, a hospital shall:
(a) Provide a designated area for the preparation, sterilization and storage of sufficient sterile supplies and medical and surgical equipment; and
(b) Dispense the sterile supplies and equipment to all departments, units and services within the hospital.
2. A hospital which prepares, sterilizes and stores its supplies and equipment directly shall develop systems and standards that are consistent with:
(a) The standards for the control of infection established by the infection control officer of the hospital;
(b) The standards developed by the Occupational Safety and Health Administration for the preparation, sterilization and storage of such supplies and equipment; and
(c) When applicable, the manufacturer’s guidelines for the use and maintenance of the equipment.
3. If the supplies and equipment are sterilized on the premises of a hospital, the process of sterilization must be supervised by a person who has received specialized training in the operation of the process of sterilization, including training in methods of testing the process to verify the efficiency of the process of sterilization.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.329 Admission of patients. (NRS 449.037) A hospital shall:
1. Develop and carry out policies and procedures for admitting patients to the appropriate levels of care; and
2. Ensure that each patient, or the parent, guardian or other person legally responsible for the patient, receives information about the proposed care of the patient.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.331 Emergency services and medical care; transfer agreements. (NRS 449.037)
1. A hospital shall develop and carry out policies and procedures to ensure that emergency services and medical care are provided in accordance with NRS 439B.410 and 42 C.F.R. § 489.24.
2. All general hospitals not having their own long-term facility shall have transfer agreements with long-term care facilities. Transfer agreements between facilities must be in writing and on file at each facility concerned. The agreements must provide for:
(a) The transfer of patients between facilities whenever the need for transfer is medically determined; and
(b) The exchange of appropriate medical and administrative information between facilities.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XVI subsecs. A, B & D, eff. 10-9-69; Ch. II part § XI, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.332 Discharge planning. (NRS 449.037)
1. A hospital shall:
(a) Have a process for discharge planning that applies to all inpatients; and
(b) Develop and carry out policies and procedures regarding the process for discharge planning.
2. The process for discharge planning must include the participation of registered nurses, social workers or other personnel qualified, through education or experience, to perform discharge planning.
3. A hospital shall, at the earliest possible stage of hospitalization, identify each patient who is likely to suffer adverse health consequences upon discharge if the patient does not receive adequate discharge planning. The hospital shall provide for an evaluation of the needs related to discharge planning of each patient so identified.
4. An evaluation of the needs of a patient relating to discharge planning must include, without limitation, consideration of:
(a) The needs of the patient for postoperative services and the availability of those services;
(b) The capacity of the patient for self-care; and
(c) The possibility of returning the patient to a previous care setting or making another appropriate placement of the patient after discharge.
5. If the evaluation of a patient relating to discharge planning indicates a need for a discharge plan, a discharge plan must be developed under the supervision of a registered nurse, social worker or other person qualified to perform discharge planning.
6. An evaluation of a patient relating to discharge planning and a discharge plan for the patient may be requested by the patient, a physician, a member of the family of the patient or the guardian of the patient, if any.
7. If a hospital finds that a patient does not need a discharge plan, the attending physician may still request a discharge plan for the patient. If the attending physician makes such a request, the physician shall collaborate as much as necessary with the hospital staff in the development of the discharge plan.
8. Activities related to discharge planning must be conducted in a manner that does not contribute to delays in the discharge of the patient.
9. The evaluation of the needs of a patient relating to discharge planning and the discharge plan for the patient, if any, must be documented in his medical record.
10. The discharge plan must be discussed with the patient or the person acting on behalf of the patient.
11. The patient, members of the family of the patient and any other person involved in caring for the patient must be provided with such information as is necessary to prepare them for the posthospital care of the patient.
12. If, during the course of a patient’s hospitalization, factors arise that may affect the needs of the patient relating to his continuing care or current discharge plan, the needs of the patient must be reassessed and the plan, if any, must be adjusted accordingly.
13. A hospital shall arrange for the initial implementation of the discharge plans of its patients.
14. If identified in a discharge plan, referral of a patient to outpatient services or transfer of the patient to another facility must be accomplished in a manner that meets the identified needs of the patient, including the sharing of necessary medical information about the patient with the receiving service or facility.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.337 Dietary services: General requirements. (NRS 449.037)
1. A hospital shall provide each patient with a nourishing, palatable, well-balanced diet that meets the daily nutritional and dietary needs of the patient.
2. The menu for a patient must meet the nutritional needs of the patient in accordance with:
(a) Recognized dietary practices; and
(b) The orders of the practitioners responsible for the care of the patient.
3. A hospital shall ensure that not less than three meals are served daily to patients and not more than 15 hours elapse between the evening meal and breakfast served the following day.
4. Nourishment and feeding between meals must be provided as required by diet prescription and must be available to each patient unless otherwise ordered by the physician of the patient.
5. Except as otherwise provided in this subsection, menus must be followed. A meal may vary from the planned menu if the change is noted in writing in the records maintained by the dietary services.
6. A hospital shall ensure that the food and religious preferences of a patient are respected to the extent practicable and that substitute food is available through the use of a selective menu or substitutes from appropriate food groups.
7. A hospital shall ensure that persons who are responsible for therapeutic diets have sufficient knowledge of food values to make appropriate substitutions when necessary.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § V, eff. 10-9-69; Ch. II § V, eff. 10-9-69]—(NAC A by R035-97, 10-30-97; R050-99, 9-27-99)
NAC 449.338 Dietary services: Provision for needs of patients; facilities; standards; permits; records. (NRS 449.037)
1. A hospital shall provide for the general dietary needs of its patients, including the preparation of modified special diets.
2. Adequate space for the preparation and service of food must be provided. Equipment for the preparation and service of food must be placed to provide aisles of sufficient width to permit easy movement of personnel, mobile equipment and supplies.
3. Well-ventilated food storage areas of adequate size must be provided.
4. Adequate space must be maintained to accommodate equipment, personnel and procedures necessary for the proper cleaning and sanitizing of dishes and other utensils.
5. Office or other suitable space must be provided for the dietitian and dietetic service supervisor.
6. In providing for the preparation and serving of food, a hospital shall:
(a) Comply with the standards prescribed in chapter 446 of NRS and the regulations adopted pursuant thereto;
(b) Obtain the necessary permits from the Bureau of Health Protection Services of the Health Division;
(c) Maintain a report of each inspection concerning the sanitation of the hospital for at least 1 year after the date of the inspection; and
(d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R068-04, 8-4-2004)
NAC 449.3385 Dietary services: Personnel. (NRS 449.037)
1. A hospital shall maintain an organized dietary service that is staffed by an adequate number of personnel. The hospital shall ensure that personnel are on duty to provide dietary services for at least 12 hours each day and that the personnel are competent to perform their duties as outlined in their job descriptions. The dietary service must be integrated with the other departments, units and services within the hospital.
2. The dietary service must be under the direction of a registered dietitian or other professional person who:
(a) Is qualified in the field of institutional management, nutritional sciences or hotel restaurant management;
(b) Has completed an academic program in culinary arts; or
(c) Is certified as a dietary manager by the Dietary Managers Association and has additional work experience with medical and therapeutic diets.
3. The director of the dietary service may be employed on a full-time or part-time basis, or as a consultant.
4. A hospital shall have on staff a dietitian manager or consultant who shall provide in-service training for all dietetic service personnel and maintain a record of the in-service training provided which includes a description of the subjects covered by the training, the date that the training was given, the duration of the training and a list of the persons who attended the training.
5. Personnel of the dietary service must:
(a) Be trained in basic techniques of food sanitation;
(b) While working in the dietary service, be clean and wear clean clothing, including a cap or hairnet, or both; and
(c) Be excluded from duty when affected by a skin infection or communicable disease.
6. If an employee of the dietary service has a beard or moustache, or both, which is not closely cropped, the employee shall cover the beard or moustache, or both, while he is on duty.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R068-04, 8-4-2004)
NAC 449.339 Dietary services: Nutritional status of patients. (NRS 449.037)
1. A hospital shall carry out a program for the systematic nutritional risk-screening of its patients to detect actual and potential malnutrition at an early stage.
2. A hospital shall ensure that each patient maintains acceptable parameters of nutritional status, including, without limitation, body weight and protein levels, unless the patient’s clinical condition demonstrates that the maintenance of those parameters is not possible.
3. A patient who is fed by an enteral feeding system must receive the appropriate treatment and services to prevent complications to the extent possible.
4. Parenteral nutrition support must be used to nourish a patient who meets clinical guidelines that are developed in accordance with nationally recognized standards of practice and approved by the medical staff of the hospital.
5. A patient must receive a therapeutic diet when it is determined that he has a nutritional problem.
6. The director of the dietary service shall develop and carry out policies and procedures for nutritional care and dietetic services. The policies and procedures must be readily available to nursing, dietary and medical staff. The director shall evaluate the policies and procedures for nutritional care and services provided by the dietary service on a regular basis and revise those policies and procedures as necessary.
7. If it is determined that the nutritional status of a patient is at risk, nutritional care for that patient must be:
(a) Planned and provided based on an assessment of his nutritional status by a registered dietitian or the attending physician, or both; and
(b) Integrated into his plan of care.
Ê The response of the patient must be monitored and reassessed as needed.
8. Pertinent dietary information must be included in a patient’s transfer records or discharge records, or both, to ensure continuity of nutritional care.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.3395 Dietary services: Sanitary conditions; supplies. (NRS 449.037)
1. A hospital shall store, prepare, distribute and serve food under sanitary conditions.
2. A hospital shall maintain on its premises at least a 1-week supply of staple foods and at least a 2-day supply of perishable foods. The supplies must be appropriate to meet the requirements of the menu. All food must be of good quality and procured from sources approved or considered satisfactory by federal, state and local authorities. Food that is contained in a container or can that:
(a) Is unlabeled, if the contents of the container or can are not readily identifiable without opening the container or can;
(b) Is rusty, leaking or broken; or
(c) Has dents or swelling,
Ê is not acceptable and must not be maintained.
3. All kitchens and kitchen areas in a hospital must be kept clean, kept free from litter and rubbish, and protected from rodents, roaches, flies and other insects. The hospital shall take such measures as are necessary for preventive pest control. All utensils, counters, shelves and equipment must be kept clean, maintained in good repair, and free from breaks, corrosions, open seams, cracks and chipped areas. Plastic ware, china and glassware that is unsightly, unsanitary or hazardous because of chips, cracks or loss of glaze must be discarded.
4. After each use, utensils used for eating or drinking or used in the preparation of food or drink must be cleaned and disinfected, or discarded.
5. Kitchen sinks must not be used for washing hands. Separate facilities for washing hands, which includes soap, running water and individual towels, must be provided.
6. Kitchen wastes that are not disposed of by mechanical means must be:
(a) Kept in containers which:
(1) Are leak proof;
(2) Are made of nonabsorbent materials; and
(3) Can be tightly closed; and
(b) Disposed of as frequently as necessary to prevent a nuisance or unsightliness.
7. Ice which is used in connection with food or drink must be from a sanitary source and must be handled and dispensed in a sanitary manner.
8. A person other than personnel of the dietary service may not be in the kitchen area unless the person is required to be there in the performance of his duties.
9. Equipment of the type and in the amount necessary for the proper preparation, service and storage of food and for proper dishwashing must be provided and maintained in good working order.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.340 Pharmaceutical services. (NRS 449.037)
1. A hospital shall have a pharmacy directed by a registered pharmacist, who may be a full-time, part-time or consulting pharmacist, or a drug room supervised by no less than a currently licensed professional nurse. If a hospital has an organized pharmaceutical service, the full-time, part-time or consulting pharmacist shall develop, supervise and coordinate all the activities of the service.
2. The pharmacy and area for drug storage must be administered in accordance with all applicable state and federal laws.
3. Except as otherwise provided in this subsection, the medical staff shall develop policies and procedures to minimize errors in the administration of the drugs. The medical staff may designate the organized pharmaceutical service of the hospital to develop the policies and procedures required by this subsection.
4. The pharmaceutical service of a hospital shall have an adequate number of personnel to ensure quality pharmaceutical services, including emergency services.
5. Drugs and biologicals must be controlled and distributed in a manner which is consistent with applicable state and federal laws.
6. When a pharmacist is not available, drugs and biologicals may be removed from the pharmacy or storage area only by personnel designated by the policies of the medical staff and pharmaceutical service, which must be established in accordance with all applicable state and federal laws, to remove the drug or biological.
7. Errors in administering a drug to a patient, adverse reactions by a patient to a drug and incompatibilities between a drug and patient must be immediately reported to the attending physician of the patient and, if appropriate, to the committee that oversees the quality improvement program established pursuant to NAC 449.3152.
8. Abuses and losses of controlled substances must be reported, in accordance with all applicable state and federal laws, to the person responsible for the pharmaceutical service and the chief executive officer of the hospital.
9. Information relating to drug interactions, drug therapy, side effects, toxicology, dosage indications for use and routes of administration must be made available to the professional members of the hospital staff.
10. A formulary system must be established by the medical staff to ensure the provision of quality pharmaceuticals at reasonable costs.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § VII subsecs. A-C, eff. 10-9-69; Ch. II part § VII, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.343 Orders for medication and biologicals. (NRS 449.037)
1. Except as otherwise provided in this section, an order for medication or biologicals for a patient must be in writing and signed by the practitioner, or other appropriate professional person authorized by state or federal law to order the medication or biological, who is responsible for the care of the patient.
2. When a telephone or verbal order is used to order medications or biologicals, the order must be:
(a) Accepted only by a person who is authorized by the policies and procedures of the medical staff, which must be consistent with state law, to accept such an order; and
(b) Signed or initialed by the prescribing practitioner in accordance with hospital policy.
3. An order for a medication or a biological must include the name of the medication or biological and the dosage, time or frequency of administration and route of administration of the medication or biological.
4. Medication and biologicals that are not specifically prescribed as to time or number of doses must be automatically stopped after a reasonable time that has been predetermined by the medical staff for that medication or biological.
5. Emergency medications approved by the medical staff or advisory physician must be kept readily available in the pharmacy or drug room and in compliance with all federal, state and local laws.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § VII subsecs. D-H, eff. 10-9-69; Ch. II part § VII, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.344 Administration of medication; security. (NRS 449.037)
1. Only members of the hospital staff who are legally authorized to administer medications may do so.
2. Security of all medications must be maintained in accordance with applicable state law.
3. The quality improvement program established pursuant to NAC 449.3152 must include a system of security to monitor and improve the process of administering medications.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.346 Rehabilitative services. (NRS 449.037)
1. Rehabilitative services are those activities used in restoring, maintaining and improving the physical and mental well-being of a patient. A hospital shall provide rehabilitative services consistent with its overall role in the treatment of a patient by or under the supervision of persons professionally licensed in this State to render such services.
2. If a hospital provides rehabilitative services, including, without limitation, physical therapy, occupational therapy, audiology or speech pathology, the services must be organized and staffed to ensure the health and safety of the patients. The organization of the services must be appropriate to the scope of the services offered.
3. The director of the rehabilitative services must have the necessary knowledge, experience and capabilities to supervise and administer properly the services provided.
4. Rehabilitative services provided by a hospital in accordance with this section must be provided by persons who meet the qualifications specified by the medical staff.
5. Rehabilitative services must be furnished to each patient in accordance with his written plan of treatment. The services must be provided pursuant to the order of a practitioner who is authorized by the medical staff to order such services, and those orders must be incorporated into the record of the patient.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XII, eff. 10-9-69; Ch. II § VIII, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.349 Emergency services. (NRS 449.037)
1. A hospital shall meet the emergency needs of its patients in accordance with nationally recognized standards of practice.
2. If a hospital does not have an emergency department on site, the policies and procedures for meeting the emergency needs of patients must be under the direction of a qualified member of the medical staff.
3. If a hospital provides emergency services through an emergency department:
(a) The services must be organized under the direct supervision of a qualified member of the medical staff;
(b) The services must be integrated with the other departments, units and services within the hospital; and
(c) The policies and procedures governing the provision of medical care in the emergency department must be established by and are the continuing responsibility of the medical staff.
4. A hospital shall have sufficient medical and nursing personnel who are qualified in emergency medical care to carry out the written emergency procedures of, and to meet the emergency needs anticipated by, the hospital.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XIV, eff. 10-9-69; Ch. II § IX, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.352 Social services. (NRS 449.037)
1. A hospital shall have effective written policies and procedures for the provision of social services by the hospital staff.
2. Social services must be provided or supervised in accordance with chapter 641B of NRS by a professional, qualified social worker who is appropriately trained and has adequate experience to meet the social and emotional needs of the patients and their families. If the social worker does not have the educational and experiential requirements of a qualified social worker, an ongoing plan for consultation between the social worker and a qualified social worker must be developed.
3. A hospital shall provide to each patient access to related social services based on the assessed needs of the patient.
4. As used in this section, “qualified social worker” means a licensed social worker who has had at least 1 year of actual work experience in a hospital setting.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XV, eff. 10-9-69; Ch. II § X, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.355 Discrimination prohibited. (NRS 449.037) A hospital shall not discriminate in the admission of, or the provision of services to, a person on the basis of his race, color, religion, national origin, age, gender, disability or ability to pay.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XVI subsec. E, eff. 10-9-69; Ch. II part § XI, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.358 Medical staff. (NRS 449.037)
1. A hospital shall have a well-organized medical staff that operates in accordance with the bylaws approved by the governing body.
2. The medical staff must be appointed by the governing body and be composed of:
(a) Doctors of medicine or osteopathy; and
(b) To the extent authorized by state law, other practitioners.
3. The medical staff shall periodically conduct appraisals of its members.
4. The members of the medical staff shall examine the credentials of candidates for membership to the medical staff and make recommendations to the governing body on the appointment of those candidates to the medical staff.
5. The medical staff is accountable to the governing body for the quality of the medical care provided to the patients of the hospital.
6. If the medical staff has an executive committee, a majority of the members of the executive committee must be doctors of medicine or osteopathy.
7. The responsibility for the organization and conduct of the medical staff must be assigned only to a doctor of medicine or osteopathy.
8. The medical staff shall adopt and enforce bylaws to carry out its responsibilities. The bylaws must:
(a) Be approved by the governing body of the hospital.
(b) Include a statement of the duties and privileges for each category of the medical staff, including, without limitation, active status and courtesy privileges.
(c) Describe the organization of the medical staff.
(d) Describe the qualifications that a candidate for membership to the medical staff must have before the medical staff will consider the recommendation of the candidate for membership.
(e) Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to persons requesting privileges.
(f ) Include a requirement that a physical examination and medical history be done on each patient not more than 7 days before or more than 48 hours after the patient is admitted into the hospital by a member of the medical staff who is a doctor of medicine or osteopathy.
9. The medical staff shall attempt to secure autopsies in all cases in which the death of the patient is unusual or is of legal, medical or educational interest. The medical staff shall:
(a) Specifically define a mechanism for documenting permission to perform an autopsy;
(b) Establish a system for notifying the members of the medical staff and the attending physician when an autopsy is to be performed; and
(c) Ensure that all autopsies performed in the hospital are authorized pursuant to NRS 451.010.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § III, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.361 Nursing services. (NRS 449.037)
1. A hospital shall have a well-organized plan that provides for 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse.
2. The governing body and the hospital shall ensure that the nursing services provided at the hospital are provided in accordance with all applicable federal and state laws and regulations.
3. The nursing service shall have a sufficient number of licensed registered nurses, licensed practical nurses and other personnel to provide nursing care to all patients as needed. A sufficient number of registered nurses and other members of the nursing staff must be on duty at all times to ensure that proper care is provided to each patient. A person who is not a registered nurse may be assigned to care for a patient, if:
(a) The extent of care provided by the person is consistent with his education and experience and is within his scope of practice; and
(b) The person is supervised by a registered nurse while providing that care.
4. A hospital shall have a system for determining the nursing needs of each patient. The system must include assessments made by a registered nurse of the needs of each patient and the provision of staffing based on those assessments.
5. The plan for providing nursing services must include a plan of administrative authority and a delineation of responsibilities for patient care.
6. A hospital shall ensure that the nursing staff develops and keeps current a plan for nursing care for each inpatient.
7. The nursing services must be under the direct supervision of a chief administrative nurse. The chief administrative nurse must be knowledgeable, skilled and competent in clinical practice and nursing management. The chief administrative nurse shall direct and supervise the nursing services in compliance with chapter 632 of NRS and nationally recognized professional standards for organized nursing services.
8. The chief administrative nurse shall define the policies, procedures and standards relating to the provision of nursing services and shall ensure that the members of the nursing staff carry out those policies, procedures and standards. The policies, procedures and standards must be documented and accessible to each member of the nursing staff in written or electronic form. The chief administrative nurse must approve each element of the policies, procedures and standards before the element may be used or put into effect.
9. A hospital shall ensure that its patients receive proper treatment and care provided by its nursing services in accordance with nationally recognized standards of practice and physicians’ orders.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § IV, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.3622 Appropriate care of patients. (NRS 449.037)
1. Each patient must receive, and the hospital shall provide or arrange for, individualized care, treatment and rehabilitation based on the assessment of the patient that is appropriate to the needs of the patient and the severity of the disease, condition, impairment or disability from which the patient is suffering.
2. The governing body shall ensure that each person’s role in providing care to a patient is determined by:
(a) The professional skills, competence and credentials of the person providing care;
(b) The care or rehabilitation to be provided to the patient;
(c) The policies of the hospital; and
(d) The relevant required licensure or certification, regulation, privileges, scope of practice and job description of the person.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.3624 Assessment of patients. (NRS 449.037)
1. To provide a patient with the appropriate care at the time that the care is needed, the needs of the patient must be assessed continually by qualified hospital personnel throughout the patient’s contact with the hospital. The assessment must be comprehensive and accurate as related to the condition of the patient.
2. Each patient must be reassessed according to hospital policy:
(a) When there is a significant change in his condition;
(b) When there is a significant change in his diagnosis; or
(c) To determine his response to the care that he is receiving.
3. The hospital shall ensure that the hospital staff develop and keep current a plan of care for each inpatient based on the assessed needs of the inpatient.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.3626 Rights of patients. (NRS 449.037) A governing body shall develop and carry out policies and procedures that protect and support the rights of patients as set forth in NRS 449.700 to 449.730, inclusive.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.3628 Protection of patients; use of physical restraints. (NRS 449.037)
1. A governing body shall develop and carry out policies and procedures that prevent and prohibit:
(a) Verbal, sexual, physical and mental abuse of patients; and
(b) The involuntary seclusion of a patient without clinical justification for that seclusion.
2. The governing body shall develop and carry out policies and procedures that prevent and prohibit neglect and misappropriation of the personal property of a patient.
3. The governing body shall develop policies and procedures for the identification and investigation of neglect and abuse of patients.
4. The governing body shall develop and carry out organizational policies and procedures that limit the use of physical restraints on patients to only those situations in which the use of physical restraints is appropriate and for which there is adequate clinical justification.
5. The governing body shall ensure that the use of any physical restraints on a patient is initiated only pursuant to a physician’s order or protocols approved by the medical staff and the hospital administration.
6. If the use of physical restraints is permitted pursuant to approved protocols, the approved protocols must include:
(a) A thorough assessment of the patient before the use of physical restraints is initiated;
(b) A provision that requires the initiation of the use of the physical restraints by a registered nurse or other authorized person according to hospital policy;
(c) A provision for notifying the physician within 12 hours after the use of the physical restraints is initiated;
(d) A requirement that a verbal or written order of the physician be obtained and entered into the medical record of the patient; and
(e) A requirement that the continued use of physical restraints beyond the first 24 hours be authorized by the physician through the renewal of the original order. The issuance of an order for the continued use of physical restraints on a patient must occur no less often than once each calendar day.
7. Organizational policies and procedures, protocols, physician’s orders and the individual needs of a patient must be used to establish the frequency, nature and extent of monitoring of a patient upon whom physical restraints are being used.
8. The hospital shall have a process for quality improvement to identify appropriate opportunities for reducing the use of physical restraints. The process for quality improvement must include areas for measurement and assessment to identify opportunities to reduce the risks associated with the use of physical restraints through the introduction of preventive strategies, innovative alternatives to the use of physical restraints and improvements to the process of using physical restraints.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.363 Personnel policies concerning employment, licensing and certification. (NRS 449.037)
1. A hospital shall have written policies concerning the qualifications, responsibilities and conditions of employment for each type of hospital personnel, including the licensure and certification of each employee when required by law.
2. The written policies must be reviewed and updated as needed and must be made available to the members of the hospital staff.
3. Personnel policies must provide for:
(a) The orientation of all health personnel to the policies and objectives of the hospital; and
(b) The maintenance of records of current employees which confirm that the personnel policies are being followed.
4. The hospital shall have evidence of a current license or certification on file at the hospital for each person employed by the hospital, or under contract with the hospital, who is required to be licensed or certified by law to perform his job.
5. The hospital shall ensure that the health records of its employees contain documented evidence of surveillance and testing of those employees for tuberculosis in accordance with chapter 441A of NAC.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.364 Obstetrical services: Administration; staffing and equipment. (NRS 449.037)
1. If a hospital provides obstetric services, the obstetric services must be provided through an obstetric department which is well-organized and sufficiently staffed to ensure the health and safety of the patients.
2. The obstetric department must be under the direction and supervision of a qualified member of the medical staff. The director of the obstetric department is responsible for the quality of medical care provided to patients by the obstetric department and for the review of the professional practices of the medical staff within the obstetric department, including, without limitation:
(a) The delineation of the privileges accorded to members of the medical staff and members of allied health professional persons in the obstetric department; and
(b) The reappraisal and appointment of each such member.
3. A roster of the privileges relating to the provision of obstetric services of each member of the medical staff must be kept in the files of the obstetric department. The roster must specify the privileges awarded to each member.
4. A hospital shall ensure that the obstetric department has adequate staffing and equipment, including, without limitation:
(a) A sufficient number of registered nurses, trained in perinatal care of a maternal patient and in newborn care, who are on duty at all times to ensure that proper care is provided to each patient;
(b) Appropriate equipment maintained in good working order;
(c) Drugs and oxygen necessary to provide obstetric care to a maternal patient and a newborn;
(d) Appropriate clinical laboratory services available to provide safe obstetric care according to the needs of the patient and medical staff of the department; and
(e) Sufficient personnel on the premises and immediately available for each delivery of a newborn who:
(1) Are trained and experienced in performing cardiopulmonary resuscitation on adults and newborns; and
(2) Have successfully completed the Neonatal Resuscitation Program endorsed by the American Academy of Pediatrics and the American Heart Association.
5. A hospital shall ensure that the obstetric department has the capability of providing:
(a) Initial evaluation of the risk-status of each patient needing obstetric services, including the appropriateness of admitting the patient; and
(b) Support of patients in labor.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. D pars. 1-8, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.3645 Obstetrical services: Labor rooms; delivery rooms; utility rooms; area for cleaning instruments. (NRS 449.037)
1. Each hospital which has an organized obstetric service shall have at least one labor room, with the need for additional labor rooms to be determined by the amount of use of the labor room.
2. Each hospital shall have at least one properly equipped delivery room, with the need for additional delivery rooms to be determined by the amount of use of the delivery room. The delivery room must have:
(a) An emergency call system that is operable without the use of hands and an adequate signal system.
(b) Emergency sterilizing facilities to support the delivery area.
(c) A heated bassinet and warmer, and resuscitation equipment for newborns which is readily available.
(d) A device for easy, positive identification of a newborn before the newborn is removed from the delivery room.
(e) Adequate storage space for sterile supplies and equipment.
(f ) Sinks and dispensers which are equipped with foot, knee or elbow controls or an alternative method of control.
3. A hospital shall have a clean utility room with adequate storage for cleaning supplies and other cleaning equipment needed for the delivery and labor rooms.
4. Major cleaning of instruments and other utensils used in the delivery or labor room must take place in a specified cleanup area or holding area for soiled materials.
(Added to NAC by Bd. Health by R050-99, eff. 9-27-99)
NAC 449.365 Obstetrical services: Required services. (NRS 449.037)
1. An obstetric department of a hospital shall provide services for labor, delivery, newborn care and recovery care, and shall maintain the areas in which these services are provided in a safe and clean manner.
2. The obstetric department must be equipped with those items needed to provide obstetrical care and emergency procedures in life-threatening situations to a mother or her baby.
(Added to NAC by Bd. Health by R050-99, eff. 9-27-99)
NAC 449.3655 Obstetrical services: Transfer or discharge of patient. (NRS 449.037)
1. No person may be transferred or discharged from an obstetric department of a hospital unless:
(a) The transfer or discharge is appropriate based on a risk assessment of the patient;
(b) A physician determines that the patient is not in active labor; or
(c) A physician determines that the medical needs of the patient exceed the capability of the obstetric department.
2. The criteria for the transfer of a patient must be in writing and included in the manual for policies and procedures of the obstetric department.
3. A patient in the obstetric department may be transferred only to a hospital capable of providing a higher level of obstetrical and neonatal care and for which there are written documents which verify that the receiving hospital agrees to accept emergency patients without regard to their ability to pay.
4. The obstetric department shall establish written protocols for the discharge of patients from the hospital, which include, without limitation:
(a) The provision of instructions to the mother regarding the care and feeding of her newborn;
(b) Plans for the examination of the mother and newborn after discharge;
(c) The provision of instructions to the mother regarding the availability of consultation services by telephone or home visit, as needed or requested by the mother; and
(d) The criteria and conditions under which a patient or newborn should be considered for transfer. Such a determination must be made by a qualified member of the medical staff and the criteria and conditions must be included in the written policies and procedures of clinical practices for the obstetric department. The written policies must be reviewed periodically by a qualified member of the medical staff and a review of all such transfers must be included in the quality improvement program established pursuant to NAC 449.3152.
(Added to NAC by Bd. Health by R050-99, eff. 9-27-99)
NAC 449.367 Obstetrical services: Nurseries. (NRS 449.037)
1. An obstetric department shall have a nursery which is organized under the direction of a qualified member of the medical staff.
2. Nurseries must be completely equipped for any neonatal emergencies.
3. The total number of bassinets in a nursery service must be at least equal to the number of beds for postpartum patients.
4. A separate storage room must be available to support the requirements of the entire nursery.
5. The following must be made available for each unit for infants:
(a) A bassinet for each infant with storage space for the infant’s supplies, such as diapers, shirts and thermometers.
(b) Incubators for infants needing supplemental oxygen, heat or humidity and for all infants with a low birth weight.
(c) A scale for weighing babies.
(d) Oxygen.
6. If a nursery for premature infants exists, it must be designed to provide for maximum observation and supervision and must include:
(a) An electrical outlet for each incubator located in the nursery; and
(b) Oxygen for every incubator.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. D pars. 9-13, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.370 Outpatient services. (NRS 449.037)
1. If a hospital provides outpatient services, the services must meet the needs of the patients in accordance with nationally recognized standards of practice.
2. A hospital shall ensure that its outpatient unit is appropriately organized and integrated with inpatient services.
3. A hospital which provides outpatient services shall:
(a) Assign a person to be responsible for the outpatient unit;
(b) Have sufficient numbers of professional and nonprofessional personnel available to provide the outpatient services; and
(c) Ensure that nursing services provided in the outpatient unit are provided under the direction of a registered nurse.
4. Equipment and supplies necessary to meet the anticipated needs of the outpatients must be readily available and in good working order.
5. The outpatient unit shall have a sufficient number of examination and treatment rooms for the outpatient service based on the volume and nature of work performed.
6. Laboratory, radiology and pharmaceutical services must be readily available to the outpatient unit.
7. If outpatient surgery is performed in the outpatient unit, the basic facilities that must be available to perform the surgery include, without limitation:
(a) A fully equipped and staffed operating room and postanesthesia recovery area;
(b) Means of control against hazards of infection, electrical or mechanical fire, and explosion;
(c) Sterile supplies that are readily available to meet the needs of the outpatients; and
(d) Equipment and instrumentation for anesthesia and emergency cardiopulmonary resuscitation.
8. If beds are provided in an outpatient unit, the number of outpatient beds must not be included in the licensed bed capacity of the hospital. Inpatients may not occupy an outpatient bed. An outpatient shall not remain in an outpatient bed for more than 48 consecutive hours.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XIII, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.371 Intensive care services. (NRS 449.037)
1. If a hospital provides intensive care services, the services must be well-organized and provided in accordance with nationally recognized standards of practice.
2. An intensive care unit must be under the direction of a qualified member of the medical staff.
3. Written policies and procedures must be developed and maintained by the director of the intensive care unit, in consultation with other appropriate health-care professionals and the administration of the hospital. The administration and medical staff of the hospital must approve procedures to be used by the intensive care unit when approval of such procedures is appropriate.
4. The responsibility and the accountability of the intensive care unit to the medical staff and administration must be set forth in writing by the director of the intensive care unit.
5. Whenever a patient is present in the intensive care unit, a registered nurse, with training and experience in intensive care nursing, shall supervise the nursing care and nursing management of the intensive care service.
6. All licensed nurses working in an intensive care unit must:
(a) Have training and experience in intensive care nursing; or
(b) Work under the direct supervision of a registered nurse who has training and experience in intensive care nursing.
7. The hospital shall establish a system for determining the nursing needs of each patient in the intensive care unit that includes an assessment made by a registered nurse trained in critical care of the patient’s needs and the provision of staffing based on that assessment.
8. The hospital shall follow the written policies for the plans for nurse staffing, which are dependent upon the acuity level of the patients in the intensive care unit, to ensure that the needs of the patients are met.
9. A respiratory therapist or respiratory technician, physical therapist and other supportive personnel must be available depending upon the requirements of the intensive care unit.
10. The equipment and supplies for the intensive care unit must be adequate to meet the needs of the patients in the intensive care unit.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.373 Laboratory services; pathology services; blood and blood products. (NRS 449.037)
1. Each hospital shall maintain or have available adequate laboratory services to meet the needs of its patients and medical staff. Each hospital shall ensure that all laboratory services provided to its patients are provided by a medical laboratory licensed pursuant to chapter 652 of NRS.
2. Laboratory services must be available 24 hours a day, 7 days a week, including holidays.
3. While a patient is under the care of a hospital, all laboratory testing must be performed:
(a) In the laboratories of the hospital;
(b) By a reference laboratory that is certified pursuant to 42 U.S.C. § 263a; or
(c) In accordance with NRS 652.217.
4. The director of a laboratory that provides laboratory services to a hospital shall establish procedures to ensure that patients who have been transfused with blood or blood products which have tested positive for the human immunodeficiency virus are promptly notified of that fact.
5. Each laboratory which provides laboratory services to a hospital shall provide for the proper receipt and reporting of tissue specimens. All reports of tissue specimens must be signed by a pathologist. The medical staff of the hospital and a pathologist shall determine which tissue specimens require a macroscopic (gross) examination and which require both macroscopic and microscopic examinations.
6. If provided in a hospital, pathology services must be under the supervision of a pathologist in a full-time, regular part-time or regular consultative basis and he shall participate in staff, departmental and clinicopathologic conferences.
7. Facilities for the procurement, safekeeping and transfusion of blood and blood products must be provided in each hospital, or readily available, with adequate control and supervision by an authorized physician. The refrigerator for the storage of blood must have an adequate recording thermograph and temperature alarm system, must be regularly inspected and must be otherwise safe and adequate to prevent the deterioration of the blood and blood products.
8. If the hospital depends on outside blood banks, there must be an agreement governing the procurement, transfer and availability of blood which is reviewed and approved by the medical staff, administration and governing body. Provision must be made for prompt blood typing, cross-matching and investigation of transfusion reactions. A committee of the medical staff, or its equivalent, shall review all transfusions of blood or blood derivatives, and blood or blood derivative reactions, occurring in the hospital and make recommendations concerning policies governing these practices.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § VIII, eff. 10-9-69]—(NAC A 10-22-93; R050-99, 9-27-99)
NAC 449.3735 Transfusions of blood. (NRS 449.037)
1. To perform a transfusion of blood safely and efficiently, hospital personnel shall follow the policies and procedures developed by the hospital, with input from the medical staff, for performing a transfusion of blood.
2. Hospital personnel may administer blood only within the scope of their practice and after they have been trained to administer blood.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.374 Nuclear medicine services. (NRS 449.037)
1. If a hospital provides nuclear medicine services, those services must meet the needs of the patients receiving those services in accordance with nationally recognized standards of practice.
2. The nuclear medicine services must be under the supervision of a doctor of medicine or osteopathy who is qualified in nuclear medicine. The director of the nuclear medicine services is responsible for the medical direction of those services.
3. The qualifications, training, functions and responsibilities of the personnel of the nuclear medicine services must be specified by the administration of the hospital and approved by the medical staff.
4. Radioactive materials used in providing nuclear medicine services must be prepared, labeled, used, transported, stored and disposed of in accordance with nationally recognized standards of practice.
5. In-house preparation of radiopharmaceuticals must be made by, or under the direct supervision of, an appropriately trained registered pharmacist or a doctor of medicine or osteopathy.
6. A radionuclide must be stored, used and disposed of in accordance with the requirements set forth in chapter 459 of NAC.
7. If laboratory tests are performed in the nuclear medicine services, the services must meet the applicable requirements for laboratory services specified in 42 C.F.R. § 482.27.
8. Equipment and supplies used for the nuclear medicine services must be appropriate for the types of nuclear medicine services offered by the hospital and must be maintained for safe and efficient performance. The equipment must be:
(a) Maintained in safe operating condition; and
(b) Inspected, tested and calibrated at least annually by persons who are qualified to do such inspections, tests and calibrations.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.375 Records for nuclear medicine services; authorization. (NRS 449.037)
1. A hospital shall maintain signed and dated reports of nuclear medicine interpretations, consultations and procedures.
2. The hospital shall maintain nuclear medicine reports, or copies thereof, for at least 5 years after the date on which the report was made.
3. A practitioner approved by the medical staff to interpret diagnostic procedures must sign and date his interpretation of the tests.
4. The hospital shall maintain records of the receipt and disposition of radiopharmaceuticals.
5. Nuclear medicine services may be ordered only by a practitioner whose scope of licensure and defined staff privileges authorize the practitioner to make such orders.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.376 Radiological services. (NRS 449.037)
1. A hospital shall have diagnostic radiological facilities available. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.
2. The hospital shall maintain or have available radiological services according to the needs of the patients.
3. Radiological services, particularly ionizing radiological procedures, must be conducted in a manner that monitors and controls hazards so that safety is maintained for patients and personnel.
4. Proper safety precautions must be maintained against radiation hazards, including, without limitation:
(a) Adequate shielding for patients, personnel and facilities; and
(b) Appropriate storage, use and disposal of radioactive materials.
5. Equipment used for providing radiological services must be periodically inspected, and any hazards identified in the inspection must be promptly corrected.
6. Radiological technicians and other persons who work with radiation must be checked periodically by the use of exposure meters or badge tests for the amount, if any, of radiation exposure.
7. Radiological services must be provided only upon the order of:
(a) A practitioner who has clinical privileges or is authorized by state law to order such services; or
(b) Other practitioners authorized by the medical staff and governing body to order such services.
8. A qualified full-time, part-time or consulting radiologist shall supervise the ionizing radiological services and shall interpret only those radiological tests that are determined by the medical staff to require the specialized knowledge of the radiologist.
9. Only personnel designated as qualified personnel by the medical staff may use radiologic equipment and administer radiological procedures.
10. Records of radiology services provided to patients must be maintained.
11. A radiologist or other practitioner who performs radiology services shall sign any report of his interpretation.
12. A hospital shall maintain the following information for at least 5 years:
(a) Copies of reports and printouts of radiology services; and
(b) Films, scans and other image records of radiology services that have been provided.
13. As used in this section, “radiologist” means a doctor of medicine or osteopathy who is qualified by education and experience in radiology.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § IX, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.377 Radiological therapeutic services. (NRS 449.037)
1. If a hospital provides radiological therapeutic services, the services must meet professionally nationally recognized standards for safety and personnel qualifications.
2. A radiological therapeutic department must be under the direction of a physician who is:
(a) Certified or eligible for certification in therapeutic radiology by the American Board of Radiology; or
(b) Certified or eligible for certification in radiology by the American Board of Radiology and has 2 years of full-time experience in radiation therapy.
3. Other personnel who may provide radiological therapeutic services, on a full-time, part-time or consultative basis, depending on the activity of the department, include:
(a) A radiological physicist who is certified in radiological physics or in therapeutic radiological physics by the American Board of Radiology;
(b) A dosimetrist, or treatment plan technologist, who is a qualified and experienced radiation therapy technologist and who has at least 1 year of additional clinical training in dosimetry;
(c) A certified therapeutic radiological technologist; and
(d) Appropriate support personnel, including licensed nurses, as required by the patient load.
4. Written policies and procedures must be developed and maintained by the director of the department in consultation with other appropriate health professional persons and the administration of the hospital.
5. Radiation therapy must be given only under the direction of a radiation therapist.
6. All cancer patients accepted for curative radiation must have adequate histological substantiation of diagnosis, unless convincing alternative evidence for diagnosis is presented.
7. Documentation of the initial evaluation and treatment plan of each patient, and dosimetry, clinical, technical and follow-up notes on each patient, must be maintained.
8. Adequate communication must be maintained between the department and the referring physicians, including periodic review of case management, complications and treatment results.
9. Calibration and operation of equipment for radiation therapy must meet the requirements specified in chapter 459 of NAC.
10. Radiation protection for patients and staff must comply with the requirements specified in chapter 459 of NAC.
11. Periodic follow-ups of a patient following the completion of his treatment must be coordinated with the physician who referred the patient.
12. Equipment and supplies for the radiological therapeutic services must conform to the requirements specified in chapter 459 of NAC.
13. The rooms in which radiation therapy machines are used must be of adequate size to permit the easy use of the machines by patients on stretchers. Shielding of those rooms must meet the requirements specified in chapter 459 of NAC.
14. Sufficient examination rooms must be available to accommodate all patients receiving the therapeutic services.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.379 Medical records. (NRS 449.037)
1. A hospital shall maintain a medical record for each person evaluated or treated in the hospital.
2. The organization of the medical records service at the hospital must be appropriate to the scope and complexity of the services performed at the hospital. A hospital shall employ adequate personnel to ensure prompt completion, filing and retrieval of the medical records.
3. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. A hospital shall use a system for author identification and record maintenance that ensures the integrity of the authentication of the record and protects the security of all entries to a medical record.
4. Except as otherwise provided in this subsection, medical records must be retained in their original form or in a legally reproduced form for at least 5 years. The medical staff may identify specific items in a medical record that must be kept for at least 10 years. The hospital shall have a system for coding and indexing its medical records. The system must allow for the timely retrieval of information by diagnosis and procedure to support studies evaluating the medical care provided at the hospital.
5. A hospital must have a procedure for ensuring the confidentiality of the medical records of its patients. Information from or copies of medical records may be released only to authorized persons, and the hospital shall ensure that unauthorized persons cannot gain access to or alter the medical records of its patients. Original medical records may be released by the hospital only in accordance with state or federal law, court orders or subpoenas.
6. A medical record must include information:
(a) Demonstrating the justification for the admission and continued hospitalization of a patient;
(b) Supporting the diagnosis of the patient; and
(c) Describing the progress of the patient and his response to the medications and services received during his hospitalization.
7. All entries to a medical record must be legible and complete, and authenticated and dated promptly by the person who is responsible for ordering, providing or evaluating the service provided. In authenticating a medical record, the person shall include his name and discipline. Authentication may include the signature or written initials of the person or a computer entry by the person.
8. All medical records must document the following information, as appropriate:
(a) Evidence that a physical examination, including a history of the health of the patient, was performed on the patient not more than 7 days before or more than 48 hours after his admission into the hospital.
(b) The diagnosis of the patient at the time of admission.
(c) The results of all consultative evaluations of the patient and the appropriate findings by clinical and other staff involved in caring for the patient.
(d) Documentation of any complications suffered by the patient, infections acquired by the patient while in the hospital and unfavorable reactions by the patient to drugs and anesthesia administered to him.
(e) Properly executed informed consent for all procedures and treatments specified by the medical staff, or federal or state law, as requiring written patient consent.
(f ) All orders of practitioners, nursing notes, reports of treatment, records of medication, radiology and laboratory reports, vital signs and other information necessary to monitor the condition of the patient.
(g) A discharge summary that includes a description of the outcome of the hospitalization, disposition of the case and the provisions for follow-up care that have been provided to the patient.
(h) The final diagnosis of the patient.
9. The medical record of a patient must be completed not later than 30 days after the date on which he is discharged.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § VI, eff. 10-9-69; A 8-26-74]—(NAC A by R050-99, 9-27-99)
NAC 449.382 Medical library. (NRS 449.037) A hospital shall have a medical library to meet the requirements of the facility, with access to current periodicals on clinical services which are offered.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § X, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.385 Surgical services. (NRS 449.037)
1. If a hospital provides surgical services, the services must be well-organized and provided in accordance with nationally recognized standards of practice. If outpatient surgical services are offered, the services must be consistent in quality, in accordance with the complexity of the services, with similar services provided to inpatients.
2. The operating rooms must be supervised by an experienced registered nurse or a doctor of medicine or osteopathy.
3. A licensed practical nurse or a surgical or operating room technician may act as a scrub nurse or scrub technician only under the direct supervision of a registered nurse.
4. Circulating duties in an operating room must be performed by a qualified registered nurse, who shall not perform circulating duties in more than one operating room at a time.
5. Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competency of each practitioner. A hospital shall maintain a roster of practitioners that specifies the surgical privileges accorded to each practitioner.
6. Policies governing surgical care must be designed by the medical staff to ensure the achievement and maintenance of high standards of medical practice and patient care.
7. Except in emergency cases and except as otherwise provided in this subsection, a complete history and physical work-up must be completed and placed in a patient’s chart before the patient undergoes surgery. A patient may undergo surgery before his complete history or physical work-up is placed in his chart if the complete history or physical work-up has been dictated but not yet recorded and a statement of that fact and an admission note have been placed in the patient’s chart by the practitioner who admitted the patient.
8. Except in emergency cases, an informed consent form properly executed by a patient for the surgery must be placed in his chart before the surgery is performed.
9. Each surgical suite must have readily available and in good working condition:
(a) A call system;
(b) A cardiac monitor;
(c) A resuscitator;
(d) A defibrillator;
(e) An aspirator; and
(f ) A tracheotomy set.
10. A hospital shall make adequate provision for immediate postoperative care.
11. The operating room register must be complete and up-to-date at all times.
12. Immediately following surgery on a patient, the surgeon shall write or dictate an operative report, which must be included in the medical record of the patient, describing the techniques used, findings and tissues removed or altered. The surgeon shall sign the report.
13. The medical staff shall define which surgeries require the presence of a first assistant. A list of the surgeries that require the presence of a first assistant must be readily available to the surgical staff of the hospital.
14. A registered nurse or operating room technician may serve as a first assistant if:
(a) The medical staff has not otherwise required that the first assistant in a surgery be a physician; and
(b) The medical staff has designated the nurse or technician as having sufficient training to assist in the procedure adequately and properly.
15. A hospital shall establish and carry out policies and procedures relating to the cleaning and sanitation of a surgical suite.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. A, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.388 Anesthesia services. (NRS 449.037)
1. If a hospital furnishes anesthesia services, the services must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital.
2. The organization of the anesthesia service must be appropriate to the scope of the services offered by the hospital. Anesthesia may only be administered by:
(a) A qualified anesthesiologist;
(b) A doctor of medicine or osteopathy, other than an anesthesiologist;
(c) A dentist, oral surgeon or podiatrist who is legally authorized, under state law, to administer anesthesia; or
(d) A certified registered nurse anesthetist who is under the direction of the operating practitioner or of an anesthesiologist who is immediately available if needed. This paragraph does not affect the requirements for qualification as a certified registered nurse anesthetist as specified in chapter 632 of NRS, and any regulations adopted pursuant thereto.
3. Anesthesia services must be consistent with the needs and resources of the hospital. Policies on anesthesia procedures must include the delineation of preanesthesia and postanesthesia responsibilities. The policies must ensure that each patient receives:
(a) A preanesthesia evaluation by a person qualified to administer anesthesia, as set forth in subsection 2, that must be performed within 48 hours before surgery.
(b) An intraoperative anesthesia record.
(c) For inpatients, a postanesthesia follow-up report by the person who administered the anesthesia. The follow-up report must be written not later than 48 hours after the surgery.
(d) For outpatients, a postanesthesia evaluation for proper anesthesia recovery, performed in accordance with the policies and procedures approved by the medical staff.
4. If the hospital does not have a department of anesthesia, the department of surgery is responsible for the organization and implementation of the policies and procedures relating to the provision of anesthesia services.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. B, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.389 Respiratory care services. (NRS 449.037) A hospital shall meet the needs relating to respiratory care of its patients in accordance with nationally recognized standards of practice. If the hospital has a unit to provide respiratory care services:
1. The director of the unit must be a doctor of medicine or osteopathy who has the knowledge, experience and capabilities to supervise and administer the respiratory care services properly. The director may serve on a full-time or part-time basis.
2. The hospital shall ensure that there are an adequate number of respiratory therapists, respiratory therapy technicians and other personnel who meet the qualifications, which must be consistent with state law, specified by the medical staff to provide respiratory care services.
3. Personnel qualified to perform specific procedures relating to the provision of respiratory care services and the amount of supervision required for such personnel to carry out specific procedures must be designated in writing.
4. If blood gases or other clinical laboratory tests are performed in the respiratory care unit, the unit must meet the requirements for clinical laboratories with respect to management, adequacy of facilities, proficiency testing and quality control.
5. Respiratory care services must be provided only upon and in accordance with the orders of a doctor of medicine or osteopathy.
6. Diagnostic studies and treatment modalities relating to respiratory care must be recorded in the patient’s medical record, including, without limitation:
(a) The type of diagnostic or therapeutic procedures used;
(b) The dates and times of the use of such procedures; and
(c) The effects of such procedures, including adverse reactions.
7. The unit shall have sufficient types and quantities of equipment to provide for the appropriate inhalation of the several gases, aerosols and such other modalities required for the anticipated nature and variety of procedures that will be performed in the unit. Equipment must be calibrated in accordance with the manufacturer’s instructions and records of such calibrations must be maintained.
8. The unit shall have sufficient space for:
(a) The storage of necessary equipment;
(b) Work areas for:
(1) Cleaning, sterilizing and repairing equipment; and
(2) Performing studies of pulmonary function and blood analyses, if such studies and analyses are performed in the unit; and
(c) Office space for the personnel of the unit.
9. The unit shall establish and carry out procedures for the safe handling and storage of medical gas cylinders. Only certified persons and persons trained by the hospital may transfer gas from one cylinder to another. Such a transfer must be completed in accordance with safety protocols.
(Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)
NAC 449.391 Dental services. (NRS 449.037)
1. If a hospital provides dental services, the services must be well-organized and provided in accordance with nationally recognized standards of practice.
2. The dental service must be under the direct supervision of a dentist, who has overall responsibilities for the dental service.
3. Dental hygienists, dental assistants or dental laboratory technicians may be employed by the hospital if the dental hygienist, assistant or laboratory technician works under the direct supervision of a dentist.
4. Members of the dental staff must be currently licensed in this State for the positions to which they are appointed.
5. Patients admitted for dental services must be admitted by the dentist, either to the department of dentistry or, if there is no department, to an organized clinical service.
6. Equipment and supplies necessary to meet the anticipated dental needs of patients must be available.
7. Equipment for the sterilization of instruments and supplies must be provided directly in the dental service or through another department, unit or service within the hospital.
8. If the dental service offers primary dental care, the dental service must:
(a) Have adequate space to provide that care; and
(b) Facilities for dental radiography.
9. There must be specific bylaws concerning the dental staff written in combination with the bylaws of the medical staff or as separate dental bylaws.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. C, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
NAC 449.394 Psychiatric services. (NRS 449.037)
1. A general hospital which has a designated area set aside for use on a continuous basis for the treatment and care of psychiatric patients is deemed to operate a psychiatric service and shall comply with the requirements in this section.
2. A licensed physician may render psychiatric care in any licensed general hospital on a short term or emergency basis.
3. A hospital shall develop and carry out policies and procedures for the provision of psychiatric treatment and behavioral management services that are consistent with NRS 449.765 to 449.786, inclusive, to ensure that the treatment and services are safely and appropriately used. The hospital shall ensure that the policies and procedures protect the safety and rights of the patient.
4. The medical direction of the psychiatric unit and the psychiatric services provided by the hospital must be under the direct supervision of a qualified member of the medical staff.
5. All nursing services provided with regard to the provision of psychiatric care must be provided under the direction of a registered nurse.
6. A consulting medical staff composed of qualified persons in appropriate specialties must be available at all times to the patients in the psychiatric unit.
[Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. E, eff. 10-9-69]—(NAC A by R050-99, 9-27-99)
FACILITIES FOR CARE OF ADULTS DURING THE DAY
General Provisions
NAC 449.4061 Definitions. (NRS 449.037) As used in NAC 449.4061 to 449.4089, inclusive, unless the context otherwise requires:
1. “Division” means the Health Division of the Department of Health and Human Services.
2. “Facility” means a facility for the care of adults during the day as defined in NRS 449.004.
(Added to NAC by Bd. of Health, eff. 6-23-86)
Licensing
NAC 449.4063 Design, construction, equipment and maintenance of facility: General requirements; prerequisites to approval for licensure. (NRS 449.037)
1. A facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the clients and personnel of the facility and members of the general public.
2. A facility shall comply with all applicable:
(a) Federal and state laws;
(b) Local ordinances, including, without limitation, zoning ordinances; and
(c) Environmental, health, fire and local building codes,
Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply.
3. Except as otherwise provided in subsection 5, before any new construction of a facility or any remodeling of an existing facility is begun:
(a) The facility must submit building plans for the new construction or remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115. The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the facility.
(b) The building plans for the construction or remodeling must be approved by the Health Division.
4. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility.
5. The provisions of subsection 3 do not apply to plans for remodeling a facility if the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area, and replacing window or wall coverings in the area.
(Added to NAC by Bd. of Health, eff. 6-23-86; A by R076-01, 10-18-2001; R074-04, 8-4-2004)
NAC 449.4065 Consultation with representative of Division; notice of nonconformity. (NRS 449.037)
1. A representative of the Division will be available upon request for consultation to assure compliance with applicable regulations.
2. If a licensed facility does not conform to any requirement for licensing, the Division will issue a written notice specifying the nature of the nonconformity and set a time within which the facility must conform.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4067 Operation in combination with other medical facility or facility for the dependent. (NRS 449.037) A facility must not be operated in combination with any other medical facility or facility for the dependent unless it is licensed as a separate and distinct unit.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4069 Insurance. (NRS 449.037)
1. A facility must maintain a contract of insurance for protection against liability to third persons in amounts appropriate for the protection of clients, employees, volunteers and visitors to the facility.
2. A certificate of insurance must be furnished to the Division as evidence that a contract is in force, and a license will not be issued until that certificate is furnished.
3. Each contract of insurance must contain an endorsement providing for a notice of 30 days to the Division before the effective date of a cancellation or nonrenewal of the policy.
(Added to NAC by Bd. of Health, eff. 6-23-86)
Operation of Facility
NAC 449.407 Advertising and promotional materials. (NRS 449.037) Advertising and promotional materials for the facility must be accurate and represent the accommodations, programs or other services actually offered by the facility.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4071 Policies and procedures; accounting. (NRS 449.037)
1. Every facility must have a written policy concerning:
(a) Admission, discharge and care of clients;
(b) Employees of the facility; and
(c) Fiscal and administrative procedures for the facility,
Ê which must be evaluated at least once a year.
2. The system of accounting and financial reporting used by a facility must reflect the fiscal experience and current financial position of the facility.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4072 Director and employees: Qualifications and duties; physical and mental health. (NRS 449.037)
1. Each facility must have the number and kind of employees required by the physical characteristics of the facility, the number of clients and the services provided.
2. The director of a facility:
(a) Must be responsible and mature and have the personal qualities which will enable him to understand the problems of aged and infirm adults.
(b) Must be at least 21 years of age.
(c) Must have a high school diploma or its equivalent.
(d) Shall designate an acting director, who is similarly qualified, to act when the director is absent from the facility.
3. Every employee of the facility:
(a) Must be in good physical and mental health.
(b) Shall provide the Division:
(1) Upon his initial employment, with the results of a physical examination conducted within the preceding 6 months, or with a copy of his medical records for the preceding 3 years, certified by a physician.
(2) Upon his initial employment, with a negative report of a tuberculin test conducted within the preceding 6 months. Thereafter, a tuberculin test must be completed every 2 years. If the report of the tuberculin test is positive, he shall provide an X-ray film of his chest.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.40723 Supervision of clients; volunteers. (NRS 449.037)
1. A client must be supervised by an employee of the facility at all times during the operating hours of the facility. The employee shall report a change in any physical, mental, emotional or social function of the client to the director of the facility. These reports must be included in the client’s file.
2. The facility may use volunteers or outside consultants or services to meet the needs of its clients.
3. A volunteer shall conform to the same standards and requirements as a paid employee who performs a similar function, except that a volunteer is only required to provide the results of a tuberculin test and not the results of a complete physical examination.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.40725 Orientation and training of employees and volunteers. (NRS 449.037) All employees and volunteers at the facility:
1. Shall participate in a program of general orientation to inform them of the programs, policies and services of the facility;
2. Must receive a copy of the facility’s policies and procedures; and
3. Must receive training at the facility on a regular basis, but not less than 12 hours per year.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4073 Files concerning employees. (NRS 449.037) A separate file must be maintained and kept current on each employee. The file must include the following:
1. The employee’s:
(a) Name, address and telephone number;
(b) Social security number;
(c) Date of birth;
(d) Date of employment;
(e) Educational qualifications; and
(f ) Application for employment.
2. The name of a person to notify in case of an emergency.
3. Records of the employee’s experience related to his work.
4. Reports of periodic evaluations of the employee.
5. All required health certificates.
6. A record of any communicable illness which caused the employee to be absent from work.
7. Records of all accidents at the facility involving the employee.
8. The date of termination of employment and the reason for the employee’s discharge or resignation.
9. Records of the employee’s training at the facility.
10. Verification of any license held by the employee.
11. Proof that the employee received the required orientation at the facility.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4074 Requirements of facility; health and sanitation; medications; exits. (NRS 449.037)
1. The facility must:
(a) Provide proper access for each client to all activities and services;
(b) Have furniture and equipment appropriate for use by the clients;
(c) Have free local telephone service available for use by clients;
(d) Have sufficient space to accommodate a full range of activities and services;
(e) Provide for each client at least 40 square feet of space inside the facility excluding areas for maintenance of the facility;
(f ) Contain offices sufficient to permit employees to work effectively and without interruption;
(g) Provide adequate space for storage of supplies;
(h) Provide at least one toilet for every 10 clients;
(i) Have sufficient areas for parking and the safe delivery and pick-up of clients; and
( j) Provide secure space for the temporary storage of the property of clients.
2. The facility and its grounds must be safe, clean and accessible to all clients.
3. Medications and prescriptions must be stored in an appropriate, locked container or area.
4. Each facility must have at least two well-identified exits.
5. Stairs, ramps and interior floors must have surfaces or carpets which inhibit falling or slipping.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4075 Preparations for fires and other emergencies; reporting of fire or disaster. (NRS 449.037)
1. Each facility must have a plan in case of a fire or other emergency. The plan must be:
(a) Understood by all employees;
(b) Posted in a conspicuous place; and
(c) Reviewed at least once a year.
2. A drill for evacuation must be conducted at least once each month. Each facility shall retain a written record of the drill on file at the facility for not less than 12 months after the drill is conducted. Fire extinguishers must be inspected periodically, and training must be provided for employees of the facility in procedures to be followed in case of a fire or other emergency.
3. A facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster.
(Added to NAC by Bd. of Health, eff. 6-23-86; A by R074-04, 8-4-2004)
NAC 449.4076 First aid. (NRS 449.037) A first-aid kit must be available at the facility.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4077 Policy for admissions; retention of signed copy. (NRS 449.037)
1. A facility’s written policy on admissions must include:
(a) A statement of nondiscrimination regarding admission to the facility and treatment after admission; and
(b) The requirements for eligibility as a client.
2. A copy of the policy must be signed by the director of the facility and the client and retained in the client’s file.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4078 Requirements for admission; designation of physician. (NRS 449.037)
1. Each client shall, before he is admitted to the facility, provide the facility with:
(a) The results of a physical examination conducted by a physician, physician assistant or advanced practitioner of nursing within the preceding 6 months;
(b) A summary of his medical history prepared by a physician, physician assistant or registered nurse, within the preceding 6 months;
(c) A statement from his physician which indicates that the facility is an appropriate setting for the client; and
(d) Any special dietary requirements.
2. Each client shall designate a physician to be called in case of emergency. The facility must make all necessary arrangements to secure the services of a licensed physician for a client if his own physician is not available.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4079 Required services. (NRS 449.037) The facility must:
1. Provide each client with such assistance as necessary for the activities of daily living;
2. Provide activities for a client which are suited to his interests and capacities;
3. Observe the health of the client and notify his next of kin, guardian, or other person responsible for him of any significant change in his physical or mental condition;
4. Establish procedures for the administration of medication to clients, either directly by the client or by an employee at the facility;
5. Provide fluids to clients as necessary to prevent dehydration;
6. Have at least one employee on the premises at all times who is trained to administer first aid and cardiopulmonary resuscitation;
7. Provide information to a client about other local, state and federal agencies in the area that may be able to assist him and his family; and
8. Prepare a monthly calendar of activities at the facility and distribute the calendar to clients and their families.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.408 Housekeeping and maintenance. (NRS 449.037) Each facility must have adequate and regular services for housekeeping and the maintenance of the facility.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4081 Administration of medication; accidents or illnesses. (NRS 449.037)
1. If the facility accepts a client who cannot administer his own medication, an employee licensed to administer medications must administer the medication to him.
2. The next of kin or guardian or other person responsible for the client must be notified immediately in case of any accident, injury or illness involving the client.
3. Each client must be treated with dignity and respect and not subjected to verbal or physical abuse of any kind.
4. Restraints or sedatives in lieu of restraints may not be used or given to any client, except by a physician’s order.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4082 Service of food; dietary consultants. (NRS 449.037)
1. Adequate facilities and equipment for the preparation, service and storage of food must be provided and meet the standards of the Division.
2. The dining area must be separated from the area used to prepare food.
3. Tables and chairs must be of proper height and of sufficient number to provide seating for the number of clients authorized for the facility. They must be sturdy and have easily washable surfaces. Chairs must be constructed so that they do not overturn easily. Tables must be designed to accommodate persons in wheelchairs.
4. Meals must be served by employees who have received training in the sanitary preparation and handling of food.
5. Each meal must provide one-third of the daily nutritional allowances recommended by the Food and Nutrition Board of the National Academy of Sciences.
6. Any client who is in the facility for 5 hours or more a day must be served a meal. If he is in the facility for more than 6 hours in any day, additional nourishment must be provided.
7. Meals must be served in a manner suitable for the client and prepared with regard for individual preferences and religious requirements. Special diets and nourishment must be provided as ordered by the client’s physician. If meals are prepared within the facility, the facility must consult with a registered dietitian for at least 4 hours each month on the planning and serving of meals. If meals are prepared outside of and delivered to the facility, the facility shall develop and provide an alternative for any client on a special diet. The facility shall not accept a client who requires a special diet if it cannot develop an alternative which conforms to the client’s prescribed diet.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4083 Discrimination prohibited. (NRS 449.037)
1. A client shall not be segregated or restricted in the enjoyment of any advantage or privilege enjoyed by other clients or provided with any assistance, service or other benefit which is different or provided in a different manner from that provided to others on the ground of race, color or national origin.
2. The facility’s policy regarding nondiscrimination must be posted in a public area of the facility.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.40833 Summary of client’s care; referrals. (NRS 449.037) When a client permanently discontinues his use of a facility, he must receive a:
1. Written summary of his care at the facility, including any recommendations for care in the future; and
2. Referral to any other agency in the community for service, as appropriate.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.40835 Records. (NRS 449.037)
1. Each facility must have a written policy regarding the records of clients. The policy must include a description of the procedures governing the use and removal of records and the release of information contained in the records.
2. An individual file must be maintained for each client and retained for 5 years after he permanently discontinues his use of the facility. Each such file must be kept in a locked place which is resistant to fire and must be available only to authorized persons. The file must contain all records, letters and other information related to the client, including:
(a) His forms for application and enrollment;
(b) His medical information;
(c) His full name, address, race, religion, occupation, date of birth and social security number;
(d) The telephone number of his physician and home address and telephone number of his next of kin or guardian or other person responsible for him; and
(e) Any signed authorizations for medical treatment for him or the release of his medical information.
3. All records and reports in the client’s file must be typewritten or legibly written in ink and dated and signed by the person responsible for the files.
(Added to NAC by Bd. of Health, eff. 6-23-86)
Medical and Ancillary Services
NAC 449.4084 Contract for provision by another person. (NRS 449.037)
1. A medical or ancillary service not directly provided by the facility may be provided by another person pursuant to a contract.
2. The contract must:
(a) Be in writing;
(b) Designate the service provided, the manner in which it will be provided and the geographical area to be served;
(c) Describe the manner in which the person providing the service will be supervised;
(d) Describe how the service will be coordinated with other services at the facility;
(e) Require the person providing the service to furnish his clinical notes and observations of a client for the file of the client;
(f ) Specify the method of determining charges for the service and the method for reimbursement by the facility;
(g) Specify the period of the contract and how frequently it is to be reviewed; and
(h) Assure that the service and any person providing the service meet the same qualifications as required for employees of and services provided by a facility.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4085 Provision by facility authorized. (NRS 449.037) A facility which otherwise meets the requirements of NAC 449.4061 to 449.4084, inclusive, may provide medical or ancillary services if the requirements of NAC 449.4086 to 449.4089, inclusive, are met.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4086 Evaluation of programs and policies. (NRS 449.037)
1. Every facility must have a written plan for the annual evaluation of its programs and policies. The plan must describe the:
(a) Schedule for the annual evaluation;
(b) Subjects covered by the evaluation; and
(c) Methods to be used in conducting the evaluation.
2. The evaluation must include an assessment of the:
(a) Success of the programs offered at the facility;
(b) Efficiency and effectiveness of the facility’s programs, including the extent to which a program is economical in terms of tangible benefits produced by the money spent; and
(c) Relation of the facility’s programs to other services in the community and the availability of long-term care.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4087 Written assessments of clients. (NRS 449.037) Upon admission, an initial written assessment must be made of any person admitted to the facility. Within 30 days after admission, another written assessment must be completed which must include:
1. An evaluation of the client’s physical and mental health;
2. A history of the client’s social development;
3. A list of formal and informal systems for emotional support which are available to the client;
4. An evaluation of the tasks required for daily living that can be performed by the client;
5. A list of programs for financial assistance which are available to the client; and
6. The plan for care of the client.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4088 Plan of care; periodic assessment. (NRS 449.037)
1. A written plan of care must be prepared for each client that provides a balance of activities to meet the client’s needs and interests. The client, his next of kin or guardian or other person responsible for him and other providers of service to him may contribute to the development and carrying out of the plan. A copy of the plan must be included in the client’s file.
2. Each plan must include:
(a) An evaluation of the client’s strengths and needs;
(b) The objectives of the plan for care;
(c) The activities recommended to achieve those objectives;
(d) Any recommendations for therapy or referrals to other providers of services;
(e) A schedule for achieving the objectives of the plan with provisions for review of the plan; and
(f ) An evaluation of the client’s nutritional requirements.
3. An assessment of each client’s needs in relation to his plan of care must be conducted at least once every 3 months and included in the client’s file.
(Added to NAC by Bd. of Health, eff. 6-23-86)
NAC 449.4089 Menus. (NRS 449.037) Menus for meals served must be in writing, planned a week in advance, dated, posted and kept in the files for 6 months. Any substitutions must be noted on the written menu so that the menu in the file reflects what was actually served.
(Added to NAC by Bd. of Health, eff. 6-23-86)
FACILITIES FOR REFRACTIVE SURGERY
NAC 449.450 “Facility” defined. (NRS 449.037) As used in NAC 449.450 to 449.4526, inclusive, unless the context otherwise requires, “facility” means a facility for refractive surgery as defined in NRS 449.00387.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002; A by R042-06, 7-14-2006)
NAC 449.4502 Applicability of provisions. (NRS 449.037) The provisions of NAC 449.450 to 449.4526, inclusive, do not apply to an ophthalmologist licensed pursuant to chapter 630 of NRS or a doctor of osteopathy licensed pursuant to chapter 633 of NRS who provides other ophthalmological medical services in addition to the evaluation of refractive errors of the eye and the surgical treatment of patients by:
1. Photorefractive keratectomy;
2. Laser in situ keratomeleusis;
3. Conductive keratoplasty;
4. Implantation of an intraocular lens; or
5. Any other available technology, technique or procedure which surgically treats refractive errors of the eye and which has been approved by the United States Food and Drug Administration.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002; A by R042-06, 7-14-2006)
NAC 449.4504 Administrator: Appointment; duties; qualifications. (NRS 449.037)
1. A licensee of a facility shall appoint an administrator to be legally responsible for:
(a) The daily operation of the facility; and
(b) Compliance with the applicable provisions of this chapter and chapter 449 of NRS.
2. The administrator of a facility must:
(a) Be at least 21 years of age;
(b) Have at least 1 year of administrative experience in a health care setting;
(c) Have experience in the administration and supervision of personnel; and
(d) Possess such knowledge of the practice of medicine as to enable him to be conversant in surgical protocols.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
NAC 449.4505 Administrator of facility that performs intraocular lens implants: Duties. (NRS 449.037) The administrator of a facility that performs intraocular lens implants shall:
1. Ensure that equipment and supplies are sufficient so that intraocular lens implants are performed in a manner that will not endanger the health and safety of the patient;
2. Ensure that all persons in the surgical area use aseptic techniques;
3. Provide suitable equipment for the rapid and routine sterilization of operating room materials;
4. Develop appropriate protocols that include a list of equipment, materials and supplies necessary to carry out the procedure properly;
5. Develop protocols for the provision of services in case of emergency and ensure that all personnel are appropriately trained in those protocols; and
6. Ensure that each circulating nurse in the operating room is a registered nurse.
(Added to NAC by Bd. of Health by R042-06, eff. 7-14-2006)
NAC 449.4506 Staffing requirements; personnel files. (NRS 449.037) The administrator of a facility shall ensure that:
1. The facility is adequately staffed with qualified personnel who:
(a) Meet the needs of and ensure the safety of each person who visits the facility; and
(b) Satisfy any applicable statutory requirements for the provision of care.
2. The facility employs at least one full-time registered nurse licensed pursuant to chapter 632 of NRS to supervise and manage the care provided to patients in the facility.
3. At least one registered nurse who is employed by the facility is present in the facility at all times that any patient is present in the facility.
4. Each member of the staff who provides patient care is adequately trained in emergency procedures and is currently certified to perform first aid and cardiopulmonary resuscitation. At least one member of the staff who is trained in emergency procedures and who has obtained the advanced certificate in first aid and adult cardiopulmonary resuscitation issued by the American Red Cross or an equivalent certification must be present in the facility whenever any patient is present in the facility.
5. A separate personnel file is established and maintained for each member of the staff of the facility that includes:
(a) Proof of any training relating to emergency response required by the facility pursuant to the policies and procedures established by the facility pursuant to NAC 449.451;
(b) Such health records as are required by chapter 441A of NAC which include evidence that the member of the staff employed by the facility or under contract with the facility has had a skin test for tuberculosis in accordance with NAC 441A.375; and
(c) Evidence that the member of the staff employed by the facility or under contract with the facility has obtained any license, certificate or registration, and possesses the experience and qualifications, required for the position held by that person.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002; A by R042-06, 7-14-2006)
NAC 449.4508 Maintenance of patient records. (NRS 449.037)
1. The administrator of a facility shall ensure that the facility establishes and maintains a record of each patient admitted to the facility which includes an assessment of the health needs of the patient and a description of any health care services provided to the patient at the facility.
2. Each record must be:
(a) Protected against loss, destruction or unauthorized use;
(b) Kept confidential, except as otherwise provided by law; and
(c) Maintained for a period of 5 years after the date the patient is discharged from the facility.
3. If the facility closes, the administrator shall notify the Bureau of the disposition of its records.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
NAC 449.451 Written policies and procedures. (NRS 449.037)
1. The administrator of a facility shall ensure that the facility has written policies and procedures available to members of the staff, patients and the public which govern the operation of the facility and services provided by the facility.
2. The policies and procedures must set forth, without limitation:
(a) The scope of services offered by the facility, the cost of those services and the procedures for the payment of fees and obtaining a refund of any deposited fees;
(b) The business hours of the facility and the care that is available at the facility during emergencies and after the normal business hours of the facility;
(c) The criteria for admission to and discharge from the facility;
(d) The qualifications required for each member of the staff of the facility and the scope of the duties of each member of the staff of the facility;
(e) The appropriate action to be taken when an emergency arises in the facility and the equipment and medication that is required to be available at the facility for such an emergency;
(f ) The manner in which the equipment and physical environment of the facility will be maintained in accordance with the requirements set forth in NAC 449.4516 and 449.4522;
(g) The conduct and responsibility of a patient relating to his treatment;
(h) The right of a patient to refuse to participate in experimental research;
(i) The procedure for filing a complaint or grievance at the facility;
( j) The rights of a patient and the procedure for informing each patient of his rights;
(k) The manner in which the records of a patient will be maintained and protected; and
(l) The manner in which medication will be administered and dispensed to a patient admitted to the facility in accordance with the laws of this State and federal law.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
NAC 449.4512 Program of quality improvement. (NRS 449.037) The administrator of a facility shall ensure that the facility has a program of quality improvement in place which:
1. Monitors and evaluates the quality of patient care;
2. Evaluates methods to improve patient care;
3. Identifies and corrects deficiencies; and
4. Reviews and resolves grievances of patients and maintains documentation of the resolutions of those grievances.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
NAC 449.4514 Rights of patients; informed consent. (NRS 449.037) The administrator of a facility shall ensure that:
1. Each patient admitted to the facility is treated with respect, consideration and dignity.
2. Each patient admitted to the facility is provided appropriate privacy.
3. Each patient admitted to the facility is informed of his rights as a patient in accordance with the provisions of NRS 449.730. The patient must be informed, at the time of his admission, of the services available, the estimated cost of those services and the policy of the facility relating to obtaining a refund of any fees that were deposited with the facility. If a patient is unable to understand his rights, they must be explained to his legal guardian, next of kin or the agency financially responsible for his care.
4. Each patient admitted to the facility is given the opportunity to participate in decisions relating to his health care, unless he is unable to do so because of his medical condition.
5. An informed consent properly executed by a patient admitted to the facility or by his legal guardian is obtained before any surgery is performed. The informed consent must authorize, by name, the person performing the surgery to perform that surgery and must name or describe the surgical procedure to be performed. Any expectations, risks or complications relating to the surgery or alternatives to the surgery that are discussed with the patient must be set forth in the informed consent.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
NAC 449.4516 Equipment and supplies. (NRS 449.037)
1. The administrator of a facility shall ensure that:
(a) The facility is adequately equipped;
(b) Any equipment used in the facility is periodically inspected and, if appropriate, tested, calibrated, serviced or repaired according to the manufacturer’s instructions to ensure that the equipment is functioning properly;
(c) All equipment and supplies used in the facility are used in accordance with the manufacturer’s instructions;
(d) Such records are maintained as required to ensure that appropriate inspections and maintenance of all equipment used in the facility are periodically accomplished by an appropriately qualified person;
(e) Each laser used in the facility meets the requirements of any applicable federal standards set forth in 21 C.F.R. Part 1040; and
(f ) Appropriate evidence of compliance with 21 C.F.R. Part 1040 is maintained for each laser at the facility.
2. The administrator of the facility shall ensure that policies and procedures are established and implemented for each laser used in the facility which include, without limitation:
(a) A safety program concerning the use of the laser; and
(b) Education and training of each person who operates the laser, including, without limitation, requirements that each member of the staff be adequately trained in the use and safety of each laser used in patient care and that the administrator ensure that proof of any required training is maintained at the facility.
3. The administrator of the facility shall ensure that a safe environment for the use of lasers is provided, including, without limitation, ensuring that:
(a) Only authorized persons are allowed in treatment areas;
(b) Door and window coverings are used where appropriate;
(c) Protective eyewear is used, when appropriate, by persons who operate a laser;
(d) Laser components which have direct contact with a patient are appropriately disinfected or sterilized;
(e) Records concerning the maintenance of each laser in the facility are maintained; and
(f ) Each laser in the facility is visually inspected and tested before each use.
4. The administrator of the facility shall ensure that appropriate fire protection concerning the use of each laser is provided, including, without limitation, the immediate availability of:
(a) Fire extinguishers which are inspected at least once a year and determined to be appropriate for electrical fires by a person who is certified by the State Fire Marshal to conduct such inspections;
(b) Water for the protection of the patient; and
(c) Noncombustible materials, supplies and solutions, as appropriate.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
NAC 449.4518 Liability for use of leased equipment. (NRS 449.037) If a licensee leases a laser or other equipment to another ophthalmologist for the surgical treatment of patients by photorefractive keratectomy and laser in situ keratomeleusis, the licensee remains responsible for the services performed by the other ophthalmologist in the facility.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
NAC 449.4522 Sanitation and hygiene; space and storage. (NRS 449.037)
1. The administrator of a facility shall ensure that all parts of the facility, including its premises and equipment, are maintained in a neat and clean condition which is free of insects, rodents, litter and rubbish. Policies and procedures must be established and implemented for cleaning, sanitizing or sterilizing equipment and supplies.
2. The administrator of the facility shall ensure that the facility has a clean, comfortable waiting room with adequate space for any family member or caregiver of the patient being treated. A separate bathroom must be maintained for the exclusive use of patients and their family members or caregivers. Provisions for the safe storage of valuables must be made available for the use of the patient.
3. The operating room must be distinctly separate and segregated from any other area, including, without limitation, the waiting room, examination room, administrative area, physician’s office and staff lounge.
4. The facility must have sufficient space for the care and storage of instruments and supplies.
5. The facility must have adequate systems for ventilation and the control of temperature.
6. All medications must be stored, administered and maintained in accordance with the requirements of the laws of this State and federal law.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
NAC 449.4524 Medical care of patients. (NRS 449.037)
1. The administrator of a facility shall ensure that:
(a) Only local anesthesia and oral medication which is administered to a patient to relieve anxiety in the patient, if the medication is not given in a dosage which is sufficient to induce in a patient a controlled state of depressed consciousness or unconsciousness similar to the state produced pursuant to the administration of general anesthesia, deep sedation or conscious sedation, are used at the facility.
(b) An appropriate and current history, including a list of current medications, dosages, physical examination and pertinent preoperative diagnostic studies, is incorporated into the patient’s medical record before surgery.
(c) Surgical procedures are performed only by an ophthalmologist licensed pursuant to chapter 630 of NRS or a doctor of osteopathy licensed pursuant to chapter 633 of NRS.
(d) A preoperative evaluation is conducted immediately before the surgical procedure by the ophthalmologist, licensed pursuant to chapter 630 of NRS, or the doctor of osteopathy, licensed pursuant to chapter 633 of NRS, who will be performing the surgery.
(e) Emergency equipment and medications as required by the policies and procedures established by the facility pursuant to NAC 449.451 are available, and properly stored and maintained at the facility.
(f ) Outdated medications are destroyed in accordance with the requirements of the laws of this State and federal law.
(g) Protocols are established and implemented for instructing patients in self-care after surgery, including, without limitation, written instructions to be given at the time of discharge.
(h) A follow-up examination of a patient is conducted by an ophthalmologist licensed pursuant to chapter 630 of NRS, a doctor of osteopathy licensed pursuant to chapter 633 of NRS or a collaborating optometrist as provided in NRS 636.374 within 24 hours after the procedure. Documentation of the results of this examination must be included as part of the permanent medical record of the patient.
2. As used in this section:
(a) “Conscious sedation” means a minimally depressed level of consciousness, produced by a pharmacologic or nonpharmacologic method or a combination thereof, in which the patient retains the ability independently and continuously to maintain an airway and to respond appropriately to physical stimulation and verbal commands.
(b) “Deep sedation” means a controlled state of depressed consciousness, produced by a pharmacologic or nonpharmacologic method or a combination thereof, and accompanied by a partial loss of protective reflexes and the inability to respond purposefully to verbal commands.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
NAC 449.4526 Application for indemnification for certain damages; claims against surety bond or substitute thereof. (NRS 449.037)
1. A person who has sustained damages as a result of the bankruptcy of or any breach of contract by a facility may file an application for indemnification with the Administrator of the Health Division. The Administrator of the Health Division shall return an incomplete application to the applicant.
2. An application filed pursuant to subsection 1 must include a copy of the court order or settlement agreement which indicates a determination that the patient sustained damages as a result of a breach of contract or bankruptcy of a facility and a notarized statement of the patient or patient’s legal representative which includes the following information:
(a) A brief description of the damages sustained by the patient as a result of the bankruptcy of or any breach of contract by the facility;
(b) The date that the damages were sustained and the amount of damages claimed; and
(c) The name and address of the facility in which the patient sustained damage.
3. The Health Division may bring an action for interpleader against all claimants upon the surety bond or substitute thereof filed or deposited pursuant to NRS 449.068 or 449.069, as applicable. If the Health Division brings such an action, the Health Division shall publish notice of the action at least once each week for 2 weeks in a newspaper of general circulation in the county in which the facility has its principal place of business. The Health Division may deduct its costs of the action, including the costs of publication of the notices, from the amount of the surety bond or substitute thereof.
4. All claims against the surety bond or substitute thereof have equal priority. If the surety bond or substitute thereof is insufficient to pay all the claims in full, the claims must be paid pro rata.
5. If no claims have been filed against the surety bond or substitute thereof deposited with the Health Division within 12 months after the license of the facility expires or is revoked, the Health Division shall release the surety bond or substitute thereof to the facility and shall not consider any claim filed by a patient against the surety bond or substitute thereof after that time.
6. If one or more claims have been filed against the surety bond or substitute thereof within 12 months after the license of the facility expires or is revoked, the proceeds must not be released to the facility or distributed to any patient earlier than 18 months after the license of the facility expires or is revoked.
(Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002)
FACILITIES FOR TREATMENT OF IRREVERSIBLE RENAL DISEASE
General Provisions
NAC 449.501 Definitions. (NRS 449.037) As used in NAC 449.501 to 449.5795, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.502 to 449.519, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.502 “Advanced practitioner of nursing” defined. (NRS 449.037) “Advanced practitioner of nursing” has the meaning ascribed to it in NAC 632.020.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.504 “Charge nurse” defined. (NRS 449.037) “Charge nurse” has the meaning ascribed to it in NAC 632.033.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5045 “Competency” defined. (NRS 449.037) “Competency” means the demonstrated ability to carry out a specified task or activity with reasonable skill and safety in accordance with the prevailing standard of practice of the community in which the task or activity is carried out.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.505 “Dialysis” defined. (NRS 449.037) “Dialysis” means the method by which a dissolved substance is removed from the body of a patient by diffusion, osmosis and convection from one fluid compartment to another fluid compartment across a semipermeable membrane.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5053 “Dialysis technician” defined. (NRS 449.037) “Dialysis technician” means a person, other than a registered nurse or physician, who provides dialysis care under the direct supervision of a registered nurse or physician.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5055 “Direct supervision” defined. (NRS 449.037) “Direct supervision” means the supervision of a task or activity that is provided by a qualified person who is present on the premises of a facility during the period in which the task or activity is performed at the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5065 “End-stage renal disease” defined. (NRS 449.037) “End-stage renal disease” means a stage of renal impairment that is irreversible and permanent and requires a kidney transplantation or regular course of dialysis to preserve the life of the person who has the disease.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.507 “Facility” defined. (NRS 449.037) “Facility” means a facility for the treatment of irreversible renal disease as defined in NRS 449.0046.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.508 “Hemodialysis” defined. (NRS 449.037) “Hemodialysis” means dialysis of the blood.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.510 “Immediate supervision” defined. (NRS 449.037) “Immediate supervision” means the supervision of a task or activity that is provided by a person who:
1. Is present on the premises of a facility during the period in which the task or activity is performed at the facility; and
2. Directly observes the task or activity.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.511 “Intermediate level disinfection” defined. (NRS 449.037) “Intermediate level disinfection” means to treat a surface using a chemical germicide or other disinfectant that, when used in accordance with the instructions of the manufacturer of the chemical germicide or other disinfectant or the guidelines established by the facility concerning the chemical germicide or other disinfectant, inactivates microorganisms other than bacterial endospores, including, without limitation:
1. Viruses;
2. Fungi; and
3. Bacteria that are actively growing, including tubercle bacteria.
Ê The term includes any bleach or any disinfectant that consists of 70 percent or more of ethanol or isopropanol.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.513 “Licensed practical nurse” defined. (NRS 449.037) “Licensed practical nurse” means a nurse who may collect data and perform a skill, intervention or other duty in accordance with the provisions of NAC 632.242.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.516 “Product water” defined. (NRS 449.037) “Product water” means the effluent that is obtained from the final component of the water treatment system of a facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.517 “Supervision” defined. (NRS 449.037) “Supervision” means the guidance and direction provided by a qualified person for the accomplishment of a task or activity, including the initial direction and periodic inspection by that person of the actual accomplishment of the task or activity.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.519 “Training” defined. (NRS 449.037) “Training” means to learn a task or activity through experience or instruction that is received during employment at a facility by a person who is capable of learning that task or activity through education or experience.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
Construction; Health and Safety
NAC 449.520 New construction or remodeling: Notification; increase in number of stations for which facility is licensed. (NRS 449.037, 449.050)
1. A facility shall notify the Bureau in writing at least 30 days before beginning any construction, renovation or modification of the physical plant of the facility.
2. A facility must obtain the approval of the Bureau before increasing the number of stations for which the facility is licensed. If a facility intends to increase the number of those stations, the facility must, at least 30 days before the proposed date to increase the number of stations, submit to the Bureau an application for a new license. The application must be submitted on a form approved by the Bureau and include:
(a) Evidence satisfactory to the Bureau that:
(1) The facility has reviewed the availability of the members of the staff of the facility and, if necessary, has increased the number of positions on the staff to accommodate the proposed increase in the number of stations; and
(2) The water treatment system of the facility is sufficient to ensure the availability of water that is safe for the proposed increase in the number of stations; and
(b) A fee of $250.
3. If a facility submits an application pursuant to the provisions of this section, the Bureau may, before considering the application, conduct an inspection of the facility to determine compliance with those provisions.
4. If the Bureau approves an application pursuant to the provisions of this section, the facility shall, not later than 21 days after commencing the use of the stations for which the application was approved, submit to the Bureau a written report concerning the chemical analysis and bacteriologic cultures of the product water of the stations. The written report must be prepared and submitted in accordance with the provisions of the most recently published edition of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, which is hereby adopted by reference. A copy of the publication may be obtained from the Association for the Advancement of Medical Instrumentation, 1110 North Glebe Road, Suite 220, Arlington, Virginia 22201, for the price of $45 for members and $90 for nonmembers.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004)
NAC 449.5205 New construction or remodeling: Submission of plans and specifications; minor changes; inspection. (NRS 449.037)
1. To determine compliance with the provisions of NAC 449.501 to 449.5795, inclusive, each facility may submit to the Bureau for its approval any plans and specifications concerning the construction of a new facility or any alteration, addition, conversion, modernization or renovation of an existing building of the facility. The plans and specifications must be submitted in accordance with the provisions of this section.
2. A facility may request the Bureau to review any minor alterations or remodeling changes to the facility that, as determined by the Bureau, do not:
(a) Alter any load-bearing partitions, change any functional operation or affect the fire safety of the facility; or
(b) Add any additional stations to the facility.
Ê A request submitted pursuant to the provisions of this subsection must be set forth in writing and include a brief description of the minor alterations or changes proposed by the facility.
3. If a facility submits any preliminary plan or specification for a project pursuant to the provisions of this section, the plan or specification must include information that is sufficient to determine the extent of the proposed project and to ensure compliance with the provisions of NAC 449.501 to 449.5795, inclusive, concerning the design and space of the project.
4. If a facility submits any final drawings or specifications pursuant to the provisions of this section, the drawings or specifications must include a complete set of the drawings or specifications. Any working drawings submitted pursuant to the provisions of this subsection must:
(a) Be of sufficient quality to ensure that a clear and distinct print may be obtained of the drawings;
(b) Include accurate dimensions of the project for which the drawings are made; and
(c) Include any required explanatory notes, schedules or legends.
5. The Bureau shall, upon completion of any construction, renovation or remodeling of a facility, conduct an inspection of the facility to ensure compliance with the provisions of NAC 449.501 to 449.5795, inclusive, concerning the design and space of the facility. The inspection must be conducted at a time and date established by the Bureau.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.522 Construction, space and design; physical environment; restrictions for treatment of patients with hepatitis B. (NRS 449.037)
1. The Bureau shall consider a facility to be in compliance with the provisions of NAC 449.501 to 449.5795, inclusive, relating to the construction, space or design of the facility if:
(a) The facility was licensed on or before July 1, 2001; and
(b) The existing construction of the facility does not have any deficiencies that are likely to cause serious injury, harm or impairment to the health and welfare of the members of the general public. If such a deficiency occurs, the facility must correct the deficiency before the facility may continue to operate.
2. Each facility shall provide a physical environment that protects the health and safety of the patients and members of the staff of the facility and the members of the general public. The premises and any structures located on the premises of the facility that are used by a patient of the facility, including, without limitation, any stairwell, corridor or passageway, must satisfy the provisions of any applicable local building or fire safety code relating to the requirements for the design and space of the premises and structures.
3. If a facility provides treatment for a patient who has tested positive for hepatitis B, the facility shall treat the patient with a designated machine, blood pressure cuff, sink and any other equipment that is appropriate for providing treatment to the patient.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5225 Safety and comfort of patients during construction; imposition of more stringent design and space requirements. (NRS 449.037)
1. If any construction occurs in or near an area of the facility that is occupied by a patient of the facility, the facility shall ensure the safety and comfort of the patient during the construction.
2. A facility may impose more stringent design and space requirements than the requirements set forth in NAC 449.501 to 449.5795, inclusive.
(Added to NAC by Bd. of Health by R130- 99, eff. 8-1-2001)
NAC 449.523 Safety requirements. (NRS 449.037)
1. Each facility shall install a system for lighting the facility that is capable of providing sufficient illumination to allow safe evacuation from each building of the facility during an emergency at the facility. Each battery pack system used by the facility must be maintained and tested at least once each month. If a facility maintains a backup generator, the generator must be installed, tested and maintained in accordance with the instructions of the manufacturer of the generator. The facility shall document the testing of the generator at least once every 6 months.
2. A facility must not be located in or adjacent to a building that is considered a high hazard building and meets the requirements of group H of Volume I of the Uniform Building Code, 1997 edition, which is hereby adopted by reference. A copy of those provisions may be obtained from the International Conference of Building Officials, 5360 Workman Mill Road, Whittier, California 90601, for the price of $67.50.
3. Each facility must be equipped with smoke detectors that are maintained in proper operating condition at all times. The smoke detectors must be tested in accordance with the specifications of the manufacturer of the smoke detectors.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5235 Maintenance and repair of equipment. (NRS 449.037)
1. Any equipment that is used by a facility, including any equipment used for backup, must be maintained free from any defect that may be hazardous to the patients or members of the staff of the facility or any visitors to the facility. Any maintenance or repair of the equipment must be performed by a member of the staff of the facility who is qualified to conduct the maintenance or repair or by contract personnel.
2. Each facility shall ensure that each person employed on the staff of the facility is able to identify any equipment that malfunctions and report the malfunction to the appropriate person for repair.
3. If any medical equipment of a facility malfunctions, the equipment:
(a) Must be removed immediately from service at the facility; and
(b) Must not be returned to service at the facility unless the malfunction is identified and corrected.
4. Each facility shall maintain written evidence of any activity concerning repair or maintenance that occurs at the facility.
5. If any repair or alteration is made to any equipment or system of a facility, the facility must test the equipment or system to ensure proper operation of the equipment or system before the equipment or system is returned to service at the facility.
6. Each facility shall comply with the provisions of 21 U.S.C. § 360i(b) concerning the reporting of a device, as defined in 21 U.S.C. § 321(h), that has or may have caused or contributed to the injury or death of a patient of the facility.
7. Each facility shall develop and comply with a written policy concerning preventative maintenance to ensure that all equipment which is used by the facility to treat a patient or which is provided by the facility for use by the patient in the patient’s residence receives electrical safety inspections, if appropriate, and maintenance at least annually or more often if recommended by the manufacturer of the equipment. Any maintenance conducted pursuant to the provisions of this subsection may be provided by a qualified member of the staff of the facility or by contract personnel.
8. Each facility shall ensure that at least one complete dialysis machine is available for use at the facility as a backup machine for every 14 dialysis machines used by the facility.
9. If a facility provides treatment for a pediatric patient, the facility shall use equipment and supplies, including, without limitation, blood pressure cuffs, dialyzers and blood tubing, that are appropriate for treating that patient.
10. Any appliance or other electrical equipment of a facility must be grounded in accordance with the provisions of section 7-5.1 of NFPA 99: Standard for Health Care Facilities, 1999 edition, which is hereby adopted by reference. A copy of those provisions may be obtained from the National Fire Protection Association, 11 Tracy Drive, Avon, Massachusetts 02322, for the price of $40.25.
11. A facility shall not use any electrical extension cord or cable in any portion of the permanent electrical wiring of the facility.
12. Each facility shall maintain emergency equipment and supplies that are immediately accessible in any area of the facility which is used to treat the patients of the facility. Such equipment and supplies include:
(a) Oxygen;
(b) Ventilatory assistance equipment, including airways, manual breathing bag and mask;
(c) Suction equipment;
(d) Any supplies specified by the medical director of the facility; and
(e) If pediatric patients are treated, the appropriate type and size of emergency equipment and supplies required by subsection 9.
13. Each facility shall establish and comply with a written policy for periodically testing and maintaining all emergency equipment used by the facility. The members of the staff of the facility shall properly maintain the equipment and maintain a written record of the testing and maintenance of that equipment.
14. If a facility uses a central delivery system for bicarbonate dialysate, the system must be:
(a) Drained at the end of each day of treatment; and
(b) Cultured at least once each week to identify any potential bacterial contamination. If the results of a culture conducted pursuant to the provisions of this paragraph indicate the presence of more than 2,000 colony forming units per milliliter, the facility shall disinfect and reculture the system.
15. As used in this section, “pediatric patient” means a person who is not more than 14 years of age and is under the care of a facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.525 Water treatment system: General requirements. (NRS 449.037)
1. The design for the water treatment system of a facility must be:
(a) Based on considerations of the source of water for the facility; and
(b) Prepared by a person who, as determined by the Bureau, has obtained education, training or experience in the design of dialysis systems.
2. If a facility does not obtain water from a public water system, any water used by the facility for medical treatment must be subjected to a bacteriological analysis conducted by the appropriate health authority or by a commercial laboratory that is certified by the Health Division. An analysis must be conducted pursuant to the provisions of this subsection at least once every 3 months.
3. The area in which the water treatment system of a facility is located must be of sufficient size to allow for the maintenance, testing and repair of the equipment. If any dialysate is mixed in the area, the area must be of sufficient size to house and allow for the mixing of the dialysate and for the maintenance, testing and repair of any equipment used to mix the dialysate.
4. Each component of the water treatment system of a facility must be arranged and maintained in such a manner as to ensure that the amount of bacterial and chemical contaminants in the product water does not exceed the standards for hemodialysis water quality relating to hemodialysis systems and maximum level of chemical contaminants set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications, adopted by reference pursuant to the provisions of NAC 449.520.
5. Each facility shall prepare and comply with a written policy concerning the operation of the water treatment system of the facility. The written policy must include guidelines for the operation of each component of the water treatment system. The facility shall:
(a) Ensure that each person who operates those components is aware of the guidelines and operates those components in accordance with those guidelines; and
(b) Establish and maintain in the area in which those components are located written procedures describing the actions to be taken if the guidelines are not complied with.
6. Except as otherwise provided in this subsection, the water treatment system of a facility must be equipped with reverse osmosis membranes or deionization tanks and not less than two carbon tanks arranged in series. If the source of water for the water treatment system is obtained from a private supply that does not use chlorine or chloramine, the water treatment system must be equipped with reverse osmosis membranes or deionization tanks and not less than one carbon tank.
7. If the water treatment system of a facility is equipped with reverse osmosis membranes, the membranes must satisfy the requirements relating to reverse osmosis set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications, adopted by reference pursuant to the provisions of NAC 449.520.
8. If the water treatment system of a facility is equipped with a deionization system, the system must satisfy the requirements relating to regenerated or reconstituted devices and deionization set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications, adopted by reference pursuant to the provisions of NAC 449.520.
9. Each carbon tank that is used in the water treatment system of the facility must:
(a) Contain acid-washed 30-mesh or smaller carbon placed in series with a minimum empty bed contact time of 3 minutes for each tank or bank of tanks; and
(b) Include a testing port that is located between the tanks or bank of tanks. The facility shall, at least once each day before providing treatment to any patient of the facility, test water from the port to determine the amount of chlorine and chloramine in the water. The initial test each treatment day for chlorine and chloramine must be conducted not less than 15 minutes after the water treatment system is started for that day.
10. If the results of a test conducted pursuant to the provisions of subsection 9 indicate the presence of more than 0.5 parts per million of chlorine or 0.1 parts per million of chloramine in the water that is obtained from the port between the initial tank and the final tank of the water treatment system, the facility shall replace the initial tank and conduct a test of the water from the final exit of the water treatment system. If the results of that test indicate the presence of chlorine or chloramine in an amount that is greater than the requirements specified in this subsection, the facility shall immediately terminate any dialysis treatment provided to a patient of the facility and notify the medical director of the facility of the results of the test.
11. If a facility uses a water softener in the water treatment system of the facility, the water softener must have the capacity to treat a sufficient amount of water to supply the facility for the entire treatment day.
12. If a facility uses a cartridge filter in the water treatment system of the facility, the cartridge filter must be made of material that does not leach surfactants, formaldehyde or other material that was used to manufacture the material.
13. If a facility uses a cartridge filter housing during disinfectant procedures, the housing must include a mechanism to clear the lower portion of the housing of the disinfecting agents. Each cartridge filter housing must be opaque.
14. The water treatment system of the facility must be:
(a) Continuously monitored during the treatment of a patient of the facility; and
(b) Protected by audible and visual alarms that are capable of being seen and heard in the dialysis treatment area if the quality of the water used in the water treatment system falls below the standards established by the facility for the water treatment system or the manufacturer of the water treatment system.
15. If the deionization tanks of the water treatment system of a facility do not follow a reverse osmosis system, standards for the rate of rejection of the membranes must ensure that the lowest rate accepted will provide product water in compliance with the maximum level of chemical contaminants set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications, adopted by reference pursuant to the provisions of NAC 449.520.
16. Each facility shall maintain a written record of the operation of the water treatment system for each treatment day. The written record must include the guidelines established by the facility for operating each component of the system and any action taken during that day if the operation of a component was not within the guidelines established by the facility for that component.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004)
NAC 449.5255 Water treatment system: Chemical testing of product water; records. (NRS 449.037)
1. Except as otherwise provided in this section, each facility shall, at least once every 6 months, conduct a chemical test of a sample of the product water of the water treatment system of the facility. The results of any test conducted pursuant to the provisions of this section must indicate that the quality of the product water satisfies the requirements relating to maximum level of chemical contaminants set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications, adopted by reference pursuant to the provisions of NAC 449.520.
2. A facility shall conduct a chemical test pursuant to the provisions of this section if substantial changes are made to the water treatment system or if the percent of rejection of a reverse osmosis system decreases 5 percent or more from the percent of rejection measured at the time the water sample for the preceding chemical test was taken. If a facility uses a water treatment system that is portable, the facility shall, at least once each year, conduct a chemical test of the product water in accordance with the provisions of this section.
3. The records maintained by a facility concerning the operation of the facility must include:
(a) The results of each test conducted pursuant to the provisions of this section and NAC 449.525 and 449.526; and
(b) Evidence satisfactory to the Bureau that the medical director of the facility reviewed the results of those tests and required corrective action to be taken if indicated by those results.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004)
NAC 449.526 Water treatment system: Microbiological testing of product water. (NRS 449.037)
1. Each facility shall, at least once each month or immediately after any repair or change is made to the water product treatment system of the facility, conduct a microbiological test of the product water. The results of any test conducted pursuant to the provisions of this section must indicate that the quality of the product water satisfies the requirements relating to hemodialysis systems set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications, adopted by reference pursuant to the provisions of NAC 449.520.
2. Sample sites selected by the facility to conduct the test must include the beginning of the distribution piping, the product water in the reuse room of the facility and the end of the distribution piping. If the results of the test do not satisfy the requirements specified in subsection 1, the facility shall immediately disinfect and reculture the water treatment system. If, after the water treatment system is disinfected and recultured, the results of the test do not satisfy those requirements, the facility shall determine the source of the contamination by immediately reculturing:
(a) The sample sites;
(b) Each patient station of the facility;
(c) Each tank of the water treatment system that is used to store water;
(d) All water that is used to mix dialysate; and
(e) The product water obtained from the final component of the water treatment system.
3. A calibrated loop must not be used to conduct a test pursuant to the provisions of this section. As used in this subsection, “calibrated loop” means a mechanism that is used to:
(a) Draw a sample of water from the water treatment system of a facility; and
(b) Conduct a test of that water for the presence of chemicals, bacteria or other impurities.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004)
NAC 449.5265 Reuse of hemodialyzer; transport of used dialyzer. (NRS 449.037)
1. If a facility reuses any hemodialyzer in providing treatment to a patient of the facility, the facility shall:
(a) Ensure that the reuse of the hemodialyzer is conducted in accordance with the provisions of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, adopted by reference pursuant to the provisions of NAC 449.520.
(b) Ensure that each transducer protector used during the treatment is:
(1) Replaced, if it becomes wet during the treatment; and
(2) Used only for one treatment.
(c) Ensure that, in any area of the facility in which the reuse occurs, the supply of water in that area incorporates a mechanism to prevent any chemical agents from flowing into the water distribution system of the facility.
(d) Ensure that any ventilation system installed in an area specified in paragraph (c):
(1) Is connected to an exhaust system that:
(I) Leads to the outside of the building in which the room is located; and
(II) Is separate from the exhaust system of the building;
(2) Has an exhaust fan that is located at the discharge end of the ventilation system;
(3) Has a system of exhaust ducts that is constructed of material that is noncombustible and resistant to corrosion; and
(4) Has an exhaust outlet that is located above the level of the roof of the building to which the exhaust outlet is attached, and if more than one exhaust outlet is installed, the facility shall ensure that each of those outlets is arranged in such a manner as to minimize any recirculation of exhaust air into the building.
(e) Adopt and comply with a policy that sets forth the criteria for reuse, including the number of reuses allowed by the facility.
(f ) Ensure that access to an area of the facility specified in paragraph (c) is restricted to persons who are authorized by the facility to enter that area.
(g) Before providing treatment to the patient:
(1) Consider and address the health and safety of the patient if he is sensitive to disinfectant solution residuals;
(2) Provide to the patient information regarding the policy of reuse for the facility and the opportunity to submit and receive a response to questions concerning the reuse; and
(3) Obtain written consent for the reuse from the patient or legal representative of the patient.
2. A facility shall not transport any dialyzer that has been used in the treatment of a patient of the facility or allow a person to transport that dialyzer for reprocessing to a location that is off the premises of the facility unless the facility:
(a) Requires the use of automated equipment at that location to reprocess the dialyzer;
(b) Remains responsible for the entire process of reuse;
(c) Adopts and complies with a policy which ensures that the transfer and transportation of any used or reprocessed dialyzer to and from the location does not increase the contamination of the dialyzer, the environment or any member of the staff of the facility; and
(d) Allows an employee of the Bureau to enter the off-site reprocessing site as part of any inspection of the facility conducted by the Bureau.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004)
NAC 449.528 Adoption of more stringent requirements for treatment of water and reuse of hemodialyzers. (NRS 449.037) A facility may adopt more stringent requirements for the treatment of water and the reuse of hemodialyzers than the requirements set forth in NAC 449.525 to 449.5265, inclusive.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5285 Sanitation: Precautions regarding blood and bodily fluids. (NRS 449.037)
1. Any activity relating to the care of a patient of a facility must be provided in accordance with the provisions of 29 C.F.R. § 1910.1030(d)(1)-(3), relating to bloodborne pathogens.
2. Each member of the staff of the facility shall wash his hands immediately before and after each contact with a patient that may expose the member of the staff to any blood or fluids of the body of the patient. The location and arrangement of any area of the facility that is used for washing hands must permit ease of access and proper use.
3. A sink that is used for washing hands must be readily accessible in each area of the facility that is used to care for patients of the facility. Each fixture and lavatory located in that area must be trimmed with valves which may be operated without the use of hands. There must be sufficient clearance for the operation of blade-type handles, if those handles are used.
4. Provisions for drying hands must be included in any area of the facility that is used for washing hands.
5. If a patient of a facility or a member of the patient’s family intends to assist a member of the staff of the facility in conducting a procedure that may cause the patient or member of the patient’s family to come into contact with any blood or bodily fluids, the member of the staff of the facility shall, before the procedure is conducted:
(a) Explain to the patient or member of the patient’s family the potential risks associated with blood and any products of blood; and
(b) Provide to the patient or member of the patient’s family the appropriate equipment to protect the patient or member of the patient’s family from those risks.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.529 Sanitation: Control of infections; nonsmoking policy. (NRS 449.037)
1. Each facility shall designate a person to monitor and coordinate the activities occurring at the facility concerning the control of infections at the facility.
2. Each facility shall develop and maintain a system to identify, monitor and record the occurrence of infections at the facility. The system must be reviewed as a part of the program to ensure the quality of the facility conducted pursuant to the provisions of NAC 449.540. The record maintained by a facility pursuant to the provisions of this subsection must include any trends, corrective actions and improvement actions taken by the facility.
3. Each facility shall establish and comply with a policy concerning nonsmoking at the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5295 Sanitation: Provision of sanitary environment; walls, floors and ceilings; blood spills. (NRS 449.037)
1. Each facility shall provide a sanitary environment that minimizes or prevents transmission of infectious diseases at the facility.
2. The base of each wall that is located in any area of a facility which is subject to frequent cleaning with water or any other liquid must be:
(a) Tightly sealed to the floor and the wall to ensure that the base of the wall is impervious to the water or other liquid; and
(b) Constructed without any voids that may harbor insects.
3. The material that is used for the surface of the floors of a facility must be easily cleanable and have resistance to wear that is appropriate for the location of the material in the facility. In each area of the facility that is subject to cleaning with water or any other liquid, the material must not be physically affected by germicidal or cleaning solutions.
4. The finish on the interior of each wall of a facility must be washable and, in the immediate area of any plumbing fixtures, must be smooth and resistant to moisture.
5. Each joint of a structural element of a facility and each floor or wall that is penetrated by a pipe, duct or conduit must be tightly sealed to reduce the possibility of entry by rodents or insects into the joint, floor or wall.
6. Each ceiling or ceiling structure that is exposed in an area of a facility which is regularly occupied by patients, staff or visitors of the facility must be finished to ensure that the ceiling or structure is cleanable with equipment which is used in daily housekeeping activities. If any tile that is located in the ceiling of any room of a facility becomes stained with blood, the facility shall clean or replace the tile immediately or as soon as practicable after the tile becomes stained.
7. A facility shall not use a ceiling fan in any area of the facility that is used to treat a patient of the facility.
8. Each spillage of blood that occurs at a facility must be cleaned immediately or as soon as practicable after the spillage occurs using a disposable cloth and an appropriate chemical disinfectant. If a blood spill occurs:
(a) The surface of the area must be subjected to intermediate level disinfection in accordance with the instructions of the manufacturer of the disinfectant that is used to clean the spill, if a commercial liquid chemical disinfectant is used; or
(b) If chlorine bleach or any other solution of sodium hypochlorite is used to clean the spill, the solution must consist of not less than 1 percent of sodium hypochlorite. Each surface that is cleaned with the chlorine bleach or other solution must be compatible with that solution.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.531 Sanitation: Disinfection of dialysis machines; culturing dialysate; cleaning of machines and equipment; handling of waste. (NRS 449.037)
1. Each facility shall periodically disinfect each active and backup dialysis machine in accordance with the policy of the facility concerning the disinfection of those machines. Any disinfection conducted pursuant to the provisions of this subsection must achieve at least intermediate level disinfection.
2. Each facility shall, at least once each month:
(a) Randomly collect a sample of dialysate from a dialysis machine that is used by the facility; and
(b) Conduct a culture of the sample.
Ê The results of a culture conducted pursuant to the provisions of this subsection must not exceed 2,000 colony forming units per milliliter. A hemodialysis machine that is used by a patient of a facility at his residence must be cultured at least once each month until results not exceeding 2,000 colony forming units per milliliter are obtained for 3 consecutive months. If those results are obtained, quarterly samples must be cultured.
3. Immediately after each patient shift but before the next patient shift, the staff of the facility shall clean the exterior of each machine that is used for dialysis, treatment chairs, tourniquets and hemostats. Any blood pressure cuff that becomes contaminated with blood must be removed from service, disinfected and allowed to dry before it is returned to service at the facility.
4. Each facility shall comply with the requirements concerning the handling of waste from health care related facilities that are established by this State or by any local government which has authority to regulate that activity at the facility.
5. All sewage or liquid waste must be disposed of in a municipal sewerage system or a septic tank system for which a permit has been obtained by the facility pursuant to state law or local regulations.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5315 Hepatitis B: Vaccinations for certain staff members; postvaccination screening; adoption of related provisions. (NRS 449.037)
1. If any member of the staff of a facility is susceptible to hepatitis B and has not been vaccinated for that disease, the facility shall offer vaccination for the disease to that member of the staff in accordance with the provisions of 29 C.F.R. § 1910.1030(f )(1) and (2), relating to bloodborne pathogens. If a member of the staff of a facility is vaccinated pursuant to the provisions of this subsection, a written record of the vaccination must be included in the health record of the member of the staff maintained by the facility.
2. Each facility shall establish and comply with a policy to conduct postvaccination screening of each member of the staff of the facility. The serologic screening must be conducted within 60 days after the final dose of vaccine is administered to the member of the staff of the facility. Any additional screening and follow-up must be based upon the results of the testing for the hepatitis B surface antigen.
3. The provisions of Appendices I and II of the National Surveillance of Dialysis-Associated Diseases in the United States, 1993 edition, are hereby adopted by reference. A copy of those provisions may be obtained free of charge from the Public Health Service, Centers for Disease Control and Prevention, National Center for Infectious Diseases, Hospital Infections Program, Mail Stop C01, Atlanta, Georgia 30333. If a facility determines pursuant to subsection 2 that a member of the staff of the facility is a responder as defined in Appendix II of those provisions, the facility shall not require the member of the staff to submit to further screening pursuant to subsection 2. If the facility determines that a member of the staff of the facility is a nonresponder as defined in that appendix, the facility shall ensure that the member of the staff is tested at least once every 6 months pursuant to that subsection.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.532 Hepatitis B: Vaccinations for certain patients. (NRS 449.037)
1. If advised by and with the consent of a patient’s attending nephrologist, each facility shall offer hepatitis B vaccine to each patient who is susceptible to hepatitis B.
2. Each facility shall, upon request by a patient of the facility, make available to the patient a publication or other information concerning the risks and benefits of receiving the vaccine for hepatitis B.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5325 Hepatitis B surface antigen: Screening of patients; additional serologic screening. (NRS 449.037)
1. Each candidate for dialysis at a facility must, if practicable, be screened for the hepatitis B surface antigen before he is admitted to the facility. The screening may be performed at any time within 30 days before the person is admitted to the facility.
2. Additional serologic screening must be based on the antigen or antibody status of the patient, as follows:
(a) If the patient tests negative for the hepatitis B surface antigen, the facility shall screen the patient at least once each month.
(b) If the patient tests positive for the hepatitis B surface antigen or anti-hepatitis B surface antigen, the facility may screen the patient less than once each month if the policy of the facility concerning the screening of that patient complies with the provisions of Appendices I and II of the National Surveillance of Dialysis-Associated Diseases in the United States, adopted by reference pursuant to the provisions of NAC 449.5315.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.534 Hepatitis B surface antigen: Treatment of patients who test positive. (NRS 449.037)
1. If a patient of a facility tests positive for the hepatitis B surface antigen, the facility shall provide treatment for the patient:
(a) On a machine that is dedicated for patients who test positive for the hepatitis B surface antigen; and
(b) In an area of the facility that includes:
(1) A sink for washing hands;
(2) A work area;
(3) An amount of equipment and supplies that is sufficient to care for the patient; and
(4) Sufficient space to prevent contamination of any other patient of the facility.
2. A patient specified in subsection 1 must be dialyzed on equipment that is dedicated for patients who test positive for the hepatitis B surface antigen.
3. If a patient specified in subsection 1 is discharged from the facility, all equipment that is provided for that patient pursuant to the provisions of subsection 2 must be given intermediate level disinfection before the equipment is used for a patient who tests negative for the hepatitis B surface antigen.
4. If a patient is admitted to a facility for treatment before a test for the hepatitis B surface antigen is conducted, the facility shall provide treatment to that patient as if he had tested positive for that antigen. The facility shall not treat the patient on a machine that is used for a patient of the facility who has tested positive for the antigen.
5. If a facility uses a central delivery system, the facility shall treat a patient specified in subsection 4 on a designated machine. The facility may not reuse the dialyzer for that machine until the results of testing for that patient are known by the facility. The dialysis machine used by the patient must be given intermediate level disinfection before the machine may be used by any other patient of the facility.
6. The facility shall obtain the results of testing for a patient specified in subsection 4 not later than 7 days after the patient is admitted to the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5345 Tuberculosis: Screening of staff and patients. (NRS 449.037)
1. A facility shall screen each member of the staff of the facility to determine whether the member has tuberculosis. The facility shall screen each member of the staff:
(a) Upon commencement of employment at the facility or upon receiving privileges as a member of the medical staff of the facility; or
(b) Before the member of the staff has any physical contact with a patient of the facility.
Ê The screening must be conducted in accordance with the provisions of NAC 441A.375.
2. A facility shall screen each patient of the facility for tuberculosis if indicated by the presence of risk factors for tuberculosis or if the patient experiences any sign or symptom of tuberculosis. The screening must be performed after any possible exposure by a patient of the facility to active laryngeal or pulmonary tuberculosis.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
Provision of Services
NAC 449.540 Program of quality assurance; recordation of accidents and incidents; reporting of certain events. (NRS 449.037)
1. Each facility shall:
(a) Conduct a systematic and comprehensive review of the facility and the care provided to each patient of the facility; and
(b) Adopt and comply with a program to ensure the quality of the facility. The program must be based on information concerning the facility provided to the facility by the End-Stage Renal Disease Network.
2. The facility shall demonstrate through quality assurance activities that the members of the staff of the facility have:
(a) Evaluated the care and services provided by the facility to the patients of the facility;
(b) Established goals concerning the treatment of those patients;
(c) Identified any available opportunities to improve the care and services provided to those patients;
(d) Developed and carried out a plan to improve the care and services specified in paragraph (c); and
(e) Evaluated the effectiveness of the plan specified in paragraph (d) until a resolution of any problems is obtained.
3. Each core staff member of the facility shall actively participate in the quality assurance activities conducted pursuant to the provisions of this section. As used in this subsection, “core staff member” means the medical director, supervising nurse, dietitian, social worker and administrator of a facility.
4. Not less than once each quarter, each facility shall conduct a meeting concerning the quality of the facility. The facility shall:
(a) Prepare written minutes of each meeting held; and
(b) Maintain the written minutes in the business office of the facility.
5. If an accident or incident occurs at a facility, including, without limitation, any error in providing medication to a patient of the facility or any adverse reaction of a patient to a drug administered to the patient at the facility, the facility shall immediately prepare a written record of the accident or incident. A written record prepared pursuant to this subsection must be maintained by the facility and be made available for review by the Bureau.
6. A facility shall report each of the following events to the Bureau within 7 days after the event occurs:
(a) Each accident or incident concerning a patient of the facility that:
(1) Occurs during dialysis treatment of the patient; and
(2) Results in the death of the patient or requires the admission of the patient to a hospital overnight;
(b) The occurrence of any fire at the facility; or
(c) If a member of the staff of the facility or a patient of the facility converts to positive for the hepatitis B surface antigen.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5405 Rights of patients. (NRS 449.037)
1. In addition to the requirements set forth in NRS 449.700 to 449.730, inclusive, each facility shall adopt and comply with a policy which ensures that each patient of the facility is:
(a) Treated with respect, dignity and complete recognition of the individuality and personal requirements of the patient;
(b) Provided with sufficient privacy during treatment to ensure that any unwarranted exposure of the patient does not occur and to ensure confidentiality of the clinical record of that patient;
(c) Provided with a safe and comfortable environment for receiving any treatment provided by the facility;
(d) Provided with information concerning his treatment in a manner which ensures that the patient or the legal representative of the patient understands that information;
(e) Informed by a physician of the medical status of the patient;
(f ) Informed about all modalities and settings for the treatment of end-stage renal disease;
(g) Informed about and participates in, if requested by the patient, each aspect of care, including, without limitation, the right to refuse treatment and the medical consequences of refusing that treatment;
(h) Aware of any services that are available to the patient at the facility and the charges for those services; and
(i) Informed about any reuse of dialysis supplies by the facility, including hemodialyzers. If any brochures or other printed materials are used to describe the facility or any services provided by the facility, the facility shall ensure that the brochures or other printed materials include a statement specifying the policy of the facility concerning the reuse of those supplies.
2. Each facility shall ensure that each patient of the facility:
(a) Receives a reasonable response by the facility to any request or requirement of the patient for treatment or service in accordance with any applicable law or regulation and within the capacity of the facility to provide the requested treatment or service;
(b) Is transferred only for:
(1) A medical reason;
(2) The welfare of the patient or any other patient or member of the staff of the facility; or
(3) The nonpayment of fees owed by the patient to the facility;
(c) Is provided with information concerning advance directives and the provisions of NRS 450B.400 to 450B.590, inclusive, concerning do-not-resuscitate identification and do-not-resuscitate orders; and
(d) Is fully informed of:
(1) The rights specified in this subsection; and
(2) All rules established by the facility concerning the conduct and responsibilities of the patient during the period he is a patient of the facility.
3. Upon admission of a patient to a facility, the facility shall provide to the patient or his legal representative a written copy of the patient’s rights and responsibilities. A copy of those rights and responsibilities must be posted:
(a) In the waiting room or other area of the facility to which the members of the general public have access; and
(b) In close proximity to the license of the facility.
4. A facility shall not transfer or discharge a patient of the facility for the nonpayment of fees by the patient unless the facility notifies the patient in writing of the intent of the facility to transfer or discharge the patient. The written notice must include a statement indicating the amount of the fees owed by the patient to the facility.
5. Upon admitting a patient to a facility, the facility shall provide to the patient a written statement that informs the patient of the manner in which he may file a complaint against the facility. The statement must include, without limitation:
(a) A statement indicating that the patient may direct such a complaint to the Bureau or file the complaint with the Health Division; and
(b) The telephone number of the local office of the Health Division.
6. Except as otherwise provided in subsection 7, if a facility has admitted more than eight patients who read the same language other than English, all written information provided by the facility to any of those patients pursuant to the provisions of this section must be written in that other language.
7. In lieu of providing written information in a language other than English pursuant to the provisions of subsection 6, a facility may use the services of an interpreter to provide that information to a patient specified in that subsection if, as determined by the Bureau, the facility maintains written documentation which indicates that the information conveyed by the interpreter to the patient was sufficient to ensure the ability of the patient to participate in the decisions made concerning his treatment at the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.541 Interdisciplinary teams; plans for care of patients. (NRS 449.037)
1. Each facility shall establish and comply with a policy which specifies that the services provided to each patient of the facility are coordinated using an interdisciplinary team. The interdisciplinary team must consist of:
(a) The primary dialysis physician of the patient;
(b) A registered nurse;
(c) A social worker; and
(d) A dietitian.
2. Each interdisciplinary team specified in subsection 1 shall develop a written, individualized and comprehensive plan to provide care to the patient for whom the plan is prepared. The plan must:
(a) Specify the services that are required to address the medical, psychological, social and functional needs of the patient; and
(b) Include a statement setting forth the objectives for providing treatment to the patient.
3. Each plan for the care of a patient prepared pursuant to the provisions of subsection 2 must include:
(a) If required to ensure the provision of safe care for the patient, evidence of coordination with any other provider of service for the patient, including a hospital, long-term care facility, an agency that provides residential or community support services, or a provider of transportation; and
(b) Evidence indicating that:
(1) The provisions of the plan were disclosed to the patient or his legal representative; and
(2) The patient or his legal representative was provided an opportunity to participate in and discuss the preparation of the plan.
4. Each plan for the care of a patient must be:
(a) Prepared within 30 days after the patient is admitted to the facility; and
(b) Revised at least once every 6 months or immediately after the occurrence of any change in the medical, nutritional or psychosocial condition of the patient.
5. Each member of the interdisciplinary team shall periodically evaluate the progress of the patient toward achieving the objectives specified in the plan. Any action taken by a member of the interdisciplinary team, if the objectives are not achieved, must be documented and included in the clinical record of the patient.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5415 Preparations for emergencies and disasters. (NRS 449.037)
1. Each facility shall adopt a written procedure to be followed by each patient and member of the staff of the facility if any emergency occurs at the facility, including, without limitation, any fire, equipment failure, power outage, medical emergency or natural disaster that may threaten the health or safety of any patient or member of the staff of the facility or any member of the general public.
2. Each facility shall prepare a plan for obtaining emergency medical services that are available for use by the facility.
3. Each facility shall employ personnel who are qualified to operate emergency equipment at the facility and to provide emergency care at the facility. The personnel must be available to operate the emergency equipment and provide emergency care during each period in which treatment is provided to a patient of the facility. A charge nurse who is qualified to provide basic cardiopulmonary life support must be present at the facility and available in the treatment area during any period in which a patient of the facility is present in that area. Each member of the clinical staff of the facility must maintain current certification and competency in basic cardiopulmonary life support.
4. Each facility shall enter into an agreement with at least one hospital that provides acute dialysis service, inpatient care and other hospital services to the patients of the facility. The agreement must include:
(a) Documentation from the hospital indicating that the patients of the facility will be accepted and treated during any emergency that occurs at the facility; and
(b) Reasonable assurances that:
(1) The transfer or referral of a patient will occur between the hospital and the facility if the transfer or referral is determined to be medically appropriate by the attending physician of the patient;
(2) The exchange of medical and other information necessary or useful in the care and treatment of the patient transferred will occur within 1 working day after the transfer or referral of the patient; and
(3) All personal property belonging to and transferred with the patient will be accounted for and protected from theft, loss or damage.
5. Each facility shall establish and comply with a written plan to protect each patient of the facility if a fire occurs at the facility. The written plan must include:
(a) Provisions concerning the evacuation of each person from each building of the facility during a fire; and
(b) A diagram that specifies the routes to be taken to evacuate each of those buildings. A copy of each diagram prepared pursuant to the provisions of this paragraph must be posted in a conspicuous place in the building for which the diagram is prepared.
6. Each facility shall, not less than once each quarter, conduct a fire drill at the facility. The facility shall rotate the occurrence of the fire drills to ensure that each patient shift participates in a fire drill at least once each year. Each fire drill must include the use of alarms and equipment and a discussion with the patients, visitors, employees and members of the staff of the facility concerning evacuation from each building of the facility. After conducting a fire drill, the facility shall prepare and maintain a written report concerning the fire drill. The written report must include evidence that the members of the staff and the patients of the facility participated in the fire drill.
7. Each facility shall ensure that each member of the staff of the facility is familiar with the location of all equipment that is used to suppress fires at the facility. The equipment must be located in such a manner that a person is not required to travel more than 75 feet from any location in the facility to reach the equipment.
8. Each facility shall prepare and comply with a written plan concerning preparation for any disaster that may occur at the facility. The plan must:
(a) Be based on an assessment of the probability and type of disaster in each region and the local resources available to the facility;
(b) Include procedures that are designed to:
(1) Minimize the harm to the patients and members of the staff of the facility; and
(2) Ensure the safe operation of the facility during a disaster; and
(c) Include provisions concerning:
(1) The assignment of responsibilities for each member of the staff of the facility during a disaster, including the assignment of direction and control of the facility;
(2) The maintenance of equipment used for communication during a disaster;
(3) The use of warning systems; and
(4) Evacuation from and closure of the facility because of a disaster.
9. Each facility shall adopt written procedures to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004)
NAC 449.543 Pharmaceutical services. (NRS 449.037)
1. Each facility shall provide pharmaceutical services in accordance with accepted professional principles and any applicable federal and state statutes and regulations.
2. Medication may be administered to a patient of a facility only if the medication is ordered by:
(a) The patient’s physician;
(b) A physician assistant; or
(c) An advanced practitioner of nursing.
3. Any verbal or telephone order for medication must be received by a licensed nurse and countersigned by the physician of the patient for which the order was received.
4. Any medication that is maintained by a facility at the site of the facility must be:
(a) Placed in a container that is of sufficient size to store the medication; and
(b) Stored in a manner which ensures that the medication is not accessible to a person who is not authorized by the facility to obtain the medication. Any refrigerator that is used to store the medication must be maintained at a temperature that is appropriate for that medication.
5. Each facility shall maintain a supply of medications that, as determined by the medical director of the facility, is sufficient to satisfy the requirements of each patient of the facility during an emergency at the facility.
6. Any medication that is prepared for administration to a patient of a facility must be prepared in an area of the facility that includes a work counter and a sink. The area must be located in a portion of the facility that prohibits any contamination of the medication.
7. If any medication is prepared for a patient of a facility and the medication is not administered to the patient immediately after it is prepared, the medication must be labeled with the:
(a) Name of the patient;
(b) Name of the medication;
(c) Dosage prepared;
(d) Initials of the person who prepared the medication; and
(e) Date on which the medication was prepared.
8. Except as otherwise provided in this subsection, any medication that is prepared for a patient of a facility must be administered by the person who prepared the medication. A dialysis technician who is qualified in accordance with the provisions of NAC 449.5705 to 449.5775, inclusive, may administer intravenous normal saline, intravenous heparin and subcutaneous lidocaine as part of a routine treatment of hemodialysis.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5435 Nursing services; physicians and other staff. (NRS 449.037)
1. Each facility shall provide nursing services to each patient of the facility to prevent or reduce complications and to maximize the functional status of the patient.
2. Each facility shall employ a full-time registered nurse to supervise and manage the care provided to patients of the facility.
3. The registered nurse employed pursuant to the provisions of subsection 2 shall:
(a) Conduct an assessment of a patient during the admission of the patient to the facility;
(b) Conduct an assessment of a patient if requested by the patient or if required because of a change in the medical status of the patient;
(c) Participate in a team review of the progress of the patient pursuant to the provisions of NAC 449.541;
(d) Recommend changes in treatment, if appropriate, based on the immediate requirements of the patient;
(e) Facilitate communication between the patient, the patient’s family and each member of the interdisciplinary team established for the patient to ensure the delivery of care required for the patient;
(f ) Provide oversight and direction to dialysis technicians and licensed practical nurses; and
(g) Participate in activities conducted by the facility to ensure the quality of the facility.
4. Each facility shall ensure that a registered nurse or a physician is present at the site of the facility and available to the treatment area to provide care at all times during which treatment is provided to a patient of the facility in that area.
5. Nursing services at the facility must be provided or supervised by a registered nurse. The registered nurse may be the charge nurse of the facility. Each facility shall ensure that a sufficient number of registered nurses, licensed practical nurses and other qualified persons are available to satisfy the requirements for nursing care of each patient of the facility.
6. Each facility shall ensure that a sufficient number of the members of the staff of the facility are available at the site of the facility to provide care directly to each patient of the facility and to satisfy the requirements of each of those patients.
7. A licensed nurse or dialysis technician shall evaluate each patient before and after treatment is provided to the patient in accordance with the policy of the facility and the amount of training received by the licensed nurse or dialysis technician.
8. A registered nurse shall conduct an initial nursing assessment of each patient of the facility at the time the patient receives his first treatment at the facility. The assessment must be completed by the registered nurse within 2 weeks after the beginning of that treatment.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.544 Nutrition services. (NRS 449.037)
1. Each facility shall provide nutrition services to each patient of the facility and the provider of care for that patient to maximize the nutritional status of the patient.
2. The dietitian for a patient of a facility shall:
(a) Conduct an assessment of the nutrition of the patient;
(b) Participate in a team review of the progress of the patient in accordance with the provisions of NAC 449.541;
(c) After consulting with the physician of the patient, recommend a therapeutic diet for the patient based on:
(1) The cultural preferences of the patient;
(2) Changes in the treatment of the patient; and
(3) The nutritional requirements of the patient;
(d) Except as otherwise provided in subsection 7:
(1) Counsel the patient and the provider of care for that patient, if required, concerning any diet prescribed for the patient at the facility; and
(2) Monitor the patient’s adherence and response to that diet;
(e) Refer the patient for assistance with any resources that are available to the patient, including, without limitation, financial assistance, community resources or assistance at the residence of the patient;
(f ) Participate in activities conducted at the facility to ensure the quality of the facility; and
(g) Monitor the nutritional status of the patient to determine the need for intervention and follow-up by the facility. In making that determination, the dietitian shall consider:
(1) Changes in the weight of the patient;
(2) The chemistry of the blood of the patient;
(3) The adequacy of the dialysis treatment provided to the patient; and
(4) Changes in the medication prescribed for the patient.
3. Each facility shall collect data to assess the nutritional status of a patient of the facility not later than 2 weeks after the patient is admitted to the facility or immediately after the patient receives seven treatments at the facility, whichever occurs later. A comprehensive assessment of the nutritional status of the patient must be completed within 30 days after the patient is admitted to the facility or immediately after the patient receives 13 treatments at the facility, whichever occurs later. Such an assessment must include a determination by the dietitian of the degree to which the patient understands the diet prescribed for him by the facility.
4. Each facility shall, annually or more often if required by the circumstances concerning the treatment of the patient, revise the comprehensive assessment of the nutritional status of each patient specified in subsection 3.
5. Each facility shall employ or contract with a dietitian to provide nutrition services for each patient of the facility. If a facility provides treatment for 100 or more patients, the facility shall ensure that one full-time equivalent dietitian is available at the facility.
6. Nutrition services must be available at each facility during scheduled periods for treatment. The facility may require a patient to obtain an appointment with a dietitian before receiving those services.
7. The provisions of paragraph (d) of subsection 2 do not apply to a correctional institution.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5445 Social services. (NRS 449.037)
1. Each facility shall provide social services to each patient of the facility and to the provider of care for the patient, if required. The facility shall ensure that the social services support and maximize the adjustment, social functioning and rehabilitation of each patient of the facility.
2. The social worker shall:
(a) Conduct a psychosocial evaluation of each patient of the facility;
(b) Participate in a team review of the progress of the patient in accordance with the provisions of NAC 449.541;
(c) Recommend changes in the treatment of the patient based on the psychosocial requirements of the patient;
(d) Except as otherwise provided in subsection 7, provide casework and group work services to the patient and, if needed, to members of his family concerning the problems associated with treating end-stage renal disease;
(e) Except as otherwise provided in subsection 7, identify public agencies that may provide social services for the patient or other resources that are available to the patient and assist the patient and each member of his family in the use of those resources; and
(f ) Participate in activities conducted at the facility to ensure the quality of the facility.
3. Each facility shall ensure that the initial contact between the social worker and each patient of the facility occurs and is documented in writing not more than 2 weeks after the patient is admitted to the facility or immediately after the patient receives seven treatments at the facility, whichever occurs later. A comprehensive psychosocial assessment of the patient must be completed within 30 days after the patient is admitted to the facility or immediately after the patient receives 13 treatments at the facility, whichever occurs later.
4. Each facility shall, annually or more often if required by the circumstances concerning the treatment of the patient, revise the comprehensive psychosocial assessment of each patient specified in subsection 3.
5. Each facility shall employ or contract with a social worker to meet the psychosocial requirements of each patient of the facility. If a facility provides treatment for 100 or more patients, the facility shall ensure that one full-time equivalent social worker is available at the facility.
6. Social services must be available at each facility during scheduled periods for treatment. The facility may require a patient to obtain an appointment with a social worker before receiving those services.
7. The provisions of paragraphs (d) and (e) of subsection 2 do not apply to a correctional institution.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.546 Patient care: Advanced practitioners of nursing and physician assistants; medical emergencies. (NRS 449.037)
1. If an advanced practitioner of nursing or a physician assistant provides treatment for a patient of a facility, the facility shall ensure that there is evidence of communication with the treating physician of the patient if the advanced practitioner of nursing or physician assistant changes any order for treatment in accordance with the provisions of chapter 630 or 632 of NRS.
2. An advanced practitioner of nursing or a physician assistant specified in subsection 1 may not replace the treating physician of the patient concerning:
(a) Participation in planning for the care of the patient; or
(b) Activities conducted at the facility to ensure the quality of the facility.
3. If a medical emergency occurs concerning a patient of a facility, the treating physician for that patient:
(a) Must be immediately notified; and
(b) Shall direct the provision of care for the patient during the emergency.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5465 Patient care: Licensed practical nurses and dialysis technicians. (NRS 449.037)
1. The provisions of NAC 449.501 to 449.5795, inclusive, do not prohibit a licensed practical nurse from practicing in accordance with the regulations adopted by the State Board of Nursing. If a licensed practical nurse acts in the capacity of a licensed practical nurse during the treatment of a patient of a facility, the licensed practical nurse must be certified to give intravenous injections by a board that is approved by the State Board of Nursing.
2. A member of the staff of a facility who acts in the capacity of a dialysis technician at the facility must be qualified in accordance with the provisions of NAC 449.5705 to 449.5775, inclusive. If the facility determines that the member of the staff is not qualified pursuant to those provisions, the facility shall not allow the member of the staff to act in the capacity of a dialysis technician until the member of the staff becomes qualified pursuant to those provisions.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.547 Self-dialysis: Provision of training and certain services. (NRS 449.037)
1. If a facility provides training to a patient of the facility concerning the performance of dialysis by the patient, a licensed nurse who has at least 12 months of experience in the applicable dialysis modality, including hemodialysis or peritoneal dialysis, must be responsible for training the patient and each member of the family of the patient who intends to assist the patient in conducting the dialysis. The licensed nurse shall supervise all other members of the staff of the facility who assist in providing that training.
2. If a patient of a facility performs dialysis for himself at his residence, the facility shall provide the following services to the patient:
(a) A yearly physical examination;
(b) Monthly communication from a member of the staff of the facility by:
(1) Telephone;
(2) Visits to the facility by the patient; or
(3) Visits to the patient’s residence by a member of the staff;
(c) A visit to the facility at least once every 3 months;
(d) Communication with the appropriate member of the interdisciplinary team that is established for the patient pursuant to the provisions of NAC 449.541;
(e) Routine laboratory work in accordance with the policy of the facility; and
(f ) A method by which the patient may contact a member of the staff of the facility, including the primary physician of the patient, at any time if an emergency concerning the condition of the patient occurs.
3. If a patient of a facility performs hemodialysis for himself at his residence, the facility shall provide the following services to the patient:
(a) Surveillance of the patient’s home adaptation, including provisions for visits to his residence;
(b) Consultation with a registered nurse, social worker and dietitian;
(c) A system for maintaining a record of treatment that ensures continuity of care for the patient;
(d) Installation and maintenance of the equipment required to perform the hemodialysis;
(e) Testing and appropriate treating of the water used for the hemodialysis; and
(f ) Ordering of supplies on a continual basis.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5475 Continuous ambulatory peritoneal dialysis. (NRS 449.037) If a facility provides continuous ambulatory peritoneal dialysis for a patient of the facility, the facility shall provide the following services to the patient:
1. Consultation with a registered nurse, social worker and dietitian;
2. A system for maintaining a record of treatment that ensures continuity of care for the patient; and
3. Ordering of supplies on a continual basis.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.549 Continuous cycling peritoneal dialysis. (NRS 449.037) If a facility provides continuous cycling peritoneal dialysis to a patient of the facility, the facility shall provide the following services to the patient:
1. Surveillance of the patient’s home adaptation, including provisions for visits to his residence;
2. Consultation with a registered nurse, social worker and dietitian;
3. A system for maintaining a record of treatment that ensures continuity of care for the patient;
4. Installation and maintenance of the equipment required to perform the dialysis; and
5. Ordering of supplies on a continual basis.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5495 Patient services by contract; laboratory. (NRS 449.037)
1. If a facility provides services to a patient of the facility by contract, the facility remains responsible for supervising the treatment of the patient and providing adequate care for the patient in accordance with the provisions of NAC 449.501 to 449.5795, inclusive.
2. If a facility maintains a laboratory for use by the facility, the laboratory must be licensed in accordance with the provisions of chapter 652 of NRS.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
Administration and Personnel
NAC 449.550 Governing body. (NRS 449.037)
1. Each facility shall establish a governing body that is legally responsible for developing and carrying out the policies of the facility regarding the management and operation of the facility.
2. The policies established and carried out pursuant to the provisions of subsection 1 must include, without limitation:
(a) The governance of the governing body;
(b) The care and safety of the patients of the facility;
(c) The general operation of the facility; and
(d) The protection of the personal and property rights of each patient of the facility.
3. The governing body shall:
(a) Receive and act upon any recommendation submitted to the governing body by a member of the staff of the facility;
(b) Appoint a medical director for the facility pursuant to the provisions of NAC 449.5505; and
(c) Ensure that the facility complies with all state and local statutes, ordinances and regulations that apply to the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5505 Medical director. (NRS 449.037)
1. The medical director of a facility:
(a) Must be certified in nephrology or pediatric nephrology or be eligible for that certification by a board that is approved by the American Medical Association; or
(b) During the 5 years immediately preceding July 1, 2001, must have served for at least 12 months as the director of a dialysis program.
2. The medical director shall:
(a) Develop objectives for the treatment of patients of the facility based on a review of data assessed through activities conducted at the facility to ensure the quality of the facility;
(b) Ensure that each licensed nurse and dialysis technician employed at the facility has received adequate training;
(c) Monitor the care and treatment provided to each patient of the facility; and
(d) Develop and carry out each policy that the facility is required to establish pursuant to the provisions of NAC 449.501 to 449.5795, inclusive.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.552 Physicians. (NRS 449.037)
1. Each patient of a facility must be under the care of a physician who is a member of the medical staff of the facility.
2. If a patient of the facility receives pediatric dialysis at the facility, the treatment provided to the patient must be supervised by a pediatric nephrologist or a pediatrician. If a pediatric nephrologist is not available to serve as the primary physician for the patient, an adult nephrologist may serve as the primary physician for the patient if a direct patient evaluation is prepared by a pediatric nephrologist or a pediatrician at the initiation of care for the patient and annually until the patient reaches 6 years of age.
3. Each patient who receives treatment at the facility must be evaluated at least once each month by a physician who is a member of the medical staff of the facility. If a patient of the facility performs dialysis for himself at his residence, the patient must be examined by such a physician at least once every 3 months. The record of any examination conducted pursuant to the provisions of this subsection must include evidence of:
(a) A monthly assessment concerning any new or recurrent problems; and
(b) A review of the adequacy of the treatment provided to the patient.
4. Each facility shall ensure that at least one physician who is a member of the medical staff of the facility is available, in person or by telecommunication, 24 hours each day to patients and members of the staff of the facility.
5. Any order concerning the treatment of a patient of a facility must be prepared in writing and signed by the physician preparing the order. If a physician prepares a routine order for treatment, the order must:
(a) Be revised at least annually; and
(b) Include a statement indicating the:
(1) Duration of treatment;
(2) Dialyzer to be used for that treatment;
(3) Rate of the flow of blood for the patient during that treatment;
(4) Target weight of the patient; and
(5) Medications required for the patient, including heparin.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5525 Orientation program for new employees; continuing education. (NRS 449.037)
1. Each facility shall develop and carry out a program to orient and familiarize each new employee of the facility with:
(a) The policies and operation of the facility; and
(b) The responsibilities of the position for which the employee is employed by the facility.
2. Each new member of the staff of a facility who will provide care directly to patients of the facility must be allowed a sufficient period to become familiar with the facility. The orientation program provided by the facility for each of those new members must:
(a) Be at least 2 weeks in duration, if the new member has experience concerning the performance of dialysis; and
(b) Include 2 weeks of training concerning the direct care of patients of the facility, if the new member has no experience concerning the performance of dialysis.
3. If a facility employs a licensed nurse who has no experience concerning the performance of dialysis, the orientation program provided by the facility to that nurse must be at least 6 weeks in duration and must include training in the following subjects:
(a) Fluid, electrolyte and acid-base balance;
(b) Kidney disease and the treatment of that disease;
(c) Dietary management of kidney disease;
(d) Principles of dialysis;
(e) Dialysis technology;
(f ) Techniques for performing venipuncture;
(g) Care of the dialysis patient;
(h) Psychological, social, financial and physical complications of long-term dialysis;
(i) Prevention of hepatitis and other diseases; and
( j) Risks and benefits of reusing hemodialyzers, if the facility reuses any hemodialyzer in providing treatment to a patient of the facility.
4. Each facility shall ensure that each member of the staff of the facility who provides care to a patient of the facility completes a course of continuing education concerning end-stage renal disease. The course must be at least 5 hours in duration and must be completed annually by each such member of the staff of the facility. The course may be provided by a member of the staff of the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.553 Medical staff: Generally. (NRS 449.037)
1. Each physician who is a member of the medical staff of a facility must be licensed to practice medicine in this State.
2. The membership of the medical staff of a facility may include a nephrologist or any other physician who has training or demonstrated experience in providing care for a patient who is diagnosed with end-stage renal disease.
3. If a facility employs an advanced practitioner of nursing or a physician assistant:
(a) The advanced practitioner of nursing must be qualified in accordance with the provisions of chapter 632 of NRS; and
(b) The physician assistant must be qualified in accordance with the regulations adopted by the Board of Medical Examiners.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5535 Nurses. (NRS 449.037)
1. Each nurse employed by a facility must be licensed to practice nursing in this State.
2. Except as otherwise provided in subsection 3, each nurse of a facility who is assigned charge responsibilities must:
(a) Be a registered nurse; and
(b) Have at least 6 months of experience as a nurse in performing hemodialysis or in providing nursing care for a patient with permanent kidney failure. The experience required pursuant to the provisions of this paragraph must be obtained within the 2 years immediately preceding the date on which the nurse is assigned charge responsibilities by the facility.
3. The provisions of paragraph (b) of subsection 2 do not apply to a registered nurse who holds a current certificate in nephrology nursing or hemodialysis issued by a board that is nationally recognized.
4. Each charge nurse of a facility shall:
(a) Make daily assignments based on the requirements of each patient of the facility for treatment;
(b) Provide immediate supervision of the care provided to each of those patients;
(c) Conduct an assessment of a patient of the facility if required by the circumstances concerning the treatment of the patient; and
(d) Communicate with the patient’s physician and the social worker and dietitian of the facility concerning the treatment of the patient.
5. If a facility provides training concerning self-care for patients of the facility, a registered nurse who has at least 12 months of experience in performing dialysis and experience in the applicable dialysis modality must:
(a) Be responsible for training the patient and each member of the family of the patient who intends to assist the patient in providing care for the patient; and
(b) Supervise other members of the staff of the facility who assist in providing that training.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.555 Dietitians. (NRS 449.037) Each dietitian employed by a facility must:
1. Be registered or eligible for registration by the Commission on Dietetic Registration for the American Dietetic Association; and
2. After becoming registered or eligible for registration, obtain at least 1 year of experience in clinical dietetics or work under the supervision of a dietitian who is qualified pursuant to this section.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5555 Social workers. (NRS 449.037) Each social worker employed by a facility must:
1. Be licensed as a social worker in this State and hold a master’s degree in social work from a graduate school of social work that is accredited by the Council on Social Work Education; or
2. Have worked for at least 2 years as a social worker, 1 year of which was in a facility or transplantation program before September 1, 1976, and have established a consultative relationship with a social worker who has a master’s degree in social work from a graduate school of social work that is accredited by the Council on Social Work Education.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.556 Staff responsible for operating water treatment system. (NRS 449.037)
1. Each member of the staff of a facility who is responsible for operating the water treatment system of the facility must demonstrate to the satisfaction of the Bureau that he understands the risks to patients of exposure to water that has not been treated by the water treatment system. The facility shall, for each of those members, prepare and maintain at the facility a written record of the training provided to those members concerning the safe operation of the water treatment system of the facility.
2. A facility shall not allow a person to repair or replace any component of the water treatment system of the facility unless the person is qualified to repair or replace the component pursuant to the provisions of NAC 449.5565. If the facility allows a person who is qualified pursuant to those provisions to repair or replace any component of the water treatment system of the facility, the facility shall prepare and maintain at the facility a written record of the training, education and experience of the person.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5565 Staff that repairs or maintains equipment used to provide care to patients. (NRS 449.037) A facility shall not allow a member of the staff of the facility to repair or maintain any equipment of the facility that is used to provide care to a patient of the facility unless the member has completed a course of instruction and demonstrated competency in repairing or maintaining that equipment. The course must include instruction in the following subjects:
1. The prevention of the transmission of hepatitis through any equipment that is used for dialysis;
2. The requirements for safety of systems that are used to deliver dialysate;
3. The control of bacteria;
4. Standards for water quality; and
5. The repair and maintenance of equipment used for dialysis or other equipment used by the facility to provide care to a patient of the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
Clinical Records
NAC 449.558 Preparation and maintenance. (NRS 449.037)
1. Each facility shall establish a system for preparing and maintaining a clinical record for each patient of the facility. The system must be developed to ensure that the care provided to each patient of the facility is:
(a) Completely and accurately documented;
(b) Readily available for retrieval by the facility; and
(c) Systematically organized to facilitate the compilation and retrieval of information.
2. If the facility maintains any clinical record on microfilm, optical disc or by any other electronic means, the facility shall ensure that the clinical record is available for review by the Bureau within 48 hours after the facility receives a request for the clinical record from the Bureau.
3. All information concerning the medical history or care provided to or treatment received by a patient at the facility must be:
(a) Maintained in the clinical record of the patient; and
(b) Protected by the facility against theft, loss or damage.
4. Each facility shall establish an area in which to store the clinical records of the facility. The area must be separate from any area of the facility that is used to provide treatment for patients of the facility and must have adequate space for reviewing, dictating, sorting or recording the information included in the clinical records. If a facility uses an optical disc, microfilm or any other electronic means to create or maintain a clinical record, the area used to store the clinical record must have adequate space for transcribing the information created or maintained on the optical disc, microfilm or by any other electronic means. If the facility determines that the clinical record of a patient of the facility is active, the facility shall store the active clinical record at the site of the facility.
5. Each facility shall ensure that:
(a) The clinical record of a patient of the facility remains confidential and is retained in accordance with the provisions of NRS 629.051; and
(b) Each entry or other information that is placed in the clinical record regarding the delivery of care to the patient is not altered without evidence and explanation of that alteration. A signature stamp must not be used to authenticate an entry in the clinical record of a patient of the facility.
6. If a facility determines that a clinical record is inactive, the facility shall store that clinical record. The facility may store the record on microfilm, optical disc or by any other electronic means and may store the clinical record at a location other than at the site of the facility if the facility ensures that:
(a) The clinical record remains secure from unauthorized access at that location; and
(b) The record is readily retrievable for review by the Health Division.
7. Each clinical record must include:
(a) Information concerning the identity of the patient for whom the clinical record is prepared;
(b) Each written notice provided to the patient at the facility and each written consent obtained from the patient at the facility;
(c) Each order prepared by a physician at the facility concerning the patient;
(d) Each progress note prepared by the facility concerning the patient;
(e) A list that specifies all problems incurred concerning the treatment and care of the patient;
(f ) The physical and medical history of the patient;
(g) Each assessment concerning the patient prepared by a registered nurse, social worker or dietitian employed by the facility;
(h) The record of each medication administered by the facility to the patient:
(1) During treatment at the facility; or
(2) For use at his residence;
(i) The record of each transfusion received by the patient at the facility;
( j) Each laboratory report prepared or received by the facility concerning the patient;
(k) Each diagnostic study concerning the patient that is ordered by the attending nephrologist;
(l) Each appropriate record of hospitalization;
(m) Each record of consultation with the patient that is requested by the attending nephrologist;
(n) If practicable, the record of creation and revision of access for each dialysis treatment provided to the patient;
(o) Each plan prepared by the facility concerning the care of the patient, including the plan developed for the patient pursuant to the provisions of NAC 449.541 and all amendments to that plan;
( p) Evidence indicating that the facility has complied with the provisions of NAC 449.501 to 449.5795, inclusive, concerning the furnishing of educational materials to the patient;
(q ) Each record of the daily treatment received by the patient at the facility; and
(r) A discharge summary, if the patient is discharged from the facility.
8. As used in this section, “progress note” means a note or other written statement that:
(a) Is signed and dated by a member of the staff of a facility; and
(b) Summarizes the facts concerning the care provided to a patient of the facility and the response of the patient to that care for the period specified in the note or other written statement.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5585 Additional requirements. (NRS 449.037)
1. In addition to the provisions of NAC 449.558, the clinical record of each patient of a facility must include:
(a) An accurate assessment of the progress of the patient, including all changes in the medical status of the patient;
(b) The results of each diagnostic test concerning the patient that is requested by the attending nephrologist;
(c) Consultation reports; and
(d) All unusual occurrences concerning the care and treatment of the patient.
2. Each member of the interdisciplinary team established pursuant to the provisions of NAC 449.541 shall prepare a written record concerning the progress of the patient. The written record must be prepared at least once every 6 months or more often if required by a change in the medical, nutritional or psychosocial condition of the patient.
3. The condition of each patient of a facility and the response of the patient to treatment must be noted on the daily treatment record of the patient.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.559 Medical history and physical examination. (NRS 449.037) Each facility shall prepare a medical history of each patient of the facility and conduct a physical examination of the patient. The medical history and physical examination must be completed within 30 days before the patient is admitted to the facility or within 2 weeks after he is admitted to the facility. Before the patient receives his first treatment at the facility, the physician for the patient must notify the charge nurse for the facility of the diagnoses, medications, hepatitis status, allergies and prescription for dialysis of the patient. All information provided by the physician to the charge nurse pursuant to the provisions of this section must be included in the clinical record of the patient.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5595 Transient patients. (NRS 449.037)
1. The clinical record of each transient patient of a facility must include:
(a) Each order for the treatment of the patient at the treating facility;
(b) Each laboratory report ordered by the treating facility concerning the patient that is prepared within 30 days after receiving treatment at the treating facility, including hepatitis B antigen status;
(c) The most recent patient care plan and treatment records received from the home facility of the patient; and
(d) All records received from the home facility concerning the care and treatment of the patient.
2. As used in this section, “transient patient” means a patient of a facility who:
(a) Is not a resident of the community in which the facility is located; and
(b) Does not receive treatment at the facility for more than 6 weeks.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.561 Discharge or transfer of patients; removal of records. (NRS 449.037)
1. If a patient of a facility is discharged from the facility, the facility shall, within 30 days after the patient is discharged, prepare a discharge summary concerning the patient. The discharge summary must specify the disposition of the patient and include:
(a) A diagnosis of the patient or, if the patient has died, the cause of death;
(b) The date of the discharge or, if the patient has died, the date and location of his death;
(c) If the patient receives a kidney transplant or is relocated, information concerning the kidney transplant or relocation; and
(d) If the patient is discharged for a reason other than kidney transplantation or death, the reason for the discharge.
2. All clinical records prepared or maintained by a facility are the property of the facility and must not be removed from the area in which the clinical records are stored except pursuant to a subpoena or order of a court or to preserve the clinical records if a disaster or other emergency occurs at the facility.
3. If a patient of a facility is transferred to another facility, the facility from which the patient is transferred shall provide to the other facility a copy of the clinical record of the patient. The copy of the clinical record must include:
(a) The most recent orders for dialysis treatment;
(b) The last three records of treatment;
(c) The most recent hepatitis status of the patient;
(d) The most recent plan of care concerning the patient; and
(e) If the patient is transferred to an outpatient facility, the most recent medical history and physical examination of the patient and the assessment of each member of the interdisciplinary team established for the patient pursuant to the provisions of NAC 449.541.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5615 Cessation of operation of facility. (NRS 449.037) If a facility ceases to operate, the facility shall:
1. Ensure the preservation of the clinical records of the facility; and
2. Not more than 30 days after the facility ceases to operate, notify the Bureau in writing of the location of the clinical records of the facility. The written notice must include the name and address of the custodian of the clinical records.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
Dialysis Technicians
NAC 449.570 General qualifications; identification to be worn during training; provision of care; requirements to act as preceptor. (NRS 449.037)
1. A person may not act as a dialysis technician at a facility unless he is qualified in accordance with the provisions of NAC 449.5705 to 449.5775, inclusive.
2. If a dialysis technician receives training in any area of a facility in which treatment is provided to a patient of the facility, the dialysis technician shall, during the period in which he is located in that area, wear a tag or similar device that identifies the dialysis technician. The tag or similar device must be worn in a visible manner.
3. Until a dialysis technician becomes qualified in accordance with the provisions of NAC 449.5705 to 449.5775, inclusive, the dialysis technician may provide care to a patient of a facility only if the care is provided:
(a) As part of the training received by the dialysis technician at the facility; and
(b) Under the immediate supervision of a registered nurse or preceptor who is assigned for that purpose by the facility.
4. A person shall not act as a preceptor for a facility unless he:
(a) Is a licensed nurse or dialysis technician who has at least 6 months of experience in performing hemodialysis obtained within the 24 months immediately preceding the date he becomes a preceptor for the facility;
(b) Obtains a recommendation from the supervising nurse of the facility to be a preceptor; and
(c) Files with the facility a current written list concerning his knowledge and skills that is prepared in accordance with the provisions of NAC 449.5745.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5705 Qualification of technician determined to be qualified before July 1, 2001. (NRS 449.037)
1. If a person completes an orientation program of a facility pursuant to the provisions of NAC 449.5525 and has been determined by the facility to be qualified to provide dialysis treatment before July 1, 2001, the person may qualify as a dialysis technician if he:
(a) Except as otherwise provided in subsection 2, passes the written examination specified in NAC 449.571 and demonstrates competency by obtaining a written list concerning his knowledge and skills prepared in accordance with the provisions of NAC 449.5745; or
(b) Demonstrates to the satisfaction of an instructor or supervising nurse for the facility that he is competent to assume the responsibilities of a dialysis technician and obtains from the instructor or supervising nurse a written list concerning his knowledge and skills prepared in accordance with the provisions of NAC 449.5745.
2. In lieu of passing the written examination pursuant to the provisions of paragraph (a) of subsection 1, a dialysis technician who is certified as a dialysis technician by a nationally recognized testing organization may provide a copy of that certification to the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.571 Program of training: Curriculum; duties of instructor; written examinations. (NRS 449.037)
1. Each program for training a dialysis technician provided by a facility must consist of a written curriculum that specifies the objectives for each portion of the course.
2. The written curriculum must include at least the following subjects:
(a) Introduction to dialytic therapies, including:
(1) The history of dialysis;
(2) Definitions and terminology;
(3) Communication skills;
(4) Ethics and confidentiality;
(5) The multidisciplinary process;
(6) The roles of the members of an interdisciplinary team established pursuant to the provisions of NAC 449.541; and
(7) Information concerning renal organizations and resources;
(b) The principles of hemodialysis, including:
(1) The principles of dialysis;
(2) Access to the circulatory system; and
(3) Anticoagulation, local anesthetics and normal saline;
(c) Understanding a person who suffers from kidney failure, including:
(1) Basic renal anatomy, physiology and pathophysiology;
(2) The effect of renal failure on the systems of the body;
(3) The symptoms and findings related to the uremic state;
(4) The modes of renal replacement therapy, including kidney transplantation;
(5) Basic renal nutrition;
(6) Basic psychosocial aspects of end-stage renal disease;
(7) The medications commonly administered to a patient who is diagnosed with end-stage renal disease, including the manner of administering and the effects of those medications;
(8) Confidentiality of the personal and clinical records of a patient of a facility;
(9) Professional conduct;
(10) The rights and responsibilities of a patient of a facility; and
(11) Rehabilitation of a patient of a facility;
(d) Procedures relating to dialysis, including:
(1) Using aseptic techniques;
(2) The technical aspects of dialysis, operation and monitoring of equipment, and the commencement and termination of dialysis;
(3) Delivering dialysis treatment adequately and circumstances that may result from inadequate treatment;
(4) Observing and reporting the reaction of a patient to treatment;
(5) Monitoring glucose and hemoglobin or hematocrit monitoring;
(6) Emergency procedures and responses, including cardiopulmonary resuscitation, the management of an air embolism, and the proper response to line separation and hemolysis;
(7) External and internal disasters, fire, natural disasters and preparation for an emergency; and
(8) Safety, control of quality and improvement of quality;
(e) Information concerning devices used for hemodialysis, including:
(1) The theory and practice of conventional, high efficiency and high flux dialysis;
(2) Dialysate composition, options, indications, complications and safety;
(3) Monitoring and safety; and
(4) Disinfecting equipment;
(f ) The treatment of water, including:
(1) Standards for water treatment used for dialysis as described in the American National Standard, Water Treatment Equipment for Hemodialysis Applications, adopted by reference pursuant to the provisions of NAC 449.520;
(2) Systems and devices;
(3) Monitoring; and
(4) The risk of harm to a patient who uses untreated water;
(g) If the facility reuses water, information concerning the reprocessing of water, including:
(1) Principles of reuse;
(2) Safety, control of quality, standard precautions and water treatment; and
(3) Standards for reuse as described in the American National Standard, Water Treatment Equipment for Hemodialysis Applications, adopted by reference pursuant to the provisions of NAC 449.520;
(h) Providing instruction for a patient of a facility, including:
(1) The role of the technician in supporting the goals of the patient concerning education; and
(2) The principles of adult education;
(i) Safety and the control of infection, including:
(1) The risk of harm to a patient from nosocomial infections and from accidents and errors in providing treatment;
(2) Standard precautions, aseptic and sterile techniques, and proper handling of a specimen;
(3) Basic bacteriology and epidemiology;
(4) The risk of harm to an employee of a facility resulting from exposure to blood and chemicals; and
(5) Electrical, fire, disaster and environmental safety and hazardous substances; and
( j) The assurance and improvement of quality, including:
(1) The role of the dialysis technician in activities concerning the assurance of quality;
(2) The principles of the assurance and improvement of quality; and
(3) The importance of the assurance of quality to ensure that safe dialysis treatments are provided to each patient of the facility.
3. In addition to the requirements set forth in subsection 2, if a dialysis technician intends to assist in providing training or treatment to a patient of the facility who receives peritoneal dialysis, the program of training for the dialysis technician must include the following subjects:
(a) The principles of peritoneal dialysis;
(b) Sterile techniques;
(c) The systems for the delivery of peritoneal dialysis;
(d) The symptoms of peritonitis; and
(e) The complications of peritoneal dialysis.
4. In addition to the requirements set forth in subsection 2, if a dialysis technician intends to cannulate a dialysis access during the treatment of a patient of the facility or administer normal saline, heparin or lidocaine to that patient, the program of training for the dialysis technician must include the following subjects:
(a) Access to circulation, including:
(1) Fistula: creation, development, placement of needles and prevention of complications;
(2) Grafts: materials used, creation, placement of needles and prevention of complications; and
(3) Symptoms to report;
(b) Safe administration of medications, including:
(1) Identifying the patient;
(2) Ensuring the proper administration of medication;
(3) Measuring the correct dose;
(4) Ascertaining the correct route to administer the dose; and
(5) Ensuring the correct time to administer the dose;
(c) Administration of normal saline, including:
(1) The reasons for administration;
(2) Potential complications;
(3) The limits of administration; and
(4) Information to report and record;
(d) Administration of heparin, including:
(1) The reasons for administration;
(2) The methods of administration;
(3) The preparation of an ordered dose;
(4) Potential complications; and
(5) Information to report and record; and
(e) Administration of lidocaine, including:
(1) The reasons for administration;
(2) The method of administration;
(3) The preparation of an ordered dose;
(4) Potential complications and risks; and
(5) Information to report and record.
5. The instructor of a course of training provided to a dialysis technician shall:
(a) Maintain a roster of attendance for each dialysis technician enrolled in the course; and
(b) At least once each week during the course, evaluate each dialysis technician enrolled in the course to determine the progress of the dialysis technician in completing the course.
6. Except as otherwise provided in subsection 7, each dialysis technician specified in subsection 5 must complete a written examination. The examination must include each of the subjects specified in subsections 2 and 3. If the dialysis technician intends to cannulate a dialysis access during the treatment of a patient of the facility or administer normal saline, heparin or lidocaine to that patient, the examination must include the subjects specified in subsection 4. To pass the written examination, the dialysis technician must achieve a score of not less than 80 percent on each of the subjects required to be included in the written examination pursuant to the provisions of this subsection.
7. The provisions of subsection 6 do not apply to a dialysis technician who is certified as a dialysis technician by an organization that is approved by the Bureau.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004)
NAC 449.5715 Program of training: Qualifications of instructors. (NRS 449.037) Each instructor who provides instruction pursuant to a program of training specified in NAC 449.571 must be:
1. A physician who is qualified as a medical director in accordance with the provisions of NAC 449.5505;
2. A registered nurse who:
(a) Has at least 12 months of experience in performing hemodialysis obtained within the 2 years immediately preceding the date he begins instruction pursuant to the program; and
(b) Has provided to the facility a current written list concerning his knowledge and skills that is prepared pursuant to the provisions of NAC 449.5745;
3. A registered nurse who provides instruction for a course of training for a dialysis technician at an accredited college or university; or
4. A qualified dietitian or social worker who provides instruction within his area of expertise.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.573 Program of training: Certain persons authorized to provide instruction and serve as preceptor. (NRS 449.037) If a licensed nurse or dialysis technician has at least 1 year of experience in performing hemodialysis and has filed with the facility a current written list concerning his knowledge and skills prepared in accordance with the provisions of NAC 449.5745, the licensed nurse or dialysis technician may:
1. Assist in providing instruction to a dialysis technician at the facility; and
2. Serve as a preceptor at the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5735 Program of training: Required hours. (NRS 449.037)
1. Except as otherwise provided in subsection 2, each program of training specified in NAC 449.571 must consist of at least 80 hours of education in the classroom and 200 hours of directly supervised clinical training for each dialysis technician who is enrolled in the program.
2. A program of training for a dialysis technician who has experience in providing care directly to a patient of a facility may consist of not less than 80 hours of combined education in the classroom and clinical training if the dialysis technician demonstrates to the satisfaction of the facility that he is competent to provide that care.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.574 Committee to review program of training. (NRS 449.037) Each facility shall appoint a committee to review the training provided pursuant to a program of training specified in NAC 449.571. The membership of the committee must consist of at least the medical director, supervising nurse and chief technician of the facility. The committee shall:
1. Review the records of each dialysis technician enrolled in the program, including:
(a) The results of each examination taken by the dialysis technician pursuant to the provisions of NAC 449.571; and
(b) Each written list concerning the knowledge and skills of the dialysis technician prepared pursuant to the provisions of NAC 449.5745;
2. Receive and consider all comments concerning the dialysis technician submitted to the committee by an instructor or preceptor; and
3. Verify that the dialysis technician has successfully completed the program of training.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5745 Written list concerning knowledge and skills. (NRS 449.037) The supervising nurse or a registered nurse of a facility who qualifies as an instructor for the facility shall complete a written list to determine the knowledge and skills of each dialysis technician in performing the following activities:
1. Assembling supplies required to provide treatment to a patient of the facility;
2. Preparing dialysate according to procedure and dialysis prescription;
3. Assembling and preparing the dialysis extracorporeal circuit;
4. Securing the correct dialyzer for the patient;
5. Installing and rinsing the dialyzer and all required tubing for the dialyzer;
6. Testing monitors and alarms, conductivity and, if applicable, testing for the presence or absence of residual sterilants;
7. Setting monitors and alarms in accordance with the protocols of the facility and the instructions of the manufacturer of the monitor or alarm;
8. Obtaining predialysis vital signs, weight and temperature of a patient of the facility in accordance with the protocols of the facility and, after obtaining that information, notifying the supervising nurse or registered nurse of all unusual findings;
9. Inspecting the dialysis access of the patient for patency and, after cannulation is performed and heparin is administered, initiating dialysis in accordance with the patient’s prescription, observing universal precautions and reporting all unusual findings to the supervising nurse or registered nurse;
10. Adjusting the rate of the flow of blood in accordance with the protocols of the facility and the prescription of the patient;
11. Calculating and setting the dialysis machine to allow the removal of fluid at a rate established in accordance with the protocols of the facility and the prescription of the patient;
12. Monitoring the patient and equipment during treatment, responding appropriately to the requirements of the patient and to machine alarms, and reporting all unusual occurrences to the supervising nurse or registered nurse;
13. Changing the rate of the removal of fluid, placing the patient in the Trendelenburg position and administering replacement normal saline as directed by:
(a) The supervising nurse or registered nurse;
(b) An order of a physician; or
(c) The protocols of the facility;
14. Documenting all findings and actions in accordance with the protocols of the facility;
15. Describing the appropriate response to:
(a) Emergencies relating to dialysis, including, without limitation, cardiac or respiratory arrest, needle displacement or infiltration, clotting, blood leaks or air emboli; and
(b) Nonmedical emergencies, including, without limitation, power outages or equipment failures;
16. Discontinuing dialysis and establishing hemostasis, including:
(a) Inspecting, cleaning and dressing the dialysis access of the patient in accordance with the protocols of the facility; and
(b) Reporting all unusual findings or occurrences to the supervising nurse or registered nurse;
17. Obtaining and recording the temperature, weight and postdialysis vital signs of the patient and reporting all unusual findings to the supervising nurse or registered nurse;
18. Discarding supplies and sanitizing the equipment and treatment chair in accordance with the protocols of the facility;
19. Communicating all emotional, medical, psychological or nutritional concerns of the patient to the supervising nurse or registered nurse;
20. Obtaining current certification in cardiopulmonary resuscitation; and
21. Maintaining professional conduct, good communication skills and confidentiality concerning the care of the patients of the facility.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.576 Peritoneal dialysis: Additional activities required. (NRS 449.037) In addition to the written list required pursuant to the provisions of NAC 449.5745, if a dialysis technician who is enrolled in a course of training pursuant to the provisions of NAC 449.571 intends to provide training or treatment for a patient of the facility who receives peritoneal dialysis, each of the following activities must be completed satisfactorily by the dialysis technician:
1. Assisting patients in ordering supplies;
2. Performing an exchange of dialysate by draining and refilling the peritoneal space with dialysate, including procedures for conducting a continuous ambulatory peritoneal dialysis exchange and the commencement or discontinuation of continuous cycling peritoneal dialysis;
3. Observing peritoneal effluent;
4. Recognizing and understanding the appropriate observations to report;
5. Collecting a specimen of dialysate;
6. Performing a change of transfer tubing; and
7. Setting up and operating the equipment required to conduct continuous cycling peritoneal dialysis.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5765 Cannulation or administration of normal saline or heparin: Additional activities required. (NRS 449.037) In addition to the written list required pursuant to the provisions of NAC 449.5745, if a dialysis technician who is enrolled in a course of training pursuant to the provisions of NAC 449.571 intends to cannulate a dialysis access of a patient of the facility or administer normal saline and heparin to that patient, each of the following activities must be completed satisfactorily by the dialysis technician:
1. Cannulation, including:
(a) Inspecting the dialysis access of the patient for patency;
(b) Preparing the skin;
(c) Using aseptic techniques;
(d) Placing needles correctly;
(e) Establishing blood access;
(f ) Replacing needles;
(g) Recognizing the circumstances under which a call for assistance may be required; and
(h) Securing needles;
2. The administration of heparin, including:
(a) Checking the prescription of the patient;
(b) Preparing the dose;
(c) Labeling the prepared syringe;
(d) Administering the dose; and
(e) Observing the patient for complications experienced by the patient;
3. The administration of normal saline, including:
(a) Understanding unit protocol;
(b) Checking the prescription of the patient;
(c) Recognizing signs of hypertension experienced by the patient;
(d) Notifying the registered nurse;
(e) Administering normal saline; and
(f ) Rechecking vital signs; and
4. The administration of lidocaine, including:
(a) Checking the prescription of the patient;
(b) Identifying the correct vial of medication for the patient;
(c) Preparing the dose;
(d) Administering the dose; and
(e) Observing the patient for complications experienced by the patient.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.577 Cannulation or administration of normal saline, heparin or lidocaine: Verification and documentation of competency required. (NRS 449.037) If a dialysis technician intends to cannulate a dialysis access during the treatment of a patient of the facility or administer normal saline, heparin or lidocaine, the medical director of the facility must, before the dialysis technician performs those tasks at the facility, verify and document whether the dialysis technician is competent to perform those activities.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5775 Documentation of successful completion of program of training; employment by another facility. (NRS 449.037)
1. A facility shall issue to each dialysis technician who successfully completes a program of training and receives an evaluation of his competency provided to him by the facility pursuant to the provisions of NAC 449.5705 to 449.5775, inclusive, a document indicating that he has successfully completed the program of training.
2. Each document issued pursuant to the provisions of subsection 1 must include a statement indicating that the program for which the document is issued satisfies the requirements of NAC 449.5705 to 449.5775, inclusive.
3. A document issued pursuant to the provisions of subsection 1 may be accepted by any other facility that employs the dialysis technician. The document may be accepted only for 6 months after the date on which the document is issued. If the dialysis technician is employed by any other facility after that date, the dialysis technician shall obtain from the facility that employs the dialysis technician a written list concerning his knowledge and skills prepared in accordance with the provisions of NAC 449.5745.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.579 Patient care: Technicians must demonstrate certain knowledge and competency. (NRS 449.037) A dialysis technician who provides care directly to a patient of a facility must demonstrate knowledge of and competency to carry out the responsibilities specified in NAC 449.5705 to 449.5775, inclusive.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
NAC 449.5795 Prohibited acts. (NRS 449.037) A dialysis technician of a facility shall not:
1. Initiate the provision of education for any patient of the facility;
2. Alter any treatment that is ordered for a patient of the facility, including shortening the period for providing treatment to the patient;
3. Administer any medication to a patient of the facility other than the administration of normal saline, heparin or lidocaine during the regular course of treatment for the patient;
4. Administer any blood or products of blood to a patient of the facility;
5. Perform a venipuncture other than a venipuncture at the point of access for dialysis;
6. Perform an arterial puncture; or
7. Accept the order of a physician.
(Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)
PROVISION OF CERTAIN SPECIAL SERVICES
Obstetric Care
NAC 449.6113 Definitions. (NRS 449.037) As used in NAC 449.6113 to 449.61178, inclusive, unless the context otherwise requires:
1. “Licensed advanced practitioner of nursing” means an advanced practitioner of nursing who is licensed pursuant to chapter 632 of NRS and who has specialized training in midwifery approved by the State Board of Nursing.
2. “Licensed physician” means a physician licensed pursuant to chapter 630 or 633 of NRS.
3. “Maternal patient” means a woman admitted to an obstetric center in accordance with NAC 449.61134 who has had a normal uncomplicated prenatal course, as determined by adequate prenatal care, and the prospect for a normal, uncomplicated birth, as defined by the criteria established by the American College of Obstetricians and Gynecologists and by reasonable and generally accepted clinical standards for maternal and fetal health.
4. “Obstetric care” means the care which is provided, in accordance with NAC 449.6113 to 449.61178, inclusive, immediately before, during and for not more than 24 hours after delivery to a maternal patient:
(a) Who has completed at least 36 weeks of gestation and not more than 42 weeks of gestation; and
(b) Whose condition is reasonably expected to result in a normal and uncomplicated vaginal birth.
5. “Obstetric center” has the meaning ascribed to it in NRS 449.0155.
(Added to NAC by Bd. of Health, eff. 7-19-96; A by R044-97, 10-30-97)
NAC 449.61132 Authorized obstetric care. (NRS 449.037) Obstetric care provided at an obstetric center must be limited to:
1. Care provided immediately before, during and for not more than 24 hours after a vaginal birth to a maternal patient, if the care provided to the maternal patient does not include general or regional anesthesia; and
2. Assessment of a maternal patient before the completion of 36 weeks of gestation, for preterm labor or premature rupture of membranes and the initiation of appropriate treatment according to established written protocols.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61134 Eligible maternal patients. (NRS 449.037) A woman may be a maternal patient at an obstetric center if:
1. She has completed at least 36 weeks and not more than 42 weeks of gestation;
2. She has no major medical problems;
3. She has no previous history of major uterine wall surgery, cesarean section, or other obstetrical complications which are likely to recur;
4. She has parity of under six unless a justification for a variation is documented by the medical director for the obstetric center;
5. She is not less than 15 years or more than 40 years of age and is not a nullipara, unless the medical director has reviewed the age and parity of the maternal patient and approves the admission of the maternal patient on a case-by-case basis;
6. She has no significant signs or symptoms of:
(a) Pregnancy-induced hypertension;
(b) Polyhydramnios or oligohydramnios;
(c) Abruptio placenta;
(d) Chorioamnionitis;
(e) Multiple gestation;
(f ) Intrauterine growth retardation;
(g) If there is fetal distress, amniotic fluid which is stained with meconium;
(h) Fetal distress;
(i) Substance abuse;
( j) Placenta previa;
(k) Diabetes mellitus; or
(l) Anemia;
7. While in active labor, she demonstrates no significant signs or symptoms of:
(a) Intrapartum hemorrhage;
(b) Active Herpes Simplex II of the genitals; or
(c) Malpresentation of the fetus including breech presentation;
8. She is in labor and progressing normally according to the established protocols of the obstetric center and the medical staff of the obstetric center;
9. Her membranes were not ruptured more than 24 hours before her admission to the obstetric center;
10. She has no evidence of an infection;
11. Her pregnancy is appropriate for a setting where analgesia is limited; and
12. Her pregnancy is appropriate for a setting where anesthesia is limited to a local infiltration of the perineum or a pudendal block.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61138 Denial of application for or renewal of license; revocation or suspension of license. (NRS 449.037)
1. An application for a license or the renewal of a license may be denied if the facility, personnel or equipment fails to meet the requirements of this chapter or if cause or circumstance exists that may, in the opinion of the Health Division, threaten or have the potential to threaten the safety or health of the public.
2. A license may be revoked or summarily suspended in accordance with this chapter and chapters 233B and 449 of NRS if the facility, personnel or equipment fails to meet the requirements of this chapter or if cause or circumstance exists that may, in the opinion of the Health Division, threaten or have the potential to threaten the safety or health of the public.
(Added to NAC by Bd. of Health, eff. 7-19-96; A by R044-97, 10-30-97)
NAC 449.6114 Design, construction, equipment and maintenance of obstetric center: General requirements; prerequisites to approval for licensure. (NRS 449.037)
1. An obstetric center must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the obstetric center and members of the general public.
2. An obstetric center shall comply with all applicable:
(a) Federal and state laws;
(b) Local ordinances, including, without limitation, zoning ordinances;
(c) Environmental, health and local building codes; and
(d) Fire and safety codes, including, without limitation, those codes relating to ingress and egress of occupants, placement of smoke alarms, fire extinguishers or sprinkler systems, and fire escape routes,
Ê related to the construction and maintenance of the obstetric center. If there is a difference between state and local requirements, the more stringent requirements apply.
3. Except as otherwise provided in subsection 4, before any new construction of an obstetric center or any remodeling of an existing obstetric center is begun, the obstetric center must submit building plans for the new construction or remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115. The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the obstetric center. The Bureau shall not approve an obstetric center for licensure until all construction is completed and a survey is conducted at the site of the obstetric center.
4. An obstetric center is not required to submit plans for remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115 if the remodeling is limited to refurbishing an area within the obstetric center, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area, and replacing window or wall coverings in the area.
(Added to NAC by Bd. of Health, eff. 7-19-96; A by R035-97, 10-30-97; R076-01, 10-18-2001; R072-04, 8-4-2004)
NAC 449.61142 Required facilities and services. (NRS 449.037)
1. An obstetric center shall provide:
(a) Services for labor, delivery, newborn and recovery care for not more than 24 hours after delivery.
(b) Areas for labor, delivery, newborn and recovery which are in a safe and clean environment in accordance with all applicable local, state and federal laws.
(c) Areas for:
(1) Maintenance and documentation of medical records of each maternal patient by physicians and nurses;
(2) Patient and family education;
(3) Treatment and examination of a maternal patient and newborn baby;
(4) Cleaning and storage of instruments and equipment which are located separately from the other areas of the obstetric center;
(5) Secure storage of drugs; and
(6) Family visitation.
(d) Simple nourishment for the maternal patient by providing:
(1) A separate area for appropriate storage of food which may be provided to the maternal patient by her family; or
(2) Food prepared by the obstetric center. If food is prepared by the obstetric center, the obstetric center must comply with all applicable local, state and federal laws relating to the preparation of food by a medical facility.
2. An obstetric center must be equipped with those items needed to provide low-risk obstetrical care without general anesthesia and initial emergency procedures for life-threatening events to a maternal patient and newborn baby, including, but not limited to:
(a) Sterile supplies for delivering and caring for a newborn baby;
(b) Equipment for performing pelvic examinations;
(c) Sphygmomanometers and stethoscopes, in adult and infant sizes;
(d) Fetoscopes, doppler and electronic fetal monitors;
(e) Supplies for measuring sugar and protein in urine;
(f ) Needles and syringes;
(g) Solutions and supplies for parenteral administration of fluids;
(h) Emergency drugs and equipment for the resuscitation of an adult and a newborn baby;
(i) Equipment for suctioning an airway, in appropriate sizes for adults and newborn babies;
( j) Protective gear for personnel of the obstetric center who may be exposed to body fluids of the maternal patient and the newborn baby;
(k) Equipment or other approved methods for warming solutions and blankets; and
(l) Oxygen and apparatus for administering oxygen, in appropriate sizes for adults and newborn babies.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61144 Required emergency electrical power. (NRS 449.037) An obstetric center must have adequate emergency electrical power:
1. By procuring batteries or an electricity-producing generator with sufficient fuel which is capable of providing power for 2 hours or more to:
(a) All lights in the obstetric center; and
(b) All equipment in the obstetric center with the exception of the wall outlets located in a reception or waiting area.
2. By having the source of emergency power serviced on a regular basis and documenting that service in the records of maintenance of the obstetric center.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61146 Requirements for birth room, toilet and bathing facilities, hallways and doors, water supply and office-based facilities. (NRS 449.037)
1. Each birth room in an obstetric center must:
(a) Be maintained in a condition which is adequate and appropriate to provide for the equipment, staff, supplies and any emergency procedures required during the period of labor, delivery and recovery for the physical and emotional care of the maternal patient, any person accompanying the maternal patient for support and the newborn baby;
(b) Have at least 256 square feet with a minimum room dimension of 16 feet;
(c) Be located so as to provide unimpeded, rapid access to an exit of the building which will accommodate emergency transportation vehicles and equipment; and
(d) Have facilities immediately available to the birth room for the washing of hands.
2. The obstetric center shall provide toilet and bathing facilities for use by a maternal patient, including:
(a) A toilet and lavatory maintained in or adjacent to the vicinity of the birth room; and
(b) A shower which is clean and in good repair.
3. Hallways and doors which provide entry into, exit from and access within the obstetric center and birth rooms must be of adequate width and configuration to accommodate the maneuvering of a stretcher from an ambulance, a wheelchair and other emergency equipment.
4. The obstetric center must have an adequate supply of hot and cold running water under pressure for human consumption and other purposes relating to the care of the maternal patient and newborn baby.
5. If office-based prenatal or other health care is provided at the obstetric center, the consultation and examining rooms for that care must be separate from the birth rooms.
(Added to NAC by Bd. of Health, eff. 7-19-96; A by R072-04, 8-4-2004)
NAC 449.61148 Governing body of obstetric center; duties. (NRS 449.037)
1. Except as otherwise provided in NAC 449.6115, each obstetric center must have a governing body that is chaired by a principal in the organization which is operating the obstetric center or the licensee with legal authority for the operation of the obstetric center.
2. The governing body shall ensure that:
(a) Each maternal patient of the obstetric center receives care from:
(1) A licensed physician or a licensed advanced practitioner of nursing; and
(2) A registered nurse licensed pursuant to chapter 632 of NRS who has 2 years or more of experience in labor and delivery;
(b) At least one licensed physician or licensed advanced practitioner of nursing, who is approved by the medical director of the obstetric center to provide care at the obstetric center, is present at the time of delivery;
(c) At least one registered nurse licensed pursuant to chapter 632 of NRS with 2 years of documented experience in labor and delivery in a general or obstetrical hospital, who is approved by the medical director to provide care at the obstetric center, is on the premises during the time pre- and postdelivery care is provided;
(d) An annual operating budget and a plan for capital expenditures for the obstetric center are established;
(e) The obstetric center is adequately staffed and equipped;
(f ) There is documentation in the files of the obstetric center of the qualifications of each consultant under contract with and each member of the staff employed by the obstetric center;
(g) The obstetric center adopts, enforces and annually reviews written policies and procedures, which must be approved by the governing board, relating to the operation of and the provisions of care by the obstetric center;
(h) The obstetric center’s protocols for treatment, assessments for risk status and criteria for the transfer of a maternal patient or a newborn baby are approved by a licensed physician who is:
(1) Currently certified by the American Board of Obstetrics and Gynecology, or an equivalent organization; and
(2) Currently practicing in the specialty of obstetric care, including routinely delivering newborn babies and caring for maternal patients;
(i) A licensed physician who is currently certified by the American Board of Obstetrics and Gynecology is readily available as a consultant, in person or by telephone, during all hours of operation of the obstetric center; and
( j) The obstetric center files the appropriate records of births and deaths.
3. The governing body shall establish a policy for authentication that:
(a) Authorizes the use of rubber stamps, except on records documenting the medical care provided to a maternal patient and newborn baby, and prohibits the use of any stamp by any person other than the person whose signature the stamp represents;
(b) Approves a method for identifying the person making an entry in any record or chart; and
(c) Requires that the entry include the professional title of the person making the entry and the date and time that entry is made.
4. The governing body shall appoint a person to administer the obstetric center who is responsible for:
(a) The daily operation of the obstetric center;
(b) Reporting the pertinent activities concerning the obstetric center to the governing body at regular intervals;
(c) Appointing a person responsible for the obstetric center in the absence of the person appointed by the governing board; and
(d) Planning for the services provided by the obstetric center and the operation of the obstetric center.
5. The governing body shall ensure that the obstetric center maintains insurance for:
(a) Nonmedical liability in an amount of $50,000 or more; and
(b) Medical liability in an amount of $1,000,000 or more.
6. The governing body shall require each medical practitioner who practices in the obstetric center to carry liability insurance in an amount of $1,000,000 or more.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.6115 Physician operator or advanced practitioner of nursing operator as licensee. (NRS 449.037)
1. If the licensee is a physician operator or an advanced practitioner of nursing operator, the obstetric center operated by the licensee is not required to have a governing body or an administrator. In such a case, the licensee is responsible for complying with the provisions of NAC 449.6113 to 449.61178, inclusive.
2. As used in this section:
(a) “Advanced practitioner of nursing operator” means a licensed advanced practitioner of nursing who is operating an obstetric center for the purpose of delivering the babies of and providing medical care to his own maternal patients.
(b) “Physician operator” means a licensed physician who is operating an obstetric center for the purpose of delivering the babies of and providing medical care to his own maternal patients.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61152 Designation and responsibilities of medical director; privileges of members of medical staff; provision of consultation services with specialists. (NRS 449.037)
1. An obstetric center shall designate a licensed physician who is currently certified by the American Board of Obstetrics and Gynecology, or an equivalent organization, and practicing obstetrics including the delivery of newborn babies and providing care to maternal clients, to serve as the medical director of the obstetric center. The medical director is responsible for:
(a) The development and implementation of policies related to the care of a maternal patient;
(b) The coordination of medical care at the obstetric center; and
(c) The development of, the maintenance of and the assurance of compliance with a written plan to provide medical care in a licensed medical facility that can provide a higher level of care to each maternal patient and newborn baby under the care of the obstetric center when the needs of the maternal patient or newborn baby exceed the capability of the obstetric center.
2. The medical director is responsible for the quality of medical care provided to each maternal patient and newborn baby under the care of the obstetric center and for the review of the ethical and professional practices of the medical staff, including, but not limited to:
(a) The selection of members of the medical staff;
(b) The delineation of the privileges accorded by the obstetric center to members of the medical staff and members of allied health professions who provide services at the obstetric center;
(c) The reappraisal and appointment of each member of the staff; and
(d) The procedure to appeal the withdrawal or denial of any privilege of a member of the staff.
3. A roster of the privileges of each member of the medical staff of the obstetric center must be kept in the files of the obstetric center specifying the privileges awarded to that member.
4. The obstetric center shall maintain and document each agreement to provide consultation services which the obstetric center enters into with a:
(a) Physician certified by the American Board of Obstetrics and Gynecology, or an equivalent organization; or
(b) Physician certified by the American Board of Pediatrics, or an equivalent organization,
Ê who has admitting privileges in his specialty at an appropriate licensed medical facility that can provide a higher level of care to a maternal patient or newborn baby than the obstetric center can provide.
5. Each member of the medical staff of the obstetric center must agree to abide by the rules of the obstetric center and NAC 449.6113 to 449.61178, inclusive.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61154 Medical records: Maintenance; access. (NRS 449.037)
1. An obstetric center shall maintain the records for each maternal patient admitted for care in the obstetric center in accordance with accepted professional practice.
2. Only authorized personnel may have access to medical records of the obstetric center. Information contained in a medical record of a maternal patient must not be released without the written consent of the maternal patient or guardian except:
(a) As required by law; or
(b) As otherwise provided by the agreement on admission.
3. A medical record must be in a format that may be readily and legibly reproduced when needed or requested.
4. A licensee who ceases operation shall notify the Health Division of the arrangements made for access to and the safe preservation of medical records in the custody of the licensee.
5. Medical records must not be removed from the obstetric center except upon the issuance of an order by a court of competent jurisdiction.
6. A complete copy of the medical record for each maternal patient transferred from the obstetric center must be sent with the maternal patient to the facility receiving that patient.
7. The medical record of a maternal patient discharged from the obstetric center must be completed within 20 days after the date that the maternal patient is discharged from the obstetric center.
8. Each medical record must be protected against loss, destruction and unauthorized use.
9. The medical record of a maternal patient must be retained for 5 years or more after the date that the maternal patient is discharged from the obstetric center.
(Added to NAC by Bd. of Health, eff. 7-19-96; A by R044-97, 10-30-97)
NAC 449.61156 Medical records: Contents. (NRS 449.037) The medical record of a maternal patient which is on file with the obstetric center must be completed, authenticated, accurate and current, and must include:
1. A complete identification of the maternal patient including information about the next of kin of the patient and the person or agency legally or financially responsible for the patient.
2. A statement concerning the admission and diagnosis of the maternal patient.
3. The medical history of the maternal patient.
4. Evidence of informed consent given for the care of the maternal patient.
5. Any clinical observation of the maternal patient, including, but not limited to, the notes of a physician, a nurse or any other professional person in attendance.
6. A report of all prescribed tests and examinations.
7. Confirmation of the original diagnosis, or the diagnosis at the time of discharge.
8. A summary of discharge prepared in accordance with the established policy of the obstetric center, and any provisions made for continuing care or follow-up of the maternal patient after discharge.
9. If the maternal patient has died while under the care of the obstetric center, documentation of the death which must be signed by the physician of record.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61158 Program for review of quality of care. (NRS 449.037) An obstetric center shall establish a program for the review of the quality of care provided by the obstetric center. The program must include, without limitation:
1. Documentation in the medical records of the maternal patient and newborn baby of the care provided as appropriate to the condition of the maternal patient or newborn baby, and the results or outcome of that care;
2. The time of admission and the time that the maternal patient was examined by a licensed physician or a licensed advanced practitioner of nursing;
3. A statement which describes the condition of the maternal patient at the time that the patient is discharged from the obstetric center;
4. The instructions given to the maternal patient upon discharge and documentation of the maternal patient’s understanding of those instructions;
5. For each maternal patient and newborn baby who is transferred to another hospital or medical facility, the reason for the transfer, the method of transfer, the time that the transfer was requested and the time that the maternal patient or newborn baby was discharged from the obstetric center;
6. Documentation of any incident of unusual occurrence or deviation from the usual standards of practice of patient care, any error in the administration of medications, any intrapartum infection of either maternal patient or newborn baby, and any morbidity or mortality; and
7. Documentation about the newborn babies delivered at the obstetric center, including, but not limited to:
(a) The number of deliveries;
(b) Any birth weight of less than 2500 grams;
(c) Any Apgar scores of newborn babies delivered at the obstetric center which are less than 6 after 5 minutes;
(d) Any congenital defect of a newborn baby; and
(e) Any perinatal complication of a maternal client or newborn baby.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.6116 Miscellaneous requirements concerning staff, provision of service and equipment. (NRS 449.037) An obstetric center must:
1. Have on the premises at least one registered nurse licensed pursuant to chapter 632 of NRS with experience in perinatal care of a maternal patient and newborn baby when a maternal patient is on the premises receiving pre- and postdelivery care;
2. Have at least two attendants present at all times during each delivery, one of whom must be a licensed physician or a licensed advanced practitioner of nursing;
3. Have the capacity of providing initial evaluation of risk status, appropriateness of admission and support of maternal patients in labor;
4. Maintain on-site equipment, drugs, oxygen and appropriately trained and educated personnel needed to provide obstetric care to a maternal patient and newborn baby;
5. Have appropriate clinical laboratory services available for use to provide safe obstetric care according to the needs of the maternal patient and medical staff of the obstetric center; and
6. Have at least two persons who are trained and experienced in performing cardiopulmonary resuscitation in adults and newborn babies on the premises and immediately available during each delivery.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61162 Requirements for transfer or discharge of patient. (NRS 449.037)
1. A maternal patient or newborn baby, as appropriate, may not be transferred from an obstetric center unless the transfer is appropriate based on the risk assessment of the maternal patient or newborn baby and the member of the medical staff determines that:
(a) The maternal patient is at high risk for a complicated labor or delivery and does not meet the criteria for a low-risk, uncomplicated labor and delivery; or
(b) The medical needs of the maternal patient or newborn baby exceed the capability of the obstetric center to provide the necessary care.
2. A maternal patient or newborn baby, as appropriate, may not be discharged from the obstetric center unless the discharge is appropriate based on the risk assessment of the maternal patient or newborn baby and a member of the medical staff determines that:
(a) If the maternal patient has not given birth, the maternal patient is not in active labor; or
(b) The maternal patient has had a normal low-risk, uncomplicated birth and that further medical problems or complications resulting from the birth are not anticipated.
3. The criteria for the transfer of a maternal patient or newborn baby must be written and included in the manual for the policy and procedure of the obstetric center.
4. If a maternal patient or newborn baby must be transferred, the maternal patient or newborn baby must be transferred to a hospital or other medical facility which is capable of providing a higher level of obstetrical and neonatal care and with which the obstetric center has a written agreement that acknowledges that the hospital or medical facility agrees to accept emergency maternal patients without regard to their ability to pay.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61164 Written protocol for discharge of patient. (NRS 449.037) An obstetric center shall establish written protocols for the discharge of a maternal patient from the obstetric center which must include, without limitation:
1. Instructions to the maternal patient regarding care and feeding of the newborn baby.
2. Examination of the maternal patient and newborn baby after discharge from the obstetric center.
3. Instructions regarding the availability of consultation services by telephone as needed or desired by the maternal patient.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61166 Policies and procedures for control of infectious agents and diseases; program to monitor health of employees. (NRS 449.037)
1. The obstetric center shall establish such policies and procedures as are necessary for the control of infectious agents and disease. The policies and procedures must:
(a) Include a method of disposal, cleaning and treatment of equipment, linens, and supplies contaminated with blood or bodily fluids; and
(b) Be in conformance with universal precautions established by the Centers for Disease Control and Prevention and with all applicable local, state and federal laws.
2. The obstetric center shall establish a program to monitor the health of each employee of the obstetric center. The program must include, but not be limited to:
(a) Annual testing for tuberculosis; and
(b) Documentation as to whether the employee has had:
(1) Rubella and, if so, when the employee had rubella.
(2) A vaccination for rubella and, if so, when the employee had the vaccination.
3. A copy of the precautions established by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services may be obtained for a cost of $46, plus shipping and handling, from:
The National Technical Information Service of the
Centers for Disease Control and Prevention
Research Department
5285 Port Royal Road
Springfield, Virginia 22161
Reference No. PB86133022
(703) 487-4870
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61168 Laboratory services; transfer of maternal patient who needs blood or blood products. (NRS 449.037)
1. An obstetric center must maintain or have available adequate laboratory services to meet the needs of its maternal patients, newborn babies and medical staff. The obstetric center shall ensure that all laboratory services provided to its maternal patients and newborn babies are provided by a medical laboratory licensed pursuant to chapter 652 of NRS.
2. Laboratory services must be available during all hours of operation of the obstetric center as necessary to meet the needs of the maternal patients, newborn babies and medical staff.
3. If work is performed by an outside laboratory, the original report must be from a laboratory licensed pursuant to chapter 652 of NRS and contained in the medical record of the maternal patient. If services are provided by an outside laboratory, the conditions, procedures and availability of work performed must be in writing and available within the obstetric center.
4. Upon the receipt of a laboratory report, an obstetric center shall promptly:
(a) File a laboratory report in the appropriate medical record; and
(b) Notify the physician or advanced practitioner of nursing who requested the report that the report has been received and filed in the medical record of the maternal patient.
5. A report of a tissue specimen must be signed by a pathologist. The medical staff of the obstetric center and a pathologist must determine whether a tissue specimen requires a macroscopic examination, or a macroscopic and microscopic examination.
6. If a maternal patient needs blood or blood products, the maternal patient must be transferred to a licensed hospital which has the capability of providing perinatal services.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.6117 Possession, distribution, administration and storage of drugs and controlled substances. (NRS 449.037)
1. An obstetric center shall ensure that drugs and controlled substances are possessed, distributed and administered by members of the medical staff in the obstetric center in conformance with all applicable federal, state and local laws.
2. All drugs and controlled substances distributed at an obstetric center must be possessed and distributed by a licensed physician or a licensed advanced practitioner of nursing in accordance with his registration from the State Board of Pharmacy and the Drug Enforcement Administration of the Department of Justice. The licensed physician or licensed advanced practitioner of nursing shall establish and maintain a list of drugs and controlled substances which are available for use by the licensed physician or licensed advanced practitioner of nursing for maternal patients and newborn babies in the obstetric center.
3. An obstetric center shall establish a policy to ensure quality control and dispensing of drugs and controlled substances. The obstetric center must have a specific area for storing the drugs and controlled substances which include, without limitation, locked storage for drugs, double-locked storage for controlled substances and locked refrigerated storage. A facility for washing hands must be provided near the area in which the drugs and controlled substances are to be distributed.
4. A drug or controlled substance may not be administered at an obstetric center without an order from a licensed physician or a licensed advanced practitioner of nursing. An order for the administration of a drug or controlled substance must be entered into the medical record of the maternal patient and be signed by the physician or advanced practitioner of nursing who made the order. The order must include the name of the drug, dosage, time or frequency of administration, and if other than oral, the route of administration.
5. The obstetric center shall provide a separate refrigerator for the storage of drugs and controlled substances. The temperature in the refrigerator must be maintained between 36 degrees Fahrenheit, or 2 degrees Centigrade, and 46 degrees Fahrenheit, or 8 degrees Centigrade. The temperature of the room in which the drugs and controlled substances that are not refrigerated are stored must not exceed 86 degrees Fahrenheit, or 30 degrees Centigrade.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61172 Anesthesia. (NRS 449.037)
1. An obstetric center may have the capability of providing anesthesia limited to local anesthesia for pudendal blocks and episiotomy repair.
2. A local anesthetic may be administered only by a licensed physician or a licensed advanced practitioner of nursing.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61174 Transfer of patient to hospital or medical facility licensed to provide high-risk perinatal care. (NRS 449.037)
1. An obstetric center must have a written agreement with at least:
(a) One hospital or medical facility licensed to provide high-risk perinatal care; and
(b) One transportation service which can provide a vehicle with equipment appropriate to the needs of a maternal patient or newborn baby during a transfer for the obstetric center,
Ê that assures the expedient transfer of a maternal patient or newborn baby in accordance to established written protocols of the obstetric center when a maternal patient or newborn baby requires care beyond the capability of the obstetric center or a maternal patient is deemed to have a condition or the potential for such a condition that would result in an abnormal or complicated delivery.
2. The medical director of the obstetric center shall:
(a) Determine the criteria and conditions under which a maternal patient or newborn baby should be considered for transfer. The criteria and conditions must be included in the written policy and procedures for the obstetric center.
(b) Annually review those criteria and conditions.
3. An obstetric center must establish written procedures to determine the level of care and the mode of transportation required to ensure that the maternal patient and newborn baby receive expeditious and safe care appropriate to the needs of the maternal patient or newborn baby during the transfer.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61176 Death of patient; notification of Health Division; provision of counseling. (NRS 449.037)
1. An obstetric center shall notify the Health Division of the death of any maternal patient or newborn baby which occurs at the obstetric center. The notification must be made not later than 24 hours after the death of a maternal patient or newborn baby.
2. An obstetric center shall establish a process pursuant to which appropriate counseling will be provided to staff of the obstetric center, a maternal patient and the family of a maternal patient when a death occurs within the obstetric center.
(Added to NAC by Bd. of Health, eff. 7-19-96)
NAC 449.61178 Required information to be provided or made available to patient; complaints. (NRS 449.037)
1. The obstetric center shall take such action as is necessary to inform the maternal patient, both orally and in writing, in language which the maternal patient understands, of the rights of the maternal patient as listed in NRS 449.700, 449.710 and 449.720, risks, alternatives of care and benefits in using the obstetric center.
2. The maternal patient has a right to be fully informed in a language the maternal patient understands about her health status, her medical conditions, the health status of her baby, and the existence of any known complications or risks.
3. A maternal patient may inspect her medical record, or any portion of the record, and, upon request, purchase standard photocopies of the record at a cost not to exceed 60 cents per page.
4. An obstetric center shall provide, within its written policies, a procedure for the registration of complaints by the maternal patient without threat of discrimination or reprisal. A complaint may include, but is not limited to, a grievance concerning the treatment that was received by the maternal patient and a grievance concerning treatment that was not provided.
5. The obstetric center must inform the maternal patient that she has the right to file a complaint relating to the care which the patient receives from the obstetric center with:
(a) The Health Division;
(b) The Board of Medical Examiners; and
(c) The State Board of Nursing.
6. The obstetric center shall provide the maternal patient with names, addresses and telephone numbers of the agencies listed in subsection 5.
(Added to NAC by Bd. of Health, eff. 7-19-96)
Open-Heart Surgery
NAC 449.612 Definitions. (NRS 449.037) As used in NAC 449.612 to 449.61256, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.612011 to 449.612017, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health, eff. 8-31-89; A 8-1-91; R107-98, 3-18-99)
NAC 449.612011 “Approval” defined. (NRS 449.037) “Approval” means the approval granted by the Health Division to a hospital authorizing the hospital to perform open-heart surgery.
(Added to NAC by Bd. of Health by R107-98, eff. 3-18-99)
NAC 449.612012 “Approved hospital” defined. (NRS 449.037) “Approved hospital” means a hospital that has obtained approval from the Health Division to perform open-heart surgery.
(Added to NAC by Bd. of Health by R107-98, eff. 3-18-99)
NAC 449.612014 “Cardiac surgery” defined. (NRS 449.037) “Cardiac surgery” means an operation performed on the heart or on the blood vessels connected to the heart in which access to the area of interest is provided by means of an incision in the wall of the thorax or for which the use of a heart-lung bypass machine is required.
(Added to NAC by Bd. of Health by R107-98, eff. 3-18-99)
NAC 449.612017 “Open-heart surgery” defined. (NRS 449.037) “Open-heart surgery” means any cardiac surgery requiring the use of a heart-lung bypass machine.
(Added to NAC by Bd. of Health by R107-98, eff. 3-18-99)
NAC 449.61202 Prerequisites to initial provision of service. (NRS 449.037) A hospital that desires to provide a new service for the performance of open-heart surgery must make application to the Health Division requesting approval of the service. A hospital shall not provide such a service until the Health Division has given its approval in writing.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61204 Form and contents of application for approval to provide service. (NRS 449.037)
1. The application for approval must include a statement describing:
(a) The qualifications of the personnel of the hospital to perform open-heart surgery;
(b) The facilities and equipment to be used in performing open-heart surgery; and
(c) The manner in which the facilities and personnel of the hospital meet or exceed the requirements of NAC 449.612 to 449.61256, inclusive.
2. The application must contain a statement by the chief of cardiac service for the hospital that the hospital has the facilities, equipment, personnel, staffing, policies and procedures required to perform surgeries at or above the rate required by NAC 449.61214.
3. The application must contain a statement by the chief operating officer of the hospital that the hospital is committed to maintaining the support personnel and equipment required to perform surgeries at or above the rate required by NAC 449.61214.
4. The application must indicate whether the hospital will, if its application is approved, perform open-heart surgery on infants or children.
5. The Health Division shall prescribe a uniform form of application.
(Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99)
NAC 449.61206 Notification of applicant upon review of application; site inspection required. (NRS 449.037)
1. Within 10 days after it receives an application for approval from a hospital, the Health Division shall notify the hospital, in writing, whether the application is complete. If the application is incomplete, the Health Division shall inform the applicant which parts of the application are deficient. If the application is complete, the Health Division shall notify the applicant of the composition of the site inspection team, the date of the team’s visit to the site and the scheduled date for the team to present its findings to the Health Division. The Health Division shall notify the applicant of any changes in this timetable as they occur.
2. The application must not be approved by the Health Division until the findings of the site inspection team verify that the hospital complies with the requirements of NAC 449.612 to 449.61256, inclusive.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61208 Composition and duties of site inspection team. (NRS 449.037) The site inspection team:
1. Must be composed of:
(a) A cardiothoracic surgeon;
(b) A cardiologist;
(c) A cardiac intensive care nurse;
(d) An administrator of a hospital at which open-heart surgery is currently performed;
(e) A surveyor of health facilities from the Health Division; and
(f ) If the hospital indicated in its application that it would perform open-heart surgery on infants or children, a pediatric cardiologist.
2. Shall review the service of the hospital for open-heart surgery and make findings concerning:
(a) The adequacy of the equipment of the hospital for use in such surgery.
(b) Whether the personnel of the hospital meet the requirements of NAC 449.612 to 449.61256, inclusive.
(c) The adequacy of the size of the staff available to perform open-heart surgery at the hospital.
(d) The adequacy and appropriateness of the policies and procedures adopted by the hospital relating to the service.
(e) Whether the hospital has sufficient facilities, staff and equipment to perform open-heart surgeries at the rate required by NAC 449.61214.
(Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99)
NAC 449.6121 Hospital to pay costs of inspection. (NRS 449.037) The costs incurred in connection with any inspection required by the provisions of NAC 449.612 to 449.61256, inclusive, must be paid by the hospital affected.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61212 Approval or denial of application; period of validity of approval; cessation of performance of surgeries. (NRS 449.037)
1. Within 15 working days after it receives the findings of the site inspection team, the Health Division shall approve or notify the hospital of its intention to disapprove the application.
2. An approval issued pursuant to this section is valid until it is revoked or suspended pursuant to NAC 449.61256.
3. A hospital that ceases to perform open-heart surgeries shall notify the Health Division in writing within 30 days after the last surgery is performed. If a hospital has notified the Health Division in writing that it is ceasing to perform open-heart surgeries and subsequently decides that it desires to begin performing open-heart surgery again, it must reapply for approval pursuant to the provisions of NAC 449.612 to 449.61256, inclusive.
(Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99)
NAC 449.61214 Amount of surgery required following approval. (NRS 449.037) After approval of a service for open-heart surgery is granted, such surgeries must be performed in an approved hospital at the following rates:
1. Not less than 80 operations during the first 12 months after approval.
2. Not less than 150 operations during the second 12-month period after approval.
3. Not less than 200 operations during the third and each succeeding 12-month period after approval.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61216 Provision of patient with preoperative instruction. (NRS 449.037) On specific orders from the patient’s physician, a cardiac surgical nurse shall provide each nonemergent cardiac surgical patient with preoperative instruction concerning the proposed surgical procedure and the general course of his treatment.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61218 Surgical team: Composition; privileges and qualifications of members; participation of qualified nurses. (NRS 449.037)
1. A surgical team assigned to each open-heart surgery at an approved hospital must be composed of a cardiovascular surgeon who will be the primary surgeon and at least one other person chosen by the primary surgeon who must be a:
(a) Cardiovascular surgeon;
(b) Vascular surgeon;
(c) General surgeon;
(d) Person who is authorized by the medical staff of the approved hospital to assist in such surgeries; or
(e) A senior surgical resident who is enrolled in a medical training program accredited by the Accreditation Council for Graduate Medical Education.
2. The primary surgeon must be certified or eligible for certification by the American Board of Thoracic Surgery.
3. A person who is authorized to assist in the surgery pursuant to paragraph (d) of subsection 1 must be accorded the privileges of a member of the allied health professions by the medical staff of the approved hospital. The medical staff shall:
(a) Establish criteria for authorizing persons to assist in open-heart surgery that are consistent with current professional standards; and
(b) Reevaluate those criteria at least once every 2 years.
4. A team of open-heart surgical nurses whose training has been verified by the head nurse shall participate in each operation.
5. As used in this section, “medical staff” means the medical staff organized by an approved hospital pursuant to NAC 449.358.
(Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99)
NAC 449.6122 Qualifications of anesthesiologist. (NRS 449.037) Anesthesia during open-heart surgery at an approved hospital must be administered by an anesthesiologist who:
1. Is certified by or who is eligible for certification by the American Board of Anesthesiologists; and
2. Has special training or experience in the administration of anesthesia in open-heart surgery.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61222 Qualifications of nurse in charge of service. (NRS 449.037) The registered nurse in charge of the service for open-heart surgery at an approved hospital must:
1. Have not less than 2 years of operating room nursing experience and not less than 1 year of current experience in open-heart surgery; and
2. Be permanently assigned to that service.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61224 Perfusion team: Use required; qualifications; approval of members by surgeon of record. (NRS 449.037)
1. An approved hospital shall use a perfusion team, which must include a senior perfusionist who is responsible for the supervision of all perfusion services provided by the team.
2. The senior perfusionist must be certified by the American Board of Cardiovascular Perfusionists. The other perfusionists of the heart-lung bypass machine must be certified or eligible for certification by the Board.
3. The senior perfusionist and the other perfusionists must:
(a) Be trained in:
(1) Aseptic techniques required in an operating room;
(2) Perfusion physiology; and
(3) The use of monitoring equipment; and
(b) Have a general understanding of commonly performed cardiac surgical procedures.
4. The cardiac surgeon of record shall approve each perfusionist involved with the surgeon’s patients as being competent to operate the heart-lung bypass machine properly before allowing that person to operate the machine during open-heart surgery.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61226 Operating rooms: General requirements. (NRS 449.037)
1. An approved hospital shall maintain two fully equipped operating rooms, one dedicated to and another available for services for open-heart surgery. Each operating room must have a minimum clearance of 400 square feet, exclusive of fixed cabinets and built-in shelves. Entry to the operating rooms must be limited to persons participating in the service.
2. The ventilation and temperature control systems of each operating room must be able to provide a minimum of 15 air changes per hour in the operating room and maintain the air temperature between 70°F and 75°F, with a relative humidity between 50 and 60 percent.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61228 Operating rooms: Equipment and staff. (NRS 449.037)
1. Each operating room designated or available for open-heart surgery must be equipped with:
(a) A heart-lung bypass machine.
(b) Proper suction and plumbing outlets for heat exchangers for the heart-lung bypass machine.
(c) An adequate supply of electrical power, including, without limitation, standby emergency electrical power.
(d) Surgical instruments.
(e) A device to conserve blood.
(f ) An electronic warmer for blood.
(g) Monitors to review the electrocardiogram and the pressure in two channels of blood flow.
(h) Operating lights which are sufficiently bright to illuminate the inside of body cavities and sufficiently maneuverable to illuminate two operating fields on a patient simultaneously.
(i) A defibrillating apparatus.
2. The operating room must have available:
(a) A complete set of pump oxygenator equipment.
(b) Facilities and appropriate support personnel for the use of an intra-aortic balloon.
3. Each operating room designated for open-heart surgery must be provided with the number of surgical nurses, technicians and ancillary personnel needed to staff the equipment and stations required in performing general surgical operations.
(Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99)
NAC 449.6123 Intensive care facility: General requirements. (NRS 449.037)
1. An approved hospital shall maintain an intensive care facility within the hospital. The facility must:
(a) Have accommodations which can isolate patients;
(b) Have a sufficient system for controlling temperature to maintain comfortable conditions for the patients and members of the hospital’s staff; and
(c) Be equipped to provide continuous electrocardiographic monitoring of each patient in the facility.
2. Each bed in the intensive care facility must be equipped with:
(a) Outlets for suction and oxygen; and
(b) Adequate lighting for illuminating minor surgical procedures.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61232 Intensive care facility: Staff. (NRS 449.037)
1. The administration of intensive care units in an approved hospital for patients recovering from or awaiting open-heart surgery must be under the direction of a qualified physician approved by the cardiac surgeon.
2. A nursing supervisor must be permanently assigned to the intensive care units designated for cardiac surgery patients. The supervisor must have not less than 2 years of experience in intensive care nursing and not less than 1 year of current experience in intensive care nursing of patients recovering from open-heart surgery.
3. The nursing supervisor and the surgical team shall:
(a) Provide organized training and continuing in-service education to each nurse; and
(b) Determine that each nurse is qualified to perform services related to postcardiac surgery,
Ê before assigning the nurse without direct supervision to full-time or periodic duty in the intensive care units.
4. One nurse on each shift must be designated as the nurse in charge for the intensive care units. There must be one nurse for not more than two cardiac surgery patients in the intensive care units for the first 24 hours after surgery.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61234 Intensive care facility: Equipment and supplies. (NRS 449.037)
1. The following equipment must be immediately available to the intensive care facility:
(a) A laryngoscope.
(b) Endotracheal tubes.
(c) Respirators.
(d) Hypothermia equipment.
(e) Tracheostomy sets.
(f ) Thoracotomy sets.
(g) A board for massaging a closed chest.
(h) An external pacemaker.
(i) An external defibrillator.
( j) Respiratory support equipment.
(k) Intravenous drip counters.
(l) An intravenous diffusion pump.
(m) Equipment which can remotely monitor, record and play back electrocardiographs and count extra systole pulses.
(n) An open-heart set with sternal spreader, staple remover, internal defibrillatory paddles, wire cutters and sufficient sutures and clamps.
(o) An intra-aortic balloon pump.
( p) An ambu bag.
2. There must be a supply of appropriate medicines stored within the intensive care facility.
3. Tele-transmitters and electronic rate counters must be used for patients with heart pacemakers while they are in the intensive care facility.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61236 Orientation and continuing education of personnel. (NRS 449.037) An approved hospital shall provide, under the direction of the cardiac surgeon, an orientation program and a program of continuing education for surgical nurses, technicians and any personnel who participate in the service for open-heart surgery.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61238 Maintenance of blood bank. (NRS 449.037) An approved hospital shall maintain a blood bank which operates 24 hours a day under the direction of qualified specialists. These persons must be able to supply blood and blood derivatives to surgical teams assigned to open-heart surgery.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.6124 Maintenance of cardiac catheterization laboratory. (NRS 449.037)
1. An approved hospital shall maintain a cardiac catheterization laboratory which operates 24 hours a day under the direction of a qualified specialist.
2. The laboratory must be located in the hospital and must have sufficient equipment to perform:
(a) Hemodynamic studies;
(b) Preoperative elective studies;
(c) Postoperative elective studies; and
(d) Emergency procedures.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61242 Maintenance of medical laboratory. (NRS 449.037) An approved hospital shall maintain a medical laboratory which operates 24 hours a day. The laboratory must have sufficient equipment to:
1. Perform standard laboratory tests;
2. Make pH determinations; and
3. Analyze samples for blood-gas and electrolytes.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61244 Maintenance of facilities to perform contrast studies and equipment to review films of operations. (NRS 449.037) An approved hospital shall maintain:
1. Facilities in which contrast studies of the cardiovascular system may be performed.
2. Film projectors and a proper filing system so that surgeons may review films of cardiac catheterization operations at any time.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61246 Maintenance of registry to record results for each patient. (NRS 449.037) A registry must be maintained at an approved hospital and used for recording the results of open-heart surgery for each patient. This registry must include or indicate, for each such patient:
1. His patient identification number.
2. His race.
3. His age.
4. His sex.
5. Any history of hypertension, smoking, diabetes mellitus, cerebrovascular disease, coronary bypass, myocardial infarction, chronic obstructive pulmonary disease or renal disease.
6. The period during which the surgery is performed.
7. The period during which the heart-lung bypass machine is used.
8. The period during which a crossclamp is in place.
9. His ASA acquity classification.
10. His New York Heart Association functional classification.
11. A record of any angioplasty performed or thrombolytic therapy.
12. A record of any use of an intra-aortic balloon pump.
13. Whether he is an elective, emergency or transfer case.
14. The number of days he is intubated.
15. The number of days he is in the cardiac surgery unit.
16. The length of his hospital stay.
17. The location to which he is discharged.
18. A record of his 30-day follow-up examination.
19. A record of his ventricular function (ejection fraction).
20. The description of the surgical procedure and, if applicable, the number of vessels involved and the type of graft (mammary or saphenous).
21. A record of any complications, including:
(a) Additional surgery for bleeding;
(b) Peri-operative myocardial infarction;
(c) Infections of the sternum, leg or intra-aortic balloon pump site; or
(d) Stroke.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61248 Maintenance of program to follow recovery of patient. (NRS 449.037) An approved hospital shall maintain a comprehensive program for following the recovery and progress of the patient toward his optimum condition of health. The condition of the patient must be assessed after discharge from the hospital by the surgeon or his designee.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.6125 Annual review and inspection of hospital. (NRS 449.037) Unless the hospital has notified the Health Division that it has ceased to perform open-heart surgeries, a surveyor of health facilities from the Health Division shall review each approved hospital annually to verify that the hospital is complying with the provisions of NAC 449.612 to 449.61256, inclusive.
(Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99)
NAC 449.61252 Annual inspection of hospital: Assessment of rate of mortality. (NRS 449.037)
1. As a part of the annual inspection of each approved hospital, the Health Division shall perform a detailed review of the patient files relating to all mortalities at the hospital.
2. In assessing whether a hospital’s adjusted rate of mortality is acceptable for the purposes of NAC 449.612 to 449.61256, inclusive, the inspection team shall fully consider, among other things, the age and sex of the patient, the acuity of the patient’s illness and the information contained in the registry maintained pursuant to NAC 449.61246.
3. As used in this section, “mortality” means the death of any patient who dies within 30 days after undergoing open-heart surgery.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61254 Further review or on-site inspection for failure to comply with provisions or for excessive rate of mortality; notice; plan for compliance. (NRS 449.037)
1. If the review conducted pursuant to NAC 449.6125 discloses that the hospital is not in full compliance with the provisions of NAC 449.612 to 449.61256, inclusive, or if a facility’s adjusted rate of mortality, after considering the factors enumerated in NAC 449.61252, is considered excessive, the Health Division may, at the expense of the hospital, require:
(a) A second review; or
(b) An on-site inspection,
Ê conducted by one or more of the persons specified in NAC 449.61208. When the Health Division has completed its final review or inspection pursuant to this subsection, it shall notify the hospital in writing of the violations and the recommendations for improvements in the hospital’s service made by the person or persons who conducted the review or inspection pursuant to this subsection.
2. Within 30 days after it receives the notice, the hospital shall reply to the Health Division in writing, indicating the measures to be taken to achieve compliance with the provisions of NAC 449.612 to 449.61256, inclusive, and to carry into effect the recommendations made by the person or persons who conducted the review or inspection pursuant to subsection 1.
3. If the Health Division determines that the hospital’s plan is satisfactory, all of the corrective actions proposed by the hospital must be completed within 90 days after the Health Division has received the plan. After that time, the Health Division may require another review of the hospital pursuant to NAC 449.6125 or a review or inspection conducted pursuant to subsection 1 of this section.
(Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99)
NAC 449.61256 Denial, suspension or revocation of approval: Grounds; hearing. (NRS 449.037)
1. The Health Division may deny, suspend or revoke its approval because of the failure of the hospital affected to comply with any provision of NAC 449.612 to 449.61256, inclusive.
2. The Health Division shall advise the hospital affected in writing whenever it intends:
(a) To deny an application for approval or for renewal of approval;
(b) To revoke approval; or
(c) To order a hospital to cease and desist providing services for open-heart surgery.
3. The hospital affected may request a hearing on the proposed action of the Health Division. The hearing must be conducted in accordance with the procedures set forth in NAC 439.300 to 439.395, inclusive.
(Added to NAC by Bd. of Health, eff. 8-31-89; A by R044-97, 10-30-97)
Transplantation of Organs
NAC 449.6126 Definitions. (NRS 449.037) As used in NAC 449.6126 to 449.6127, inclusive, unless the context otherwise requires:
1. “Approval” means the approval granted by the Health Division to a hospital authorizing it to provide a service for the transplantation of organs.
2. “Transplantation of organs” means the implantation of one or more organs from the body of a human being into the body of another as a substitute for one or more abnormally functioning organs of the recipient.
(Added to NAC by Bd. of Health, eff. 8-31-89; A 8-1-91)
NAC 449.61262 Application for approval to provide services. (NRS 449.037) An application for approval submitted pursuant to NRS 449.087 must include:
1. A statement of the kinds of organs that are to be transplanted;
2. Proof that the hospital is a member of the United Network for Organ Sharing;
3. A letter of commitment from the hospital to accept all patients eligible for the service;
4. A statement signed by the chief operating officer of the hospital that the hospital is committed to providing a service for the transplantation of organs and that an adequate budget will be maintained to ensure that the service is provided continuously for not less than 3 years;
5. A statement signed by the administrator of the hospital that:
(a) The hospital will, in testing for histocompatibility in connection with the service, use a laboratory accredited by the American Society for Histocompatibility and Immunogenetics; and
(b) The hospital maintains letters of agreement or contracts with one or more members of the Association of Organ Procurement Organizations or hospital-based organizations for the procurement of organs that comply with the standards of ethics and criteria for membership adopted by the Association of Organ Procurement Organizations, except that the hospital is not required to be a nonprofit institution; and
6. If approval for the service is required by NRS 439A.100, a copy of the letter of approval from the Director of the Department of Health and Human Services.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61264 Evaluation of application for approval. (NRS 449.037)
1. The Health Division will evaluate the application to determine whether it conforms with the requirements of NAC 449.6126 to 449.6127, inclusive. If the Health Division finds that the application is incomplete, it will inform the applicant which parts of the application are deficient.
2. If the application is found to be complete and in compliance with the provisions of NAC 449.6126 to 449.6127, inclusive, approval will be given to the hospital, effective for 5 years.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61266 Duties of hospital providing services. (NRS 449.037) A hospital that provides services for the transplantation of organs shall:
1. Supply the Health Division with the same information from the patient registry that is provided to the United Network for Organ Sharing, at the time that information is provided.
2. Comply with the representations required by NAC 449.61262.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.61268 Revocation of approval. (NRS 449.037)
1. The Health Division may revoke its approval if:
(a) The hospital fails to comply with any provision of NAC 449.6126 to 449.6127, inclusive;
(b) The United Network for Organ Sharing suspends or terminates the membership of the hospital; or
(c) The hospital resigns its membership in the United Network for Organ Sharing.
2. If the Health Division revokes its approval, the hospital affected may not reapply for approval for 2 years after the date of the revocation.
(Added to NAC by Bd. of Health, eff. 8-31-89)
NAC 449.6127 Notice of intent to deny application or revoke approval; hearing. (NRS 449.037)
1. If the Health Division intends to deny an application for approval or to revoke its approval, it shall so advise the hospital affected in writing.
2. The hospital may request a hearing on the proposed action of the Health Division. The hearing must be conducted in accordance with the procedures set forth in NAC 439.300 to 439.395, inclusive.
(Added to NAC by Bd. of Health, eff. 8-31-89; A by R044-97, 10-30-97)
INDEPENDENT CENTERS FOR EMERGENCY MEDICAL CARE
Licensing
NAC 449.61302 Limitations on issuance of license. (NRS 449.037) The Health Division shall not issue a license to operate an independent center for emergency medical care unless the center:
1. Is located more than 30 minutes by ground transportation from a facility which is licensed to provide a higher level of emergency medical care; and
2. Routinely provides limited emergency medical care or holds itself out to the general public as a facility which provides limited emergency medical care.
(Added to NAC by Bd. of Health, eff. 11-1-95; A by R044-97, 10-30-97)
NAC 449.61306 Denial of application for license or renewal of license. (NRS 449.037) An application for a license to operate an independent center for emergency medical care or for the renewal of the license may be denied if the center, employees of the center or equipment within the center do not meet the requirements of NAC 449.61302 to 449.61384, inclusive, or, in the opinion of the Health Division, threaten or potentially threaten the health or safety of the general public.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61308 Compliance with regulations; ground for suspension or revocation of license. (NRS 449.037) For the duration of his license to operate an independent center for emergency medical care, a licensee shall continuously maintain the center in compliance with the provisions of NAC 449.61302 to 449.61384, inclusive. Any violation of those provisions is a ground for the suspension or revocation of the license.
(Added to NAC by Bd. of Health, eff. 11-1-95)
Administration and Personnel
NAC 449.6132 Requirement of governing body; adoption of written rules. (NRS 449.037)
1. Except as otherwise provided in NAC 449.61322, each independent center for emergency medical care must have a governing body. The chairman of the governing body must be a person who is a principal in the organization of the center with legal authority for the operation of the center.
2. The governing body shall adopt written rules which:
(a) Prescribe criteria for the selection of the members and officers of the governing body, their terms of office and duties;
(b) Specify the frequency of the meetings of the governing body;
(c) Require the annual review and approval of the rules by the governing body; and
(d) Require the recordation of the minutes of the meetings of the governing body and provide for the availability of the minutes to all members of the body.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61322 Exception to requirements of governing body. (NRS 449.037)
1. If the licensee of an independent center for emergency medical care is a physician operator, the center operated by the licensee is not required to have a governing body or an administrator. In the absence of a governing body or an administrator, the licensee is responsible for complying with the provisions of NAC 449.61302 to 449.61384, inclusive.
2. As used in this section, “physician operator” means any physician or group of physicians:
(a) Licensed pursuant to the provisions of chapter 630 or 633 of NRS; and
(b) Operating an independent center for emergency medical care.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61324 Standards of care; policy for authentication. (NRS 449.037)
1. The governing body of an independent center for emergency medical care or, if there is no governing body, the medical director, shall ensure that:
(a) Each patient of the center receives care which is supervised by a physician licensed pursuant to the provisions of chapter 630 or 633 of NRS;
(b) Each patient of the center has a comfortable and clean environment which protects him from injury or accident;
(c) At least one physician and one registered nurse are on the premises of the center during all hours of its operation;
(d) An annual operating budget and plan for capital expenditures are established;
(e) The center is adequately staffed and equipped; and
(f ) The center maintains documents concerning the qualifications of all consultants under contract with the center and all employees of the center.
2. The governing body or, if there is no governing body, the medical director, shall establish a policy for authentication that:
(a) Authorizes the use of rubber stamps and prohibits the use of any stamp by any person other than the person whose signature the stamp represents;
(b) Approves a method for identifying the person making an entry in any record or chart; and
(c) Requires that the professional title of the person making such an entry and the date of that entry is included with the entry.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61326 Program to review quality of care; contents of program. (NRS 449.037) Each independent center for emergency medical care shall establish a program to review the quality of care provided at the center. The program must designate which person or group of persons will review the quality of care. The program must include, without limitation, a review of:
1. The documentation in the medical records of a patient which describes the medical care provided to the patient and the results of that care;
2. The time of arrival and the time the patient was seen by a provider of medical care at the center;
3. The medical condition of the patient when he was discharged from the center;
4. The appropriateness of the instructions given to the patient upon his discharge and the documentation that the patient understood the instructions; and
5. If a patient is transferred to another medical center or facility, the appropriateness of the transfer, the method of transfer, the date and time the transfer was requested and the date and time the patient was discharged from the center.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61328 Integration into local emergency medical system. (NRS 449.037) Each independent center for emergency medical care shall take all action necessary to ensure that it is integrated into the local emergency medical system for providing treatment for trauma. The integration with the local system must include:
1. The capability to communicate with ambulances, air ambulances, agency vehicles and hospitals in accordance with the local health authority as defined in NRS 450B.077;
2. Written agreements with hospitals which are licensed to provide acute medical and trauma care for the transfer of patients; and
3. A system to maintain information on each patient treated at the center which includes the external cause of injury to a patient as classified in the index of international classification of diseases.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.6133 Appointment and responsibilities of administrator. (NRS 449.037) Except as otherwise provided in NAC 449.61322, the governing body of an independent center for emergency medical care shall appoint a person to administer the center. The administrator is responsible for:
1. The daily operation of the center;
2. Serving, along with any committee appointed for the purpose of serving, as a liaison between the governing body, the medical staff and all the departments of the center;
3. Reporting the pertinent activities of the center to the governing body at regular intervals;
4. Appointing a person responsible for the center in the absence of the administrator; and
5. Planning for the services provided by the center and the operation of the center.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61332 Employment and duties of medical director. (NRS 449.037) Each independent center for emergency medical care shall employ a physician to serve as medical director of the center. Except as otherwise provided in NAC 449.61322, the director is answerable to the governing body for the quality of medical care provided to patients and the ethical and professional practices of the members of the medical staff. The director shall:
1. Create and carry out policies for the care of patients; and
2. Coordinate medical care at the center.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61334 Standards and procedures for selection, treatment and retention of medical staff and members of allied health professions. (NRS 449.037)
1. Each independent center for emergency medical care shall adopt standards and procedures for:
(a) The selection of members of the medical staff of the center;
(b) The privileges which will be accorded to members of the medical staff and members of allied health professions who provide services at the center;
(c) Appealing the withdrawal or denial of any privilege; and
(d) The reappraisal and appointment of each member of the medical staff.
2. A roster which specifies the privileges accorded each member of the medical staff must be kept in the files of the center.
3. Each member of the medical staff shall abide by the rules of the center and NAC 449.61302 to 449.61384, inclusive.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61336 Rules for organization of medical staff. (NRS 449.037) The medical staff of an independent center for emergency medical care must be organized under a set of rules approved by the governing body or, if there is no governing body, by the medical director. The rules must include:
1. An outline which describes the organization of the medical staff;
2. A statement concerning the qualifications which a member of the medical staff must possess to practice at the center;
3. A policy concerning the requirements for meetings of the medical staff, including the minimum number of meetings each member of the staff must attend each year;
4. A provision requiring, except in a medical emergency, the informed consent of a patient or his legal representative for a surgical procedure;
5. A requirement that if a patient is treated for dental or podiatric care at the center, a physician who is responsible for the medical care of the patient must be in attendance throughout the patient’s care at the center; and
6. A requirement that if any member of an allied health profession provides services at the center, his entries on the medical record of a patient must be verified by his signature.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61338 Employment and duties of chief nurse; size of on-duty nursing staff; limitation on scope of practice by person who is not registered nurse; oversight of nursing staff. (NRS 449.037)
1. Each independent center for emergency medical care shall employ a chief nurse who is a registered nurse and is responsible for the supervision and evaluation of the nursing staff and its activities. The chief nurse shall:
(a) Establish job descriptions for the nursing staff of the center;
(b) Provide for the orientation and training of the nursing staff;
(c) Evaluate the performance of the nursing staff; and
(d) Assign nurses.
2. A sufficient number of members of the nursing staff must be on duty at all times during the operation of the center to ensure:
(a) That proper care is provided to each patient; and
(b) The immediate availability of a registered nurse for the care of any patient.
3. A person who is not a registered nurse may be assigned to care for a patient to the extent consistent with his education, experience and authorized scope of practice.
4. The governing body or, if there is no governing body, the medical director, shall ensure the adequacy of treatment, medications and care provided by the nursing staff.
(Added to NAC by Bd. of Health, eff. 11-1-95)
Facilities
NAC 449.6135 Design, construction, equipment and maintenance: General requirements; prerequisites to approval for licensure. (NRS 449.037)
1. An independent center for emergency medical care must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the independent center for emergency medical care and members of the general public.
2. An independent center for emergency medical care shall comply with all applicable:
(a) Federal and state laws;
(b) Local ordinances, including, without limitation, zoning ordinances; and
(c) Environmental, health, fire and local building codes,
Ê related to the construction and maintenance of the independent center for emergency medical care. If there is a difference between state and local requirements, the more stringent requirements apply.
3. Except as otherwise provided in subsection 4, before any new construction of an independent center for emergency medical care or any remodeling of an existing independent center for emergency medical care is begun, the independent center for emergency medical care must submit building plans for the new construction or remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115. The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the independent center for emergency medical care. The Bureau shall not approve an independent center for emergency medical care for licensure until all construction is completed and a survey is conducted at the site of the independent center for emergency medical care.
4. An independent center for emergency medical care is not required to submit plans for remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115 if the remodeling is limited to refurbishing an area within the independent center for emergency medical care, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area, and replacing window or wall coverings in the area.
(Added to NAC by Bd. of Health, eff. 11-1-95; A by R035-97, 10-30-97; R076-01, 10-18-2001; R070-04, 8-4-2004)
NAC 449.61352 Contents of center: Emergency entrance; reception and waiting areas; treatment and examination rooms; space for storage and maintenance of medical records and supplies. (NRS 449.037) An independent center for emergency medical care must contain:
1. An emergency entrance located at the ground level which:
(a) Is sheltered from the weather;
(b) Can accommodate a stretcher without rotating the stretcher more than 30 degrees about the longitudinal axis or 30 degrees about the lateral axis; and
(c) Is readily identifiable as an entrance and accessible to the general public;
2. A reception area located near the entrance;
3. A waiting area for the general public with toilets, a telephone, a drinking fountain and adequate seating;
4. Treatment rooms which meet the requirements of NAC 449.61354;
5. Rooms for the general examination of patients which must:
(a) Be at least 80 square feet in area, including at least two and one-half feet of clearance at the foot and at each side of the examination table;
(b) Have at least one sink for washing hands;
(c) Be near a toilet which is located near the examination room and easily accessible for a person in a wheelchair; and
(d) Be easily accessible for a standard size stretcher with sufficient space to transfer a person onto a stretcher without jeopardizing the physical condition of the person;
6. Special examination rooms which must not be smaller in size than the general examination rooms and which are near a toilet which is easily accessible for a person in a wheelchair;
7. Treatment rooms for minor surgery, including cast procedures, which must be:
(a) At least 120 square feet in area, and at least 10 feet in length and width; and
(b) Located near a toilet which is easily accessible for a person in a wheelchair; and
8. Sufficient space for:
(a) Equipment and storage;
(b) A clean workroom with a sink for the storage and assembly of supplies for medical procedures; and
(c) Storage and maintenance of medical records.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61354 Contents of treatment rooms; accessibility to person in wheelchair. (NRS 449.037)
1. Each treatment room in an independent center for emergency medical care must contain:
(a) Cabinets for the storage of supplies and equipment;
(b) A sink for washing hands;
(c) A sink for dirty equipment or an area designated for the cleaning and handling of dirty equipment which is separate from the sink for washing hands;
(d) A work counter;
(e) Sufficient space for a stretcher; and
(f ) Emergency medical equipment and supplies necessary to perform critical procedures and resuscitation in a cardiopulmonary or traumatic emergency, including, without limitation:
(1) A device for monitoring the electrical activity of the heart with the capability of performing manual defibrillation and external cardiac pacing;
(2) Equipment for the advanced management of a patient’s airway including a laryngoscope, and blades and endotracheal tubes in sizes for infants, children and adults;
(3) A sterile tray with tracheostomy tubes in sizes for infants, children and adults necessary to create an emergency surgical airway;
(4) Sterile needles, tubing and other equipment necessary to administer intravenous and intraosseous therapy for infants and children and specialized procedures to stabilize the vital signs of a patient;
(5) Apparatus for the suction of an airway with wide-bore tubing and rigid pharyngeal suction tips and assorted sizes of sterile suction catheters;
(6) Devices to stabilize a patient’s neck in sizes for infants, children and adults; and
(7) A sterile tray and equipment necessary to insert a tube into a patient’s chest, appropriate for the age, size and sex of the patient, for drainage of the chest cavity.
2. Each treatment room must be located near a toilet which is easily accessible for a person in a wheelchair.
(Added to NAC by Bd. of Health, eff. 11-1-95)
Medical Services and Medical Records
NAC 449.6137 Requirement for minimum level of care in certain situations. (NRS 449.037) Each independent center for emergency medical care shall maintain on its premises, during all hours of operation, the staff, equipment and drugs necessary to provide an initial evaluation and stabilization of a patient of any age whose condition threatens the loss of his life, any of his limbs or his functional ability, including, without limitation, the staff, equipment and drugs necessary to enable the center:
1. To perform advanced cardiopulmonary resuscitation; and
2. To provide appropriate diagnostic radiology and clinical laboratory services.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61372 Criteria for denial of care, transfer or discharge of patient; compliance with state and federal laws. (NRS 449.037)
1. An independent center for emergency medical care shall not deny a person emergency medical care at the center because of the inability of the person to pay unless a physician has evaluated the person and determined that he does not have a medical condition which requires emergency medical care.
2. An independent center for emergency medical care shall not transfer or discharge a patient from the center unless the transfer or discharge is appropriate based upon the medical needs of the patient.
3. An independent center for emergency medical care shall comply with all applicable state and federal laws concerning the admission, discharge and transfer of patients.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61374 Laboratory services and reports; procedures for storage and administration of tissue specimens, blood and blood products; agreements with outside blood banks; review of blood transfusions and reactions. (NRS 449.037)
1. Each independent center for emergency medical care shall maintain or have available adequate laboratory services during all hours of operation provided by a medical laboratory which is licensed pursuant to chapter 652 of NRS to meet the needs of its patients and medical staff.
2. If laboratory services are provided by a laboratory outside the center:
(a) The original report of services must be provided by a laboratory which is licensed pursuant to the provisions of chapter 652 of NRS and contained in the medical record of the patient; and
(b) The conditions, procedures and availability of work performed by the laboratory must be in writing and available within the center.
3. Each independent center for emergency medical care shall ensure that each laboratory report is promptly filed in the medical record of the patient and that the physician requesting the report is notified of its availability.
4. All laboratory reports of tissue specimens must be signed by a pathologist. The medical staff of an independent center for emergency medical care and a pathologist shall determine whether a tissue specimen requires a macroscopic examination, a microscopic examination, or both.
5. If an independent center for emergency medical care provides for the storage and administration of blood and blood products:
(a) The center shall ensure that an authorized physician provides adequate control and supervision of the storage and administration; and
(b) The refrigerator for the storage of blood and blood products must:
(1) Have an adequate recording thermograph and temperature alarm system;
(2) Be regularly inspected; and
(3) Be otherwise safe and adequate to prevent the deterioration of the blood and blood products.
6. If an independent center for emergency medical care depends upon outside blood banks for the storage of blood and blood products, the center shall have an agreement with a blood bank which governs the procurement, transfer and availability of blood which is reviewed and approved by:
(a) The medical staff of the center; and
(b) The administrator and governing body of the center or, if none, the medical director of the center.
7. Each independent center for emergency medical care shall:
(a) Provide for the prompt blood typing, cross-matching and investigation of transfusion reactions; and
(b) Have a committee of the medical staff of the center review all transfusions of blood and blood derivatives and blood or blood derivative reactions which occur at the center and make recommendations concerning the policies governing these practices.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61376 Program for control of infection. (NRS 449.037) Each independent center for emergency medical care shall establish a program for the control of infection at the center, including, without limitation:
1. Policies and procedures for the control of infectious agents and diseases;
2. Methods of disposal of blood and bodily fluids; and
3. Methods of treatment of equipment and supplies contaminated with blood and bodily fluids.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61378 Radiological services: Availability; interpretation and reporting of films; storage and retention. (NRS 449.037)
1. Each independent center for emergency medical care shall provide basic radiological services performed by a person who is certified by the American Registry of Radiological Technologists or a person who has equivalent qualifications. Radiological services must be available during all hours of operation of the center to meet the needs of its patients and medical staff.
2. All X-ray films requested by a physician at an independent center for emergency medical care must be interpreted by a radiologist. The radiologist shall provide a final report for each X-ray film signed by the radiologist which must be filed with the medical record of the patient. A duplicate copy of the report must be kept within the radiology department of the center. Any positive or abnormal results from the X-ray report must be reported to the patient and the physician who requested the X ray.
3. All X-ray reports and roentgenograms must be preserved or microfilmed for at least the length of time specified in the applicable statute of limitations governing medical malpractice.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.6138 Distribution and administration of drugs and controlled substances. (NRS 449.037)
1. Each independent center for emergency medical care shall provide for the distribution and administration of drugs in conformance with all federal, state and local laws. A list of the drugs available for use at the center must be maintained.
2. All dangerous drugs and controlled substances distributed at an independent center for emergency medical care must be:
(a) Owned by and stored in a licensed pharmacy; or
(b) Owned by a licensed physician.
3. If a pharmacy is located on the premises of an independent center for emergency medical care, the pharmacy must be licensed by the State Board of Pharmacy.
4. If a pharmacy is not located on the premises of an independent center for emergency medical care, the center must contain an area for the storage, administration, quality control and dispensing of drugs. The storage area must include locked storage for drugs and double-locked storage for controlled substances, and refrigerated storage for both drugs and controlled substances. Refrigerators for the storage of drugs and controlled substances must be maintained between 36 degrees Fahrenheit and 46 degrees Fahrenheit. Room temperature for the storage of drugs and controlled substances must not exceed 86 degrees Fahrenheit. Facilities for washing hands must be located near the area of distribution.
5. A drug or controlled substance may not be administered at an independent center for emergency medical care without the order of a physician. The order must be entered in the medical record of the patient and signed by the physician. The order must include the name of the drug or controlled substance, the dosage, the time or frequency of administration and if the drug or controlled substance is not to be taken orally, the method of administration.
6. The development and training of the medical staff of an independent center for emergency medical care must include training provided by a pharmacist licensed by the State Board of Pharmacy. The training must include policies and procedures concerning the procurement, storage, repackaging and dispensing of drugs. The distribution of drugs at the center must be physically monitored at least quarterly by a licensed pharmacist, who shall report his findings and recommendations to the administrator or medical director of the center.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61382 Medical records: Maintenance; access; authorized release; completion after discharge. (NRS 449.037)
1. Each independent center for emergency medical care shall maintain medical records in accordance with accepted professional practices for each patient admitted to the center.
2. Only authorized personnel may have access to the medical records. Information contained in a medical record of a patient must not be released without the written consent of the patient or his guardian except:
(a) As required by law;
(b) Under a contract assented to by the patient with a person or entity who has agreed to pay for the medical expenses of the patient; or
(c) As otherwise provided by the agreement of admission assented to by the patient.
3. Original medical records must not be removed from an independent center for emergency medical care unless a court of competent jurisdiction authorizes their removal. A medical record may be microfilmed if the record can be legibly reproduced.
4. Each medical record must be protected from loss, destruction and unauthorized use.
5. If a licensee of an independent center for emergency medical care ceases the operation of the center, he shall notify the Health Division of the arrangements made for the safe preservation of and access to the medical records of each patient.
6. The records of each patient discharged from an independent center for emergency medical care must be completed within 30 days after the date of discharge.
(Added to NAC by Bd. of Health, eff. 11-1-95)
NAC 449.61384 Contents of medical records. (NRS 449.037) The medical record of each patient of an independent center for emergency medical care must be complete, authenticated, accurate and current. Each medical record must contain the following:
1. A complete identification of the patient, including information on his next of kin and the person or agency who is legally or financially responsible for the patient;
2. A statement concerning the admission and diagnosis of the patient;
3. The medical history of the patient;
4. Evidence of any informed consent given by the patient or his legal guardian for the care of the patient;
5. Any clinical observation of the patient, including notes of a physician, nurse or any other professional in attendance;
6. Reports of all prescribed tests and examinations of the patient;
7. Confirmation of the original diagnosis or, if the diagnosis changed, the diagnosis at the time of discharge;
8. A summary of the discharge of the patient prepared in accordance with established policy, including any provisions made for the continuing care or follow-up treatment of the patient after his discharge; and
9. If the patient has died, the documentation of death and necropsy report, if available.
(Added to NAC by Bd. of Health, eff. 11-1-95)
INTERMEDIATE CARE FACILITIES
General Provisions
NAC 449.614 Definitions. (NRS 449.037) As used in NAC 449.614 to 449.743, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.617 to 449.659, inclusive, have the meanings ascribed to them in those sections.
(Supplied in codification; A by Bd. of Health by R066-04, 8-4-2004)
NAC 449.617 “Administrator” defined. (NRS 449.037) “Administrator” means a licensee or a person appointed by the licensee who has the responsibility for the management of a facility.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.2, eff. 12-5-75]
NAC 449.620 “Developmentally disabled person” defined. (NRS 449.037) “Developmentally disabled person” means a person who has a condition manifested in childhood which is attributable to mental retardation, cerebral palsy, epilepsy or other neurological conditions similar to or requiring treatment similar to that required by mental retardation.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.3, eff. 12-5-75]
NAC 449.623 “Facility” defined. (NRS 449.037) “Facility” means an intermediate care facility.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.5, eff. 12-5-75]
NAC 449.629 “Intermediate care facility as a distinct part of a health and care facility furnishing more than one level of care” defined. (NRS 449.037)
1. “Intermediate care facility as a distinct part of a health and care facility furnishing more than one level of care” means an intermediate care facility which is an entire unit such as a clearly identifiable ward or contiguous wards, wing, floor or building consisting of all beds and related facilities in the unit and housing all intermediate care residents. It is clearly identified and is licensed by the Health Division as an intermediate care facility.
2. The distinct part may share such central services and facilities as management services, dietary, maintenance and laundry with other units.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 1.1.2 & 1.1.2.1, eff. 12-5-75]
NAC 449.632 “Intermediate care facility for the mentally retarded or persons with developmental disabilities” defined. (NRS 449.037) “Intermediate care facility for the mentally retarded or persons with developmental disabilities” means a facility which offers specialized services to the mentally retarded or persons with related conditions.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.1.1, eff. 12-5-75]
NAC 449.635 “Licensee” defined. (NRS 449.037) “Licensee” means the person, corporation, partnership, voluntary association, or other public or private organization responsible for the overall operation of an intermediate care facility.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.6, eff. 12-5-75]
NAC 449.638 “Long-term care facility” defined. (NRS 449.037) “Long-term care facility” means an intermediate care facility, a skilled nursing facility or a chronic disease hospital.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.7, eff. 12-5-75]
NAC 449.641 “Mentally retarded person” defined. (NRS 449.037) “Mentally retarded person” means a person having a condition of significantly subaverage intellectual functions existing concurrently with deficits in adaptive behavior. The condition manifests itself during the developmental period before the age of 18.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.8, eff. 12-5-75]
NAC 449.644 “Mixed facility” defined. (NRS 449.037) “Mixed facility” means a skilled nursing facility which also admits residents of an intermediate care facility who receive care and services appropriate to their needs. Residents are discriminately assigned to beds in the facility and are not assigned to a distinct part of the facility.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.9 eff. 12-5-75]
NAC 449.647 “New facility” defined. (NRS 449.037) “New facility” means an intermediate care facility which is a newly built structure or an intermediate care facility which is under new ownership.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.13, eff. 12-5-75]
NAC 449.650 “Nursing home” defined. (NRS 449.037) “Nursing home” means an intermediate care facility or a skilled nursing facility.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.10, eff. 12-5-75]
NAC 449.653 “Patient in an intermediate care facility I” defined. (NRS 449.037) “Patient in an intermediate care facility I” means a resident who requires 24-hour supervision under the care of a licensed vocational nurse but needs only periodic professional treatment, observation and evaluation.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.1.3, eff. 12-5-75]
NAC 449.656 “Patient in an intermediate care facility II” defined. (NRS 449.037) “Patient in an intermediate care facility II” means a resident who requires 24-hour supervision under the care of a registered nurse. The resident requires observation, evaluation and assistance with personal care continuously.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.1.4, eff. 12-5-75]
NAC 449.659 “Resident” defined. (NRS 449.037) “Resident” means a patient in an intermediate care facility.
[Bd. of Health, Intermediate Care Facilities Reg. § 1.12, eff. 12-5-75]
Licensing
NAC 449.668 Provisional licenses. (NRS 449.037) The Health Division may issue a provisional license to a facility which:
1. Is in operation at the time of the adoption of new regulations, to provide a reasonable time, not to exceed 1 year from the effective date of the regulations, within which to comply with the new regulations; or
2. Has failed to comply with NAC 449.614 to 449.743, inclusive, but which is in the process of making necessary changes or has agreed in writing to effect changes within a reasonable time specified by the Health Division, not to exceed 1 year.
[Bd. of Health, Intermediate Care Facilities Reg. § 2.6, eff. 12-5-75; A 12-27-77]
Administration and Personnel
NAC 449.671 Financing; liability insurance. (NRS 449.037)
1. Each facility shall:
(a) Have a sound plan for financing which assures sufficient funds to provide proper care for residents and to carry out the stated purposes, programs and services;
(b) If it is a new facility, have reasonable expectations of sufficient funds to carry it through the first 4 months of operation and be able to furnish evidence to that effect;
(c) Maintain a recognized financial accounting and reporting system which fulfills all requirements established by the Commissioner of Insurance pursuant to chapter 449 of NRS.
2. Liability insurance is required in amounts appropriate for the protection of residents, employees, volunteers and visitors to the facility. A certificate of insurance must be furnished to the Health Division as evidence that the policy is in force. Each insurance policy must contain an endorsement providing for 30 days notice to the Health Division, Capitol Complex, Carson City, Nevada 89710, before the effective date of cancellation or the nonrenewal of the policy.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 3.9-3.10.2, eff. 12-5-75]
NAC 449.674 Administrator: Qualifications. (NRS 449.037)
1. A facility must be administered by a person licensed in Nevada as a nursing home administrator, except in the case of intermediate care facilities for the mentally retarded.
2. If a hospital is qualifying as a facility, it must be administered by the administrator of the hospital.
3. The administrator shall have the necessary authority and responsibility for the management of the facility and the implementation of administrative policies.
4. The administrator may be designated as the resident services director pursuant to NAC 449.677.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 5.1-5.3, eff. 12-5-75]
NAC 449.677 Employees: General requirements. (NRS 449.037)
1. A facility must maintain methods of administrative management which assure that:
(a) There are on duty, all hours of each day, members of the staff sufficient in number and qualifications to carry out the policies, responsibilities and programs of the facility; and
(b) The numbers and categories of personnel are adequate for the number of residents and their particular needs.
2. There must be an orientation program for all new employees that includes the review of all policies of the facility. An educational program must be planned and conducted for the development and improvement of skills of all of the facility’s personnel. Records must be maintained which indicate the content of and participation in all orientation and developmental programs.
3. The administrator or any person on the professional staff of the facility must be designated as resident services director and assigned the responsibility for the coordination and monitoring of the overall plan of care for the residents.
4. The facility must maintain effective arrangements for required institutional services. There must be written agreements with outside resources in those instances where the facility does not employ a qualified professional person to render a required institutional service. The responsibilities, functions, objectives and terms of the agreement with each outside resource must be delineated in writing and signed by the administrator or authorized representative and the outside resource. These services may include physical, occupational or speech therapy and social, dental or dietetic services.
5. A designated member of the staff who is suited by training or experience must be responsible for arranging social services and for the integration of social services with other elements of the overall plan of care.
6. A member of the staff who is qualified by experience or training in directing group activities must be responsible for the program of activities.
7. A designated member of the staff who is suited by training or experience in food management or nutrition must be responsible for planning and supervising menus and meals.
8. The facility must furnish the Health Division with such information from payroll records as may be requested regarding staffing patterns.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 6.1-6.8, eff. 12-5-75]
NAC 449.680 Employees: Health; physical examinations. (NRS 449.037)
1. A facility must maintain evidence that members of the staff are free from health problems which would have a harmful effect on the residents or would interfere with the effective functioning of the program.
2. All persons employed in intermediate care facilities must have a preemployment physical examination or certification of a 3-year health record from a physician and a skin test or chest X ray for tuberculosis.
3. An annual skin test or chest X ray for tuberculosis is required after employment. If a positive skin test is found, then a chest X ray is required.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 12.1 & 12.2, eff. 12-5-75]
NAC 449.681 Employees of facility which provides care to persons with dementia: Continuing education. (NRS 449.0357, 449.037)
1. Except as otherwise provided in subsection 4, each person who is employed by a facility which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, who has direct contact with and provides care to persons with any form of dementia and who is licensed or certified by an occupational licensing board must complete the following number of hours of continuing education specifically related to dementia:
(a) In his first year of employment with a facility, 8 hours which must be completed within the first 30 days after the employee begins employment; and
(b) For every year after the first year of employment, 3 hours which must be completed on or before the anniversary date of the first day of employment.
2. The hours of continuing education required to be completed pursuant to this section:
(a) Must be approved by the occupational licensing board which licensed or certified the person completing the continuing education; and
(b) May be used to satisfy any continuing education requirements of an occupational licensing board and do not constitute additional hours or units of required continuing education.
3. Each facility shall maintain proof of completion of the hours of continuing education required pursuant to this section in the personnel file of each employee of the facility who is required to complete continuing education pursuant to this section.
4. A person employed by a facility which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, is not required to complete the hours of continuing education specifically related to dementia required pursuant to subsection 1 if he has completed that training within the previous 12 months.
5. As used in this section, “continuing education specifically related to dementia” includes, without limitation, instruction regarding:
(a) An overview of the disease of dementia, including, without limitation, dementia caused by Alzheimer’s disease, which includes instruction on the symptoms, prognosis and treatment of the disease;
(b) Communicating with a person with dementia;
(c) Providing personal care to a person with dementia;
(d) Recreational and social activities for a person with dementia;
(e) Aggressive and other difficult behaviors of a person with dementia; and
(f ) Advising family members of a person with dementia concerning interaction with the person with dementia.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
REVISER’S NOTE.
The regulation of the Board of Health filed with the Secretary of State on August 4, 2004 (LCB File No. R066-04), the source of this section (section 22 of the regulation), contains the following provisions not included in NAC:
“1. Each person who on August 4, 2004, is employed by a facility which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, and who is required to complete the hours of continuing education specifically related to dementia required pursuant to section 22 of this regulation [NAC 449.681], shall complete at least 8 hours of continuing education specifically related to dementia within 12 months after August 4, 2004, unless the person has completed the training within the 12 months before August 4, 2004.
2. Evidence that such a person has completed the training required pursuant to subsection 1 must be included in his personnel file and must be kept at the facility.”
Construction and Operation: Generally
NAC 449.685 Design, construction, equipment and maintenance: General requirements; prerequisites to approval of facility for licensure. (NRS 449.037)
1. A facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the facility and members of the general public.
2. Except as otherwise provided in this section and NAC 449.732 to 449.743, inclusive:
(a) A facility shall comply with the provisions of NFPA 101: Life Safety Code, adopted by reference pursuant to NAC 449.0105.
(b) Any new construction, remodeling or change in the use of a facility must comply with the Guidelines for Design and Construction of Hospital and Health Care Facilities, adopted by reference pursuant to NAC 449.0105, unless the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area, and replacing window or wall coverings in the area.
3. A facility shall be deemed to be in compliance with the provisions of subsection 2 if the facility is licensed on February 1, 2004, the use of the physical space in the facility is not changed and there are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the public health and welfare.
4. Except as otherwise provided in subsection 5, a facility shall comply with all applicable:
(a) Federal and state laws;
(b) Local ordinances, including, without limitation, zoning ordinances; and
(c) Life safety, environmental, health, fire and local building codes,
Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply.
5. A facility which is inspected and approved by the State Public Works Board in accordance with the provisions set forth in chapter 341 of NRS and chapter 341 of NAC is not required to comply with any applicable local building codes relating to the construction and maintenance of the facility.
6. A facility shall submit building plans for new construction or remodeling to the entity designated to review such plans by the Health Division pursuant to NAC 449.0115. The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the facility. Before the construction or remodeling may begin, the plans for the construction or remodeling must be approved by the Health Division. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.692 Sanitary requirements. (NRS 449.037)
1. A facility must meet all state and local environmental health standards.
2. The quality and type of food service equipment must be appropriate to the type of food service program and approved by fire and health authorities.
3. Environmental health inspection reports must be on file in the facility and note the date and nature of the correction of any deficiency within a reasonable period following the report not to exceed 3 months. Copies of reports must be sent by the inspector to the Health Division.
4. Cleaning of the premises and equipment must be performed as needed to protect the health of the residents and staff. The facility must have the necessary cleaning and maintenance equipment with storage facilities and appropriate procedures for regular cleaning and routine maintenance as evidenced by a clean establishment maintained in good repair. Cleaning equipment, cleaning agents, aerosol cans and other hazardous chemical agents must be stored in areas separate from clean linen, food and other supplies and be inaccessible to residents. Dirty linen storage must be separate from the storage of clean linen, food and other supplies. Items for personal use, such as combs, toothbrushes, towels, bar soap and other similar items, must not be used in common.
5. Soap dispensers and individual disposable towels must be provided at all lavatories and bathrooms designated for use by the staff or the public.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 11.1-11.4, eff. 12-5-75]
NAC 449.695 Laundry requirements. (NRS 449.037)
1. Adequate facilities must be provided for the proper and sanitary washing and finishing of linen and other washable goods laundered in the intermediate care facility. The laundry must be situated in an area which is separate and apart from any room where food is stored, prepared or served. The laundry area must be well lighted and ventilated, adequate in size for the needs of the facility, maintained in a sanitary manner and kept in good repair.
2. The temperature of water entering the washer must be 140°F to 150°F (60°C to 65°C).
3. All soiled linen must be collected and transported to the laundry in washable containers in a sanitary manner. Soiled laundry must not be transported through areas used for preparing or serving food. Soiled linen must be handled and stored in such a manner as to prevent contamination of clean linen. A secure area must be provided for the storage of laundry supplies.
4. Clean linen to be stored, dried, ironed or folded must be handled in a sanitary manner. Clean linen must be transferred, stored and distributed in a sanitary manner. Closets which are conveniently located must be provided on each floor for the storage of clean linen and must not be used for any other purpose.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 11.5-11.7.2, eff. 12-5-75]
NAC 449.698 Fire inspections; hazardous conditions; operation of other business. (NRS 449.037)
1. At the time of application for a license and at least annually, all facilities must be inspected by the fire or building authority having jurisdiction to ensure that fire and safety requirements are being met. The Health Division may request a fire inspection at any time it deems appropriate.
2. No facility may be located where surrounding conditions may be hazardous to the physical or mental well-being of residents.
3. No other business detrimental to the facility may be conducted on the premises.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 13.4-13.6, eff. 12-5-75]
NAC 449.701 Preparations for emergencies; reporting of fire or disaster. (NRS 449.037)
1. A facility must have a written and regularly rehearsed disaster preparedness plan for members of the staff and residents to follow in case of fire, explosion or other emergency.
2. There must be written procedures for personnel to follow in an emergency, including:
(a) The care of the residents and emergency coverage by physicians;
(b) The notification of attending physicians and other persons responsible for the residents;
(c) Arrangements for transportation for hospitalization or other appropriate services; and
(d) Arrangements to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water.
3. A facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 3.6-3.7.3, eff. 12-5-75]—(NAC A by R066-04, 8-4-2004)
NAC 449.704 Written policies and procedures for facility; admission agreements; transfer agreements. (NRS 449.037)
1. A facility must have written policies and procedures available to the members of the staff, residents and the public which govern all areas of services provided by the facility.
2. The policies for the admission, transfer and discharge of residents must assure that:
(a) Only those persons are accepted whose needs can be met by the facility directly, in cooperation with community resources or other providers of care with which it is affiliated or has contracts;
(b) As changes occur in their physical or mental condition, necessitating service or care which cannot be adequately provided by the facility, residents are transferred promptly to hospitals, skilled nursing facilities or other appropriate facilities; and
(c) Except in the case of an emergency, the resident, his next of kin, attending physician and the responsible agency, if any, are consulted in advance of the transfer or discharge of any resident, and casework services or other means are utilized to assure that adequate arrangements exist for meeting his needs through other resources.
3. An admission agreement may not provide the licensee the right to act in behalf of the resident in legal matters or be given general power of attorney, except in the case of a person remanded to the custody of the Division of Mental Health and Developmental Services.
4. The written policies of the facility must set forth the rights of residents, prohibit their mistreatment or abuse, and provide for the registration and disposition of complaints without threat of discharge or other reprisal against any employee or resident.
5. Every facility must have in effect a transfer agreement with one or more hospitals sufficiently close to the facility to make feasible the transfer between them of residents and their records. Any facility which does not have such an agreement in effect but has attempted in good faith to enter into such an agreement with a hospital is considered to have an agreement if it is in the public interest and essential to assuring services for eligible persons in the community.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 3.1-3.4.1, eff. 12-5-75]
NAC 449.707 Money of residents. (NRS 449.037)
1. A written account, available to residents and their families, must be maintained on a current basis for each resident with written, signed and dated receipts for:
(a) All personal possessions and money received by or deposited with the facility.
(b) All disbursements made to or on behalf of the resident. The purpose of the disbursement must be noted on the receipt.
2. Receipts for each resident must be kept in each resident’s personal needs envelope or otherwise safely and systematically filed.
3. A ledger must be maintained for the handling of residents’ personal money. The beginning ledger sheet must be credited with the resident’s money on hand. The ledger must be kept current. Personal needs money is for the exclusive personal use of the resident. The ledger and receipts for each resident must be made available for review upon the request of the Health Division.
4. If the resident is managing his own personal money, the money must be turned over to anyone at the request of the resident. A signed, itemized and dated receipt from anyone receiving the resident’s personal money is required for deposit in the resident’s personal envelope or other file.
5. If a resident is unable to manage his own money, there must be legal authority, such as appointment as conservator, guardian or trustee, for a relative or other person to carry out these acts for the resident.
6. Except as otherwise provided in this subsection, no licensee or employee of a facility may accept appointment as guardian, or conservator, of the estate of any resident or become a substitute payee for any payments made to any resident, or accept power of attorney. If a resident is legally determined to be unable to manage his money, his sole source of money is in the form of monthly benefit checks, and documentary evidence can be produced which shows that efforts to obtain a legal guardian for the resident have failed, this requirement may be waived to the extent that the facility may be the substitute payee on the checks.
7. All money held by the facility on behalf of residents must be maintained in a financial institution in the community where the facility is located in a separate trustee account apart from the operating accounts of the facility and must be clearly designated. Small amounts may be kept on hand by the facility for the incidental personal use of a resident. Upon the death of a resident, a receipt must be obtained from the resident’s personal representative or from a relative who presents an affidavit under the provisions of NRS 146.080 before releasing the balance of the personal needs money.
[Bd. of Health, Intermediate Care Facilities, Reg. §§ 3.5-3.5.8.2, eff. 12-5-75]
NAC 449.710 Inventory of residents’ belongings. (NRS 449.037)
1. There must be an inventory of the personal belongings of a resident upon admission which is made a part of the resident’s record and updated as needed. All personal belongings, especially items of clothing, must carry permanent identification of ownership.
2. Provision must be made on the premises for the temporary safe storage of a resident’s valuables. Residents must be encouraged to store their valuables off the premises, such as in a safe-deposit box. Every facility must take appropriate measures to safeguard and account for the personal articles of residents and any cash entrusted to the care or control of the licensee.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 3.14-3.15.1, eff. 12-5-75]
NAC 449.713 Program requirements. (NRS 449.037)
1. A facility must maintain arrangements through which medical, dental and remedial services, such as laboratory services or X-ray, required by the resident but not regularly provided within the facility, may be obtained when needed.
2. The facility must provide, according to the needs of each resident, specialized and supportive rehabilitative services either directly or through arrangements with qualified outside resources.
3. These services must be provided under a written plan of care:
(a) Based on the attending physician’s orders;
(b) Based on an assessment of the resident’s needs;
(c) Which is reviewed regularly, noting a resident’s progress; and
(d) Which is altered or revised as necessary.
4. Services must be provided in accordance with accepted professional practices by qualified therapists or by qualified assistants or other supportive personnel under appropriate supervision.
5. Areas utilized to provide therapy services must be of sufficient size and appropriate design to accommodate necessary equipment, conduct examinations and provide treatment.
6. The facility must provide social services as needed by the residents either directly or by written arrangement with an outside source. A designated member of the staff who is qualified by training or experience must be responsible for implementing and coordinating social services. A plan for social services must be recorded in the patient’s record and must be periodically evaluated in conjunction with the total plan of care for the resident.
7. The facility must provide a program of activities.
8. A plan for independent and group activities must be developed for each resident in accordance with his needs and interests. The program of activities must be incorporated in the overall plan of care for the resident. The program must be reviewed with the participation of the resident at least quarterly and altered as needed.
9. Adequate recreational areas must be provided and sufficient equipment and materials must be available.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 4.1-4.4.2.1, eff. 12-5-75]
NAC 449.716 Dietary services. (NRS 449.037)
1. At least three meals or their equivalent must be served daily at regular times with not more than 14 hours between a substantial evening meal and breakfast. A second serving must be provided for those residents who desire one.
2. Therapeutic diet menus must be planned by a qualified dietitian or be reviewed and approved by the attending or staff physician.
3. Menus must be planned and followed to meet the nutritional needs of the residents in accordance with the orders of a physician and, to the extent medically possible, in accordance with the recommended dietary allowances of the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences. Menus must be in writing, planned at least a week in advance, dated, posted and kept on file for 90 days. Any substitutions on a menu must be noted on the written menu so that the menu on file reflects what was actually served.
4. Adequate facilities and equipment for the preparation, serving, refrigeration and storage of food in a sanitary manner must be provided.
5. A facility with more than 10 clients shall:
(a) Comply with all applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto;
(b) Obtain the necessary permits from the Bureau of Health Protection Services of the Health Division;
(c) Maintain a report of each inspection concerning the sanitation of the facility for at least 1 year after the date of the inspection; and
(d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action.
6. Residents needing special equipment, implements or utensils to assist them when eating must have those items provided.
7. Where a facility operates on the cottage plan, provision must be made for food service that ensures hot, palatable meals. If the cottage plan provides for a central dining area, walkways to the dining area providing protection from the elements must be provided.
8. A qualified professional person must be used as a consultant on meal planning and food service. Four hours of consultation each month is the minimum requirement. A qualified person is:
(a) A person who is registered as a dietician with the Commission on Dietetic Registration of the American Dietetic Association; or
(b) A graduate from an accredited college with a major in food and nutrition who has 2 years of supervisory experience in health care institutions or who has participated in a food service supervisor’s course.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 8.1-8.7.1.2, eff. 12-5-75]—(NAC A by R066-04, 8-4-2004)
NAC 449.719 Health services. (NRS 449.037)
1. A facility must provide health services which assure that each resident receives treatments, medications, diets and other health services as prescribed and planned, all hours of each day.
2. Immediate supervision of the health services of the facility on all days of each week must be provided by a registered nurse employed full time on all day shifts. The nurse must be licensed to practice in Nevada. In the case of facilities which serve less than 20 intermediate care facility II patients, a licensed practical or vocational nurse may serve as the supervisor of health services, if consultation is provided by a registered nurse, licensed to practice in Nevada, through formal contract, at regular intervals, but not less than 4 hours weekly. Either a registered nurse or a licensed practical or vocational nurse licensed to practice in Nevada must be employed on the night shift on all days of each week. Intermediate care facilities for the mentally retarded are exempt from this requirement.
3. At least two members of the staff must be on duty and awake at all times to assure prompt, appropriate action in cases of injury, illness, fire or other emergencies. Intermediate care facilities for the mentally retarded with less than 16 beds are exempt from this requirement.
4. A written health care plan must be developed and implemented by appropriate members of the staff for each resident. The levels of care must be no less than those stated in section 501.3 of Chapter V of the Welfare Division Medicaid Manual. The plan must be reviewed and revised at least quarterly.
5. Nursing services, including restorative nursing, must be provided in accordance with the needs of the residents.
6. Hours for nursing care must be at least 0.25 hours per resident for an intermediate care facility I and at least 1.25 hours per resident for intermediate care facility II.
7. Immediate supervision in an intermediate care facility for the mentally retarded which is licensed for 16 or more beds must be by a currently licensed registered nurse or licensed practical nurse on all day shifts. Facilities in which a licensed practical nurse serves as the supervisor of health services must contract with a registered nurse for at least 4 hours of weekly consultation. Facilities with not more than 15 beds with residents certified by a physician as not in need of professional nursing services must have a formal contract with a registered nurse to visit as required for minor illnesses, injuries or emergencies. There must be a responsible member of the staff immediately available to all residents at all times.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 7.1-7.6.1.1, eff. 12-5-75]
NAC 449.722 Pharmaceutical services. (NRS 449.037)
1. If a facility does not employ a licensed pharmacist, it must have formal arrangements with a licensed pharmacist to provide consultation on methods and procedures for ordering, storage, administration, disposal and recording of drugs and biologicals.
2. Medications administered to a resident must be ordered either in writing or orally by the resident’s attending or staff physician. Oral orders by a physician for prescription drugs must be given only to a licensed nurse, pharmacist or physician. All oral orders for medication must be recorded, signed by the person receiving them and countersigned by the attending physician within 72 hours.
3. Medications not specifically limited as to time or number of doses when ordered must be controlled by automatic stop orders or other methods in accordance with written policies. The attending physician must be notified.
4. Self-administered medication is allowed only with the permission of the attending physician of the resident.
5. The pharmacist and a registered nurse shall review each drug regimen of a resident monthly and shall notify the physician if problems occur or changes are appropriate.
6. Drug regimens must be reviewed quarterly by the attending or staff physician.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 9.1-9.5.1, eff. 12-5-75]
NAC 449.725 Records. (NRS 449.037)
1. A facility must maintain an organized system for keeping residents’ records. A resident’s records must be available to professionals and other members of the staff who are directly involved with the resident. The records must be available to representatives of the Health Division.
2. The record for each resident must include the following:
(a) Information, relating to the resident’s identification.
(b) Admission data, including past medical and social history.
(c) Copies of initial and periodic examinations, evaluations and progress notes.
(d) Assessments and goals of each plan of care and modifications to the plan.
(e) Discharge summaries.
(f ) An overall plan of care describing the goals to be accomplished through individually designed activities, therapies and treatments.
(g) The plan of care must indicate which professional service or person is responsible for the care or service.
(h) Entries describing treatments and services rendered.
(i) Medications administered.
( j) All symptoms and other indications of illness or injury, including the date, time and action taken regarding each such incident.
3. Records must be adequately safeguarded against destruction, loss or unauthorized use.
4. Records must be retained for a minimum of 3 years following the discharge of a resident.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 10.1-10.4, eff. 12-5-75]
NAC 449.728 Supervision by physician; volunteers; advertising. (NRS 449.037)
1. A facility must maintain policies and procedures to assure that each resident’s health and care is under the continuing supervision of a physician who sees the resident as needed and in no case less often than every 60 days unless justified otherwise and documented by the attending physician.
2. Volunteers and volunteer groups may be used to supplement the services and programs of the facility. Volunteers may not be used to provide basic services to residents.
3. Residents may perform such duties and tasks as are consistent with their plans of care.
4. Advertising and promotional materials must be accurate and must not misrepresent accommodations, services or programs offered by the facility.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 3.8, 3.11-3.13, eff. 12-5-75]
NAC 449.731 Discrimination prohibited. (NRS 449.037) No facility accepting a person for resident care, for whom all or part of the payment for care is made from funds of the Division of Welfare and Supportive Services or any other agency funded in whole or part by federal funds, may deny admission to a prospective resident on the grounds of race, color or national origin. No resident may be segregated, given separate treatment, restricted in the enjoyment of any advantage or privilege enjoyed by others under the program or provided with any aid, care services or other benefits which are different or provided in a different manner from that provided to others under the program, on the grounds of race, color or national origin. Employment practices, including, but not limited to, hiring, discharge, rate of remuneration, assignments or work hours scheduled, may not be based on discriminatory grounds.
[Bd. of Health, Intermediate Care Facilities Reg. § 15.1, eff. 12-5-75]—(Substituted in revision for NAC 449.746)
Construction and Operation: Facilities for Mentally Retarded or Persons With Developmental Disabilities
NAC 449.732 Definitions. (NRS 449.037) As used in NAC 449.732 to 449.743, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.7322 and 449.7324 have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7322 “Facility” defined. (NRS 449.037) “Facility” means an intermediate care facility for the mentally retarded or persons with developmental disabilities with 17 or more beds.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7324 “New facility” defined. (NRS 449.037) “New facility” means a facility which is newly built or a facility which is under new ownership.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7326 Standards for construction, remodeling or change in use of facility; fire alarms; emergency radio system; submission and approval of building plans. (NRS 449.037)
1. The construction of a new facility or the remodeling or change in use of an existing facility must be in accordance with the most recently adopted local building codes and NFPA 101: Life Safety Code adopted by reference pursuant to NAC 449.0105.
2. Fire alarms must be manually operated and connected to an electrically supervised system. Each alarm signal must be coded to indicate the location of the station of origin.
3. The facility must contain a device for emergency radio communications to be prepared for disasters.
4. The radio system must be self-sufficient in an emergency and be capable of operation without reliance on the building’s service or the emergency power system. The radio system must be linked with state and community communication networks.
5. Building plans for the construction of a new facility, for remodeling or for the change in use of an existing facility must be submitted to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115. The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the facility.
6. The Health Division shall not approve the plans for licensing until all construction has been completed and a survey is conducted at the site.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7328 Elevators. (NRS 449.037)
1. All facilities with services for patients or bedrooms located on floors other than the floor of the main entrance must have elevators.
2. At least one elevator of the type used in hospitals must be provided if 1 to 59 patients are located on floors other than the floor of the main entrance. Two elevators must be provided if 60 to 200 patients are located on floors other than the floor of the main entrance. Three elevators must be provided if 201 to 350 patients are located on floors other than the floor of the main entrance. For facilities with more than 350 beds, the number of required elevators will be determined by a study of the plan of the hospital and the estimated need for vertical transportation.
3. The cars of the elevators must have inside dimensions that will accommodate a patient’s bed and attendants and must be at least 5 feet (1.52 meters) wide and 7 1/2 feet (2.29 meters) deep.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.733 Electrical systems. (NRS 449.037)
1. All electrical installations and systems must be tested to show that the equipment is installed and operates as planned or specified. A written record of tests on electrical systems and equipment must be supplied to the owner.
2. All spaces occupied by people, machinery and equipment within buildings, approaches to buildings and parking lots must have lighting. Rooms for patients must have general lighting. All switches for lighting in patient areas must operate quietly.
3. If fuel is stored for an emergency generator, the storage capacity must be sufficient for at least 24 hours of continuous operation.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7332 Mechanical systems. (NRS 449.037)
1. Before the completion and acceptance of a facility, all mechanical systems must be tested, balanced and operated to demonstrate to the owner or his representative that the installation and performance of the systems conform to the requirements of the plans and specifications.
2. The owner must be furnished with a complete set of operating maintenance and preventative maintenance instructions and parts listed with numbers and descriptions for each piece of equipment.
3. Facilities must be built and maintained in accordance with NFPA 101: Life Safety Code adopted by reference pursuant to NAC 449.0105.
4. All air supply and air exhaust systems must be mechanically operated.
5. Hot water must be:
(a) Maintained at a temperature of:
(1) Not more than 125°F (52°C) for clinical use;
(2) Not more than 180°F (82°C) for dishwashing;
(3) Not more than 110°F (43°C) for toilet, bath and shower areas and any lavatories equipped for washing hands which are used by patients; and
(4) At least 150°F (66°C) for use in the laundry.
(b) Provided with at least 25 pounds of pressure.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7334 Doors, windows, ceilings, walls and floors. (NRS 449.037)
1. All rooms for occupancy by patients must be equipped with doors and hardware which permit access from the outside in any emergency.
2. The minimum width of all doors to those rooms must be 3.66 feet (111.7 centimeters). Doors to the toilet rooms of patients and other rooms needing access for wheelchairs must have a minimum width of 2.83 feet (86.3 centimeters). Doors opening onto corridors must not swing into the corridor unless they lead to spaces that are not occupied.
3. Windows and outer doors which may frequently be left open must be provided with screens for protection against insects.
4. Safety glass or plastic glazing materials must be used for shower doors, bath enclosures and in doors and windows of rooms for patients.
5. The height of a ceiling must be 8 feet (2.44 meters) in rooms which are occupied. Ceilings in storage rooms, corridors, toilet rooms and other minor rooms may have a height of 7.5 feet (2.29 meters) but may not have any projection lower than 7 feet (2.13 meters).
6. Flooring materials must be easily cleaned and maintained in good repair. Floors in areas subject to wet cleaning must not be physically affected by germicidal and cleaning solutions. Nonslip surfaces must be provided for areas subject to traffic while wet. Wall bases in kitchens and operating and delivery rooms must be integrated with the floor.
7. Wall finishes must be washable. Walls around plumbing fixtures must be resistant to moisture. Walls and floors must be free from cracks and holes.
8. Ceilings must be easily cleaned. Areas for preparing food must have ceilings which cover all overhead piping and ductwork. Acoustical ceilings must be provided in corridors in patient areas, nurses’ stations, dayrooms, dining areas and waiting rooms. If acoustical ceilings cannot be provided, other methods of eliminating excessive noise and echoing must be used.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7336 Entrances and lobbies; miscellaneous space. (NRS 449.037)
1. The entrance to administrative and public areas must be at grade level, sheltered from the weather and capable of accommodating wheelchairs if no other access for wheelchairs is available.
2. The lobby must include a reception or information counter, waiting space for the public, toilet facilities, public telephones, a drinking fountain and storage space for wheelchairs.
3. The area used for interviews must be conveniently available to the lobby.
4. A space for a business office, a multipurpose room and adequate storage space must be provided.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7338 Dining and storage space. (NRS 449.037)
1. Dining space of 15 square feet (1.39 square meters) per seated person must be provided for ambulatory patients, staff and visitors.
2. Storage space must be provided for housekeeping equipment and supplies.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7342 Facilities for employees and volunteers. (NRS 449.037) In addition to the facilities for employees required in certain departments, all employees and volunteers must have lockers, lounges and toilets to accommodate their needs.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7344 Areas for engineering and maintenance. (NRS 449.037)
1. A room or separate building for boilers, mechanical equipment and electrical equipment must be provided.
2. An area for an engineer’s office and maintenance shop must be provided.
3. A toilet and emergency shower must be provided in the engineering area.
4. Storage for supplies for the maintenance of the building must be provided.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7346 Janitors’ closets. (NRS 449.037)
1. In addition to the janitors’ closets required in certain departments, janitors’ closets must be provided throughout the facility to maintain a clean and sanitary environment.
2. At least one janitors’ closet must be provided for each nursing unit and for each floor.
3. A janitors’ closet must contain a floor receptor or service sink and storage space for housekeeping equipment and supplies.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7348 Linen service. (NRS 449.037)
1. If linen is processed at the facility, there must be equipment which can process a 7-day supply within a regularly scheduled workweek.
2. There must be a room for receiving, holding and sorting soiled linen, with facilities for washing hands immediately available. An area for storing clean linen must be provided. Areas for inspecting, mending and issuing clean linen must be provided. Storage areas for laundry supplies must be provided.
3. If linen is processed outside the facility, only a holding room for soiled linen and a storage room for receiving, holding and inspecting clean linen need to be provided.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.735 Area for medical records. (NRS 449.037) An area for working on and storing medical records must be provided.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7352 Nursing units. (NRS 449.037)
1. Nursing units must be limited to 60 beds. The maximum room capacity is two patients.
2. The minimum area for a room, exclusive of toilet rooms, closets, lockers, wardrobes and vestibules of less than one-half of the width of a room, is 100 square feet (9.29 square meters) in rooms with one bed and 80 square feet (7.43 square meters) per bed in multibed rooms. In multibed rooms, there must be at least 3.66 feet (1.12 meters) of clear area at the foot of each bed and at least 5 feet (1.5 meters) of clear area between each bed. No more than two beds may be beside one another, parallel to the wall with a window.
3. Each patient must have access to a toilet and lavatory without entering the general corridor. One toilet and lavatory may serve no more than four beds and no more than two patients’ rooms.
4. Each patient must have a wardrobe, locker or closet with clear internal dimensions of at least 1.83 feet (55.9 centimeters) by .83 feet (25.4 centimeters) with a shelf and enough vertical height to hang full-length garments.
5. A patient’s room must not be located more than 120 feet (36.58 meters) from:
(a) The nurses’ station; and
(b) The clean and soiled workrooms.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7354 Service areas. (NRS 449.037)
1. Space must be provided at the nursing station for charting, communication systems and necessary equipment and storage.
2. Lavatories and toilets for the staff must be conveniently located near the nursing station.
3. A clean workroom must be provided for the storage and assembly of supplies for nursing procedures. The room must contain a work counter and a sink equipped with blade-type faucets.
4. A soiled workroom must be provided and contain a clinical sink, work counter and receptacles for waste and soiled linen.
5. A medicine room conveniently located near the nursing station must contain a sink equipped with blade-type faucets, a refrigerator, locked storage and facilities for the preparation and dispensing of medication. A double-locked area must be provided for controlled substances. The clean workroom and medicine room may be combined. The medicine room may be a self-contained cabinet located in the clean workroom.
6. A nourishment station or carts for supplying nourishment and ice to the patients must be provided.
7. A bathtub or shower must be provided at the rate of one for each 12 beds which are not otherwise served by bathing facilities within the patients’ rooms. Each central bathing tub or shower must be in a room or enclosure which provides space for private use of the bathing fixture, drying and dressing. The tub and shower must have a nonskid floor. At least one bathing area on each floor must have space for a wheelchair and an attendant. A toilet must be accessible from each central bathing area without entering a general corridor. This toilet may be used as a training toilet.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.7356 Processing of waste. (NRS 449.037) Space and facilities must be provided for the sanitary storage and disposal of waste by mechanical destruction, compaction, containerization or removal by a combination of these techniques.
(Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004)
NAC 449.736 Personnel. (NRS 449.037)
1. A facility for the mentally retarded or persons with developmental disabilities must be administered by a person with sufficient authority and responsibility to manage the facility and implement administrative policy. The administrator must be a currently licensed nursing home administrator, a qualified mental retardation professional or a hospital administrator if a hospital is qualifying as an intermediate care facility for the mentally retarded.
2. A qualified professional in mental retardation must be one of the following:
(a) A psychologist with at least a master’s degree from an accredited program with specialized training or 1 year of experience in treating the mentally retarded;
(b) A currently licensed physician or osteopath with the training or experience described in paragraph (a);
(c) An educator with a degree from an accredited program with the training or experience described in paragraph (a);
(d) A social worker with either a bachelor’s degree in social work or a bachelor’s degree in a field other than social work and with the training or experience described in paragraph (a);
(e) A qualified physical or occupational therapist with the training or experience described in paragraph (a);
(f ) A speech pathologist or audiologist with the training or experience described in paragraph (a);
(g) A registered nurse with the training or experience described in paragraph (a); or
(h) A therapeutic recreational specialist who is a graduate of an accredited program and with the training or experience described in paragraph (a).
3. Each facility shall retain a qualified mental retardation professional who is responsible for:
(a) Supervising the implementation of each resident’s plan of care;
(b) Integrating the facility’s total program;
(c) Recording each resident’s progress; and
(d) Initiating a quarterly review of each resident’s plan of care.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 16.2-16.4.4, eff. 12-5-75]—(Substituted in revision for NAC 449.734)
NAC 449.737 Plan of care. (NRS 449.037)
1. Each resident in a facility for the mentally retarded or persons with developmental disabilities must be a regular participant in an individual plan of care which must be prepared in written form by an interdisciplinary team consisting of at least a physician, a social worker, a qualified professional in mental retardation and such other professional specialists indicated in unusual cases.
2. The plan of care must:
(a) Contain a complete medical, social and psychological evaluation of the resident;
(b) Indicate the resident’s need for institutional care;
(c) Be stated in quantifiable terms and made available to the members of the staff who implement its provisions; and
(d) Prescribe an individually designed integrated program of therapies, experiences, activities or training.
Ê The ultimate goal of any plan of care is the maximal normalization of the resident.
3. Each resident’s plan of care must be reviewed at least quarterly by the interdisciplinary team. This review must include:
(a) A review of the resident’s progress toward the objectives of the plan;
(b) An evaluation of the appropriateness of the elements of the plan;
(c) An assessment of the need for continuing institutional care; and
(d) A consideration of alternate methods of care.
4. If an interdisciplinary team determines that a resident no longer requires institutional care, a postinstitutional plan must be written by a qualified mental retardation professional and other appropriate professionals providing for appropriate services, protective supervision where necessary, and other follow-up services in the resident’s new environment. A summary must be placed in the resident’s file.
5. The facility must provide or arrange for the provision of the services of qualified professionals as indicated in the resident’s individualized plan of care. Available services must include, but are not limited to:
(a) Physical and occupational therapy;
(b) Psychological services;
(c) Social services;
(d) Speech pathology and audiology;
(e) Organized recreational activities; and
(f ) Physician’s services, including:
(1) An annual physical examination; and
(2) Formal arrangements for 24-hour emergency treatment every day of the week.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 16.5-16.7 & 16.14-16.14.6.2, eff. 12-5-75]
NAC 449.740 Corporal punishment; restraints. (NRS 449.037)
1. Corporal punishment of residents in a facility for the mentally retarded or persons with developmental difficulties by members of the staff or other residents is prohibited.
2. Physical restraints may not be used except as absolutely necessary for the safety of the resident, his peers or the staff and then only under the following conditions:
(a) The facility shall have a written policy clearly stating the conditions under which restraint may be employed and enumerating which members of the staff may authorize its use;
(b) No restraint may remain in force for more than 12 hours;
(c) A resident in restraint must be checked at least every 30 minutes by trained members of the staff and a written record of these checks must be maintained;
(d) The restraint file must be reviewed daily by the administrator or his appointee and a copy of the record placed in the resident’s file; and
(e) The restraints used must be designed so as not to cause physical injury or great discomfort to the resident. A resident must be released from restraint for at least 10 minutes of every 2-hour period they are restrained.
3. Any totally enclosed crib or other barred enclosure is considered a restraining device.
4. Excessive chemical restraints must not be employed for the convenience of members of the staff.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 16.10-16.13, eff. 12-5-75]
NAC 449.743 Records. (NRS 449.037)
1. A file must be maintained for each resident in a facility for the mentally retarded or persons with developmental disabilities which contains:
(a) Identification information;
(b) The resident’s legal status;
(c) Admission data;
(d) Past medical, developmental and social history;
(e) Copies of all facility examinations and evaluations of the resident or his plan of care; and
(f ) A discharge summary.
Ê Entries must be made noting any treatments or services rendered, medications administered or symptoms of illness or injury.
2. Residents’ records must be secured against loss, destruction or unauthorized use. The records must be made available to licensing and certification authorities upon request.
[Bd. of Health, Intermediate Care Facilities Reg. §§ 16.8 & 16.9, eff. 12-5-75]
COMMUNITY TRIAGE CENTERS
NAC 449.74311 Definitions. (NRS 449.037) As used in NAC 449.74311 to 449.74375, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.74313 to 449.74325, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74313 “Administrator” defined. (NRS 449.037) “Administrator” means the person who is appointed by the governing body of a facility who has primary responsibility for the overall operations of the facility.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74315 “Facility” defined. (NRS 449.037) “Facility” means a community triage center as defined in NRS 449.0031.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74317 “Governing body” defined. (NRS 449.037) “Governing body” means a body that has the ultimate authority for the administration of a facility pursuant to NAC 449.74327.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74319 “Mentally ill person” defined. (NRS 449.037) “Mentally ill person” has the meaning ascribed to it in NRS 433A.115.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74321 “Patient” defined. (NRS 449.037) “Patient” means any person who is under observation or receiving care or treatment in a facility.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74323 “Program” defined. (NRS 449.037) “Program” means a program described in NAC 449.74339.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74325 “Psychologist” defined. (NRS 449.037) “Psychologist” has the meaning ascribed to it in NRS 641.027.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74327 Governing body; bylaws and policies. (NRS 449.037)
1. Each facility must have a governing body which has the ultimate authority for the administration of the facility.
2. The governing body shall:
(a) Adopt written bylaws and policies that define the powers and duties of the governing body, its committees, the administrator and any advisory group;
(b) Review and revise annually the bylaws, policies and procedures of the governing body;
(c) Appoint an administrator of the facility who is qualified by education, experience and training to manage the facility;
(d) Establish policies governing the responsibilities, authority and duties of the administrator that are designed to enable the administrator to perform the administrative and treatment functions of the facility;
(e) Appoint a medical director of the facility who is responsible for the medical services provided at the facility;
(f ) Adopt controls designed to achieve and maintain maximum standards of service;
(g) Review and approve an annual budget to carry out the objectives of each program; and
(h) Review and approve annually the program goals and objectives set forth in NAC 449.74339.
3. The bylaws and policies adopted pursuant to subsection 2 must:
(a) Identify the overall goals of the facility;
(b) Include, without limitation, an organizational chart of the facility;
(c) Define the major lines of authority and areas of responsibility within the program of treatment provided by the facility;
(d) Define the membership of the governing body, the types of membership, the method of selection or appointment of members, officers or committees and their terms of office; and
(e) Define the frequency of meetings of the governing body and attendance requirements.
4. The governing body shall meet at least semiannually. Minutes must be kept of the meetings and must include, without limitation:
(a) The date of the meeting;
(b) A list of the persons who attended the meeting;
(c) A list of the topics discussed at the meeting; and
(d) A list of all decisions made by the governing body and any actions taken.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74329 Policies and procedures for services and operation of facility. (NRS 449.037)
1. The governing body shall adopt written policies and procedures that govern the operation of the facility and the services provided by the facility.
2. The policies and procedures adopted pursuant to subsection 1 must:
(a) Ensure that only those persons are accepted as patients whose needs can be met by the facility directly or in cooperation with community resources or other providers of treatment with which it is affiliated or has contacts;
(b) Ensure that a patient whose physical or mental condition has changed to such an extent that he can no longer be adequately served by the facility will be transferred promptly to an appropriate facility;
(c) Set forth the rights of patients and members of the staff, including, without limitation, the rights of patients set forth in NRS 449.700 to 449.730, inclusive, and provide for the registration and disposition of complaints without threat of discharge or reprisal against an employee or patient;
(d) Ensure that the admission agreement between the administrator and the patient specifically prohibits the administrator, his designee or any member of the staff of the facility from being given durable power of attorney for health care for the patient; and
(e) Be available to members of the staff, patients and the public.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74331 Transfer of patient. (NRS 449.037)
1. Except in the case of an emergency:
(a) The transfer of a patient must not be effected until the patient, attending physician of the patient, if any, and responsible agency are consulted in advance.
(b) If a patient is transferred to a hospital or other medical facility, a summary of discharge containing a plan for continuation of care must be prepared and forwarded to the receiving facility if the patient or his guardian consents to release such information to the receiving facility.
2. If a patient is transferred to a hospital or other medical facility as a result of a medical emergency, information required for appropriate continuation of care must be released to the receiving facility in compliance with the standards set forth in 42 C.F.R. Part 2.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74333 Handling of money of patient. (NRS 449.037)
1. If a facility handles the money of a patient, a written ledger account of all deposits, disbursements and other transactions must be maintained. A record must be made available to the patient.
2. If the amount of money of a patient which the facility handles is $75 or more, the money must be maintained in a financial institution in the community where the facility is located in a separate trustee account apart from the operational accounts of the facility and must be clearly designated.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74335 Inventory of belongings of patient. (NRS 449.037) If a facility holds or stores the belongings of a patient, there must be an inventory of the belongings on admission, made a part of the record of the patient and updated as needed. These belongings must be returned to the patient upon his exit.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74337 Liability insurance. (NRS 449.037) Liability insurance in a sufficient amount to protect patients, members of the staff, volunteers and visitors must be maintained by each facility. A certificate of insurance must be furnished to the Health Division. The certificate must include, without limitation, provision for 30 days’ notice to the Health Division of the cancellation or the nonrenewal of a policy of liability insurance.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74339 General requirements for programs and services. (NRS 449.037)
1. Each program for the provision of detoxification services, each social model detoxification program or its equivalent and each modified medical detoxification program or its equivalent of a facility must be certified in accordance with the provisions of chapter 458 of NRS and chapter 458 of NAC.
2. Each component of each program described in subsection 1 must develop objectives that complement the goals of the program.
3. The facility shall provide for the medical, emergency dental and psychological services needed to fulfill the goals of each program and meet the needs of all of its patients to the extent that is possible, with assistance from available community resources.
4. Patients who are admitted and receive detoxification services must be provided such services under the direction of a qualified physician licensed in accordance with the provisions of chapter 630 or 633 of NRS.
5. If a facility provides services through outside sources, formal, written arrangements must be made ensuring that the services are supplied directly by, or under the supervision of, qualified persons.
6. A facility shall provide case management services as needed by a patient through a social worker or a registered nurse or by written agreement with a social worker or a registered nurse.
7. A plan for case management must be recorded in the records of a patient and must be periodically evaluated in conjunction with the treatment plan of the patient.
8. Each facility shall review each program described in subsection 1 at least annually. The review must include, without limitation, an evaluation of:
(a) The appropriateness of the admission of patients;
(b) The lengths of stay of patients;
(c) Planning for the discharge of patients;
(d) The use of services and utilization of the components of the program;
(e) The use of outside services; and
(f ) Any unusual incidents that resulted or may have resulted in harm to a patient.
9. Written reports of the annual reviews conducted pursuant to subsection 8 must be evaluated by the governing body and the administrator. Documentation of the evaluation process must be maintained at the facility. Outcome reports and reports of actions taken must be maintained for a period of at least 6 years.
10. As used in this section:
(a) “Detoxification” means the process of eliminating the toxic effects of alcohol and drugs from the body.
(b) “Social model detoxification program” means a treatment program that concentrates on providing psychosocial services and nonmedical detoxification.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74341 Responsibilities and duties of administrator. (NRS 449.037)
1. The administrator of a facility is responsible to the governing body of the facility for the operation of the facility in accordance with the policies and procedures of the facility.
2. The administrator shall:
(a) Organize the administrative functions of each program, delegate duties and establish a formal means of accountability on the part of subordinates.
(b) Ensure that a written manual defining the policies and procedures of each program is prepared, regularly revised, and updated at least annually. The manual must:
(1) Contain all policies and procedures of the facility, including, without limitation, definitions and other documentation required by NAC 449.74311 to 449.74375, inclusive; and
(2) Be available to members of the staff of the facility at all times at designated and convenient locations.
(c) Appoint a person who is qualified by education, experience and training to act as administrator in his absence.
(d) Notify the Bureau within 24 hours after the administrator becomes aware of:
(1) The death of a patient at the facility; or
(2) The elopement from the facility of an at-risk patient.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74343 Policies and procedures concerning employees. (NRS 449.037)
1. The administrator or his appointee must be present and responsible for the operations of the facility during normal hours.
2. All members of the counseling staff of a facility must be authorized by state law to provide counseling.
3. Each person employed in a facility must have a preemployment physical examination or certification of a 3-year health record from a physician, and be tested for tuberculosis as required in chapter 441A of NAC.
4. Each facility shall:
(a) Have on duty, at all hours of the day, members of the staff sufficient in number and qualifications to carry out policies, responsibilities and program continuity.
(b) Provide an orientation session to new employees. Documentation of the session must be maintained in the personnel file of the employee.
(c) Have written policies and procedures:
(1) For the recruitment, selection, promotion and termination of members of the staff;
(2) Concerning rules of conduct, and training and development of the staff; and
(3) Governing disciplinary actions that clearly define the mechanism for the suspension or dismissal of members of the staff.
(d) Maintain a written job description for each position at the facility. The job description must accurately reflect the actual job situation and must be reviewed annually or whenever a change in the responsibilities of the job or qualifications occurs. Job descriptions must be available on request to all members of the staff. Each job description must include, without limitation:
(1) The title of the job;
(2) The tasks and responsibilities of the job;
(3) The skills, education and experience necessary for the job;
(4) The relationship of the job to other jobs within each program; and
(5) The working conditions, location and shift of the job, and the materials and equipment to be used on the job.
(e) Maintain a personnel record for each employee of the facility. The record must include, without limitation:
(1) The employment application;
(2) Letters of recommendation;
(3) Records from any investigation of the employee;
(4) Verification of training, experience and certification;
(5) Job performance evaluations;
(6) Incident reports; and
(7) Disciplinary actions taken.
(f ) Maintain personnel records in a secure manner and make them available only to those persons authorized to receive personnel records in the written policies and procedures of the facility. An employee must have access to his own file upon request.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74345 Nursing services. (NRS 449.037)
1. Each facility shall have an organized plan for nursing service that provides nursing services 24 hours per day. The nursing services must be provided or supervised by a registered nurse in compliance with state law, including, without limitation, chapter 632 of NRS and chapter 632 of NAC.
2. The nursing service shall have a sufficient number of registered nurses, licensed practical nurses and other personnel to provide care in general medical nursing, psychiatric nursing and nursing related to treatment of alcohol and drug abuse.
3. The administrator shall ensure that the nursing staff develops and keeps current a plan for nursing care for each patient.
4. The administrator shall appoint a chief administrative nurse to direct the nursing service. The chief administrative nurse must:
(a) Be a registered nurse;
(b) Be knowledgeable, skilled and competent in clinical practice and the management of nurses; and
(c) Comply with the provisions of chapter 632 of NRS and chapter 632 of NAC and follow professional standards established for organized nursing services.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74347 Health services. (NRS 449.037)
1. Each facility shall provide health services which ensure that each patient receives treatment, prescribed medication, adequate diets and other health services consistent with each program administered by the facility.
2. There must be policies and procedures designed to ensure the early detection of complications or conditions considered to be common among alcohol and drug abusers and mentally ill persons.
3. The policies and procedures must be developed with assistance from and approved by the medical director of the facility.
4. Policies and procedures must be developed and implemented to ensure the early detection of patients at risk for suicide. The policies and procedures must be developed with assistance from and approved by the medical director of the facility and a psychiatrist.
5. Before a patient is admitted to a facility, a general medical and psychological assessment, including an assessment of suicide risk and a drug history of the patient, must be taken by a physician, a physician assistant, an advanced practitioner of nursing or a designated member of the nursing staff of the facility who has psychiatric experience. The drug history of the patient must include, without limitation:
(a) Drugs used in the past;
(b) Drugs used recently;
(c) Drugs of preference;
(d) Frequently used drugs;
(e) Drugs used in combination;
(f ) Dosages used;
(g) Date of first usage;
(h) Incidents of overdose, withdrawal or adverse drug reactions;
(i) Previous history of treatment; and
( j) History of mental illness and treatment.
6. Except as otherwise provided in subsection 7, a physical examination and review of the medical and drug history of a patient must be conducted by a physician, nurse practitioner or physician assistant within 24 hours after the patient is admitted to a facility.
7. If the assessment conducted in accordance with subsection 5 concludes that a physical examination of the patient should be completed within less than 24 hours after the patient is admitted, the physical examination must be conducted within the time recommended in the assessment.
8. Each facility shall have written policies and procedures defining the appropriate action to be taken when a medical emergency arises. The policies and procedures must be reviewed and approved by the medical director of the facility.
9. Staff providing patient care must be qualified by the American Red Cross or another similar nationally recognized agency to administer cardiopulmonary resuscitation.
10. Each patient of a facility must be tested for tuberculosis as required by the provisions of chapter 441A of NAC.
11. First-aid supplies must be maintained and readily available at each facility.
12. A facility that provides laboratory testing shall do so in compliance with the provisions of chapter 652 of NRS and chapter 652 of NAC.
13. If a facility has no provisions for the isolation of a patient diagnosed with an infectious disease, the patient must be transferred to a facility that provides such service. The decision to transfer the patient must be made by the medical director of the facility or his designee.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74349 Mental health services. (NRS 449.037)
1. Mental health services provided by a facility must be supervised by a psychiatrist or a psychologist who has a master’s degree in clinical or counseling psychology. The mental health staff of the facility must be adequate in number and qualified to carry out their assigned responsibilities.
2. The mental health staff may assist in:
(a) Diagnosis and testing;
(b) Program development and evaluation;
(c) In-service training; and
(d) Therapeutic activity in group settings or one-on-one therapeutic activity.
3. Mental health services must be provided by a staff member of the facility who:
(a) Has a master’s degree in clinical or counseling psychology;
(b) Is an advanced practitioner of nursing with at least 2 years of clinical practice in the field of psychiatric nursing or nursing related to the treatment of alcohol and drug abuse; or
(c) Is licensed as a clinical social worker in accordance with the provisions of chapter 641B of NRS.
4. A psychiatrist licensed in accordance with the provisions of chapter 630 of NRS must be available at each facility to approve mental health service policies and procedures and to provide consultation for patients who need mental health services.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74351 Pharmaceutical services. (NRS 449.037)
1. Each facility shall have:
(a) A pharmacy directed by a registered pharmacist;
(b) A drug room supervised by no less than a currently licensed professional nurse; or
(c) A contract for 24-hour pharmaceutical service with a licensed pharmacy.
2. If a facility maintains a pharmacy or drug room, the pharmacy or drug room must be administered in accordance with all applicable state and federal laws and must have a full-time, part-time or consulting pharmacist who is responsible for developing, supervising and coordinating all of the activities of the pharmaceutical service.
3. Each facility shall have and implement policies and procedures that minimize errors in the administration of drugs. The medical director of the facility and the pharmacist who is responsible for the pharmaceutical service must approve the policies and procedures.
4. Drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice and state and federal laws.
5. When a pharmacist is not available at the facility, drugs and biologicals may be removed from the pharmacy or drug area only by a member of the staff who is authorized to remove such substances by the policies and procedures of the facility, which must be established in accordance with state and federal laws.
6. Errors in administering a drug, adverse reactions by a patient to a drug and any incompatibility between a drug and a patient must be reported immediately to the attending physician of the patient or the medical director of the facility.
7. Abuses and losses of controlled substances must be reported to the pharmacist who is responsible for the pharmaceutical service, the administrator and the chief administrative nurse of the facility, in accordance with all applicable state and federal laws.
8. Information relating to drug interactions and information on drug therapy, side effects, toxicology, dosage indications for use and routes of administration must be available to the professional members of the staff of the facility.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74353 Medication and biologicals. (NRS 449.037)
1. Except as otherwise provided in subsection 2, an order for medication or biologicals for a patient must be in writing and signed by the practitioner, or other appropriate professional person authorized by state or federal law to order the medication or biological, who is responsible for the care of the patient.
2. When a telephone or verbal order is used to order medications or biologicals, the order must be:
(a) Accepted only by a person who is authorized by the policies and procedures of the facility, which must be consistent with state law, to accept such an order; and
(b) Signed or initialed by the prescribing practitioner in accordance with the policies and procedures of the facility.
3. Each order for a medication or biological must include, without limitation, the name of the medication or biological, and the dosage, time or frequency of administration and route of administration of the medication or biological.
4. Only a member of the staff of the facility who is authorized by state law to administer medication or biologicals may administer medication or biologicals at the facility.
5. Each facility shall have a system to monitor and improve the process of administering medication and biologicals.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74355 Records of patients. (NRS 449.037)
1. Each facility shall maintain an organized system for the records of patients.
2. The records of a patient must be available to professional members of the staff of the facility who are directly involved with the patient.
3. The records of patients must be available to representatives of the Health Division.
4. The records of a patient must include, without limitation:
(a) Identification information;
(b) Past medical and social history;
(c) Copies of all initial and periodic examinations;
(d) Evaluations and progress notes; and
(e) Assessments and goals of the plan of treatment of the patient.
5. The plan of treatment must state who is responsible for providing treatment or services to the patient.
6. Entries must be made describing treatments and services rendered, medications administered, and any symptoms or other indications of illness or injury, including, without limitation, the date, time and action taken regarding each incident.
7. Records must be adequately safeguarded against destruction, loss or unauthorized use.
8. A discharge plan, as determined by a case management assessment of the patient, must be documented for each patient discharged from the facility.
9. Records must be retained for at least 5 years after the discharge of a patient from a facility.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74357 Laundry requirements. (NRS 449.037)
1. Each facility shall have the proper equipment for the sanitary washing and finishing of linen and other washable goods or shall maintain a written agreement with a commercial establishment to provide proper laundry services.
2. The laundry area of a facility must be situated in an area of the facility that is separate and apart from any room where food is stored, prepared or served. The laundry area must be well-lighted, ventilated, adequate in size to house equipment, maintained in a sanitary manner and kept in good repair.
3. Soiled linen must be collected and transported to the laundry in washable or disposable containers in a sanitary manner. Soiled linen must not be transported through areas of the facility used for preparing or serving food.
4. Clean linen to be dried, ironed, folded, transferred or distributed must be handled in a sanitary manner in accordance with a written plan maintained by the facility.
5. Closets for storing linen and laundry supplies must be provided and must not be used for any other purpose.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74359 Dietary services. (NRS 449.037)
1. Each facility shall serve at least three meals or their equivalent daily, at regular times, with not more than 14 hours between a substantial evening meal and breakfast.
2. Additional food and between-meal nourishment must be provided to a patient when needed, based on an assessment of the medical condition of the patient.
3. Menus must be planned and followed to meet the nutritional needs of the patients in accordance with the recommended dietary allowances of the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences.
4. Therapeutic menus must be planned by a registered dietitian or must be reviewed and approved by the attending physician of the patient or the medical director of the facility.
5. Menus must be in writing, planned in advance, dated and posted, and kept on file at the facility for at least 90 days. Any substitution must be noted on the written menu so that the menu on file reflects what was actually served.
6. A person who meets the requirements for registration with the Commission on Dietetic Registration as a dietitian or dietetic technician must be used as a consultant on planning meals and serving food. This person shall consult at least monthly with the staff of the facility.
7. The facility shall provide:
(a) Adequate facilities and equipment for the preparation, serving, refrigeration and storage of food in a sanitary manner;
(b) Storage space for dry foods, refrigerated food and frozen food;
(c) Any special equipment, implements or utensils that are needed by a patient to assist the patient in eating;
(d) Dining space for ambulatory patients, staff and visitors that is separate from sleeping areas, food preparation areas and distribution areas;
(e) Tables and chairs in the dining space that are sturdy and cleanable; and
(f ) In each kitchen area:
(1) Sinks for washing hands with blade-type faucets, soap and paper towels for drying hands; and
(2) A separate janitors’ closet for the storage of housekeeping chemicals and supplies which contains a floor sink with backflow prevention.
8. A facility with more than 10 patients shall:
(a) Comply with all applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto;
(b) Obtain the necessary permits from the Bureau of Health Protection Services of the Health Division;
(c) Maintain a report of each inspection concerning the sanitation of the facility for at least 1 year after the date of the inspection; and
(d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action.
9. A facility that contracts with a food management company shall comply with all applicable regulations of the State Board of Health.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74361 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of facility for licensure. (NRS 449.037)
1. Except as otherwise provided in subsection 4, before any new construction of a facility or any remodeling of an existing facility is begun:
(a) The facility shall submit a copy of the building plans for the new construction or remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115. The entity’s review of those plans is advisory only and does not constitute approval for licensure of the facility.
(b) The building plans must be approved by the Health Division.
2. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility.
3. The Health Division shall not issue a license to operate a facility until the Bureau has approved the construction of the facility.
4. The provisions of subsection 1 do not apply to plans for remodeling a facility if the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting in the area, replacing flooring in the area, repairing windows in the area or replacing window and wall coverings in the area.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74363 Design, construction, equipment and maintenance of facility. (NRS 449.037)
1. Each facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the facility and members of the general public.
2. Each facility shall comply with all applicable:
(a) State and federal laws;
(b) Local ordinances, including, without limitation, zoning ordinances; and
(c) Environmental, life safety, fire, health and local building codes,
Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply.
3. Each facility shall comply with the provisions of NFPA 101: Life Safety Code, as adopted by reference pursuant to NAC 449.0105.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74365 Entrances, lobbies and offices; storage space. (NRS 449.037) Each facility shall provide:
1. A covered entrance to protect patients from the elements;
2. A lobby which measures not less than 100 square feet, has access to toilet facilities and may be used for multiple purposes;
3. Offices for the administrator or his designee;
4. Offices for social services which may be used for more than one purpose if the offices are large enough to accommodate multiple use and patient privacy can be maintained;
5. A storage space for office supplies and equipment; and
6. Medical record storage that is adequate to protect patients’ health care records in accordance with federal requirements for the protection of medical information.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74367 Patients’ rooms; toilet and bathing facilities. (NRS 449.037)
1. Each facility shall provide separate patient rooms for male and female patients. Each patient room must:
(a) Be at least 80 square feet per bed, exclusive of toilet facilities, closets or entryways;
(b) Include a bed with clean linens and blankets; and
(c) Have storage for patient belongings.
2. Each facility shall provide:
(a) Toilet and bathing facilities to patients in a manner that ensures their privacy while bathing and in adequate number to meet the needs of the patients;
(b) Fixtures in toilet and bathing facilities designed to minimize the possibility of injury or suicide; and
(c) Mirrors in toilet and bathing facilities which are constructed of safety glass.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74369 Service areas; miscellaneous requirements. (NRS 449.037)
1. Each facility shall provide:
(a) A nursing station which includes, without limitation:
(1) Space for computer and printer equipment and for writing;
(2) A medication room or storage space for a medication dispensing unit;
(3) A separate utility room for clean materials;
(4) A separate utility room for soiled materials;
(5) A break room for staff;
(6) Separate toilet facilities for staff; and
(7) Lockers or secured storage for staff belongings;
(b) A separate room for secured storage of patient belongings that have been determined to be hazardous;
(c) A separate room for the storage of clean linen;
(d) A separate room for nourishments that contains an ice machine, which must be self-dispensing if it is accessible to patients or visitors;
(e) A treatment room which is at least 120 square feet and which includes, without limitation:
(1) A hand-washing sink with blade-type handles or hands-free operation;
(2) A writing space;
(3) Sufficient lighting;
(4) Storage space for clean and sterile supplies;
(5) Locked storage for medications and double-locked storage for controlled substances in schedules I to IV, inclusive, as described in chapter 453 of NRS;
(6) Cabinets for the storage of equipment; and
(7) An examination table and a chair for the use of patients;
(f ) Flooring which is easy to clean and intact, without cracks or holes;
(g) Insulation within the building to conserve energy, protect personnel, prevent vapor condensation and reduce noise;
(h) Air conditioning, heating and ventilation to maintain a comfortable interior temperature; and
(i) Laundry facilities to meet the needs of the patients or, if the facility has a contract for linen services, a room for receiving laundry. If the facility provides laundry facilities, then those laundry facilities must be located in a room that is at least 100 square feet. The room must be constructed of 1-hour fire-resistant-rated construction, be fully equipped with sprinklers and have a 45-minute fire-resistant-rated door. The vents in the room must have fire and smoke dampers installed in accordance with the requirements of NFPA 101: Life Safety Code, as adopted by reference pursuant to NAC 449.0105.
2. Each nursing station and each floor of the facility must have a janitors’ room with a floor sink and backflow prevention. The janitors’ room must:
(a) Provide sufficient storage space for housekeeping chemicals and supplies, housekeeping mops, brooms, service carts and cleaning supplies; and
(b) Be separate from any storage space used for the storage of food.
3. Each facility shall have a procedure for the safe disposal of hazardous biological materials.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74371 Safety and sanitation. (NRS 449.037)
1. The premises and equipment of each facility must be maintained in a safe, functional and sanitary condition. Each facility shall have the necessary cleaning and maintenance equipment with sufficient storage areas and appropriate procedures to maintain a clean and orderly establishment. Janitorial supplies, including, without limitation, aerosols, must be stored in areas separate from clean linen, food and other supplies. The storage of dirty linen must be separate from the storage of clean linen, food and other supplies.
2. Items for personal use, including, without limitation, combs, toothbrushes, towels and bar soap, must not be shared by patients.
3. All toilet facilities in a facility must be provided with soap and individual, disposable towels.
4. Each facility shall ensure that the environment of the facility is free of hazards that may cause accidents.
5. Each facility shall maintain an effective program to control pests and rodents in order to ensure that the facility is free from pests and rodents.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74373 Preparations for disasters; reporting of fire or disaster. (NRS 449.037)
1. Each facility shall develop a written plan for internal and external disasters which outlines procedures for members of the staff and patients to follow in case of fire or other emergency and provides for meeting the needs of patients if the facility must be evacuated or is damaged or destroyed.
2. Each facility shall conduct fire drills at least monthly, and a written record of each drill conducted must be retained in the facility for not less than 1 year after the drill is conducted.
3. A simple floor plan showing the routes for evacuating must be posted in prominent locations on each floor of the facility.
4. The facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster.
5. Each facility shall conduct a disaster drill annually for each shift and retain a written record of the drill in the facility for not less than 12 months after the drill is conducted.
6. Each facility shall adopt procedures to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water.
7. No room or space of a facility may be occupied for sleeping, living or dining that is accessible only by a ladder, by folding stairs or through a trapdoor.
8. If a basement of a facility is used for living or dining, at least one exit must be provided directly to the outside at ground level. No facility may:
(a) Be situated more than one story below the ground; and
(b) Use any basement or space in a basement for sleeping.
9. Each facility shall prohibit smoking within the facility and within 25 feet of the facility.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
NAC 449.74375 Discrimination prohibited. (NRS 449.037)
1. No facility that accepts a person for treatment for whom all or part of the payment for treatment is made from federal or state money may deny treatment to a prospective patient on the grounds of race, color, national origin, age, gender or disability.
2. No patient may be segregated, given separate treatment, restricted in the employment of any advantage or privilege enjoyed by others under the program or provided with any aid, treatment, services or other benefits which are different or provided in a different manner from that provided to others under the program on the grounds of race, color, national origin, age, gender or disability.
3. Employment practices of a facility, including, without limitation, hiring, firing, the rate of remuneration, assignments or work hours, may not be based on race, color, national origin, age, gender or disability.
(Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)
FACILITIES FOR SKILLED NURSING
General Provisions
NAC 449.744 “Facility for skilled nursing” defined. (NRS 449.037) As used in NAC 449.744 to 449.74549, inclusive, unless the context otherwise requires, “facility for skilled nursing” has the meaning ascribed to it in NRS 449.0039.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R067-04, 8-4-2004)
Licensing and Administration of Facility
NAC 449.74411 Applicability of license; limitation on number of patients; coverage against certain liabilities. (NRS 449.037)
1. A facility for skilled nursing must be operated and conducted in the name designated on the license for the facility, with the name of the person responsible for its operation also appearing on the face of the license. The license is not transferable.
2. A facility for skilled nursing shall not admit more patients to the facility than the number of beds for which it is licensed, except in emergencies. A facility that admits more patients to the facility than the number of beds for which it is licensed shall immediately notify the Bureau of the additional admissions.
3. A facility for skilled nursing shall retain proof that it is adequately covered against liabilities resulting from claims incurred in the course of its operation.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R119-05, 11-17-2005)
NAC 449.74413 Change in ownership, use or construction of facility. (NRS 449.037)
1. The owner of a facility for skilled nursing shall, at least 30 days before there is a change of ownership, change of use or change in the construction of the facility, notify the Bureau of that change. If the facility is not in compliance with the Guidelines for Design and Construction of Hospital and Health Care Facilities adopted by reference pursuant to NAC 449.0105, the notice must identify those provisions of the guidelines with which the facility has failed to comply.
2. Upon a change in use or change in the construction of a facility, the facility must comply with the Guidelines for Design and Construction of Hospital and Health Care Facilities before admitting patients to the area that is being changed or is under construction.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R067-04, 8-4-2004)
NAC 449.74415 Responsibilities of governing body. (NRS 449.037) A facility for skilled nursing must have a governing body that is legally responsible for establishing and carrying out policies regarding the management and operation of the facility.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74417 Administrator of facility. (NRS 449.037)
1. The governing body of a facility for skilled nursing shall appoint a qualified administrator for the facility.
2. The administrator:
(a) Must be licensed under the provisions of chapter 654 of NRS; and
(b) Is responsible for the management of the facility.
3. A facility for skilled nursing must be administered in a manner that enables it to use its resources effectively and efficiently in order to attain and maintain the highest practicable physical, mental and psychosocial well-being of each patient.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74419 Committee for quality assurance. (NRS 449.037)
1. A facility for skilled nursing shall establish a committee for quality assurance.
2. The committee must be composed of:
(a) The chief administrative nurse;
(b) A member of the staff who is a physician and appointed by the administrator; and
(c) At least three other members of the staff who are appointed by the administrator.
3. The committee shall:
(a) Meet at least quarterly to identify problems and concerns related to the care provided to patients for which corrective actions are necessary; and
(b) Adopt and carry out appropriate plans of action to correct the problems and concerns that are identified.
4. The Bureau may not require the disclosure of the records of the committee unless such disclosure is required to ensure compliance with the provisions of this section.
5. Good faith efforts made by a committee to identify problems and concerns related to the care provided to patients and to correct the problems and concerns that are identified may not be used as grounds for imposing administrative sanctions against a facility for skilled nursing.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74421 Procedures for emergency or disaster. (NRS 449.037)
1. A facility for skilled nursing shall adopt written procedures to be followed by the members of the staff and patients in the case of an emergency or disaster, including, without limitation, fires, severe weather and locating missing patients.
2. The facility shall provide training to an employee regarding these procedures upon his employment by the facility and periodically review the procedures with members of the staff.
3. The facility shall periodically conduct unannounced drills to practice carrying out the procedures adopted pursuant to subsection 1.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
Admission, Transfer and Discharge of Patient
NAC 449.74423 Certain conditions for admission prohibited. (NRS 449.037) A facility for skilled nursing shall not, as a condition of admitting or providing for the expedited admission of a patient to, or allowing a patient to remain in, the facility:
1. Require a patient to waive his rights to benefits under any state or federal program that is available to assist patients in the payment of services provided by the facility, including, without limitation, Medicaid and Medicare.
2. Require a patient to provide a written or oral confirmation that he is not eligible for or will not apply for benefits under such a program.
3. Charge, solicit, accept or receive any gift, money, contribution or other consideration on behalf of a patient who is eligible for benefits under such a program in addition to any amount otherwise required to be paid to the facility under the program. The provisions of this subsection do not prohibit a facility from:
(a) Charging such a patient for an item or service not covered under the program if:
(1) The item or service is requested by the patient;
(2) The facility does not require the patient to request the item or service as a condition of admission to or remaining in the facility; and
(3) The facility informs the patient that there will be a charge for the item or service and the amount of the charge.
(b) Soliciting, accepting or receiving a charitable, religious or philanthropic contribution from an organization or a person who is unrelated to the patient, but only to the extent that the contribution is not a condition of admitting or providing for the expedited admission of the patient to, or allowing the patient to remain in, the facility.
4. Require a third person to guarantee the payment of fees charged by the facility for services provided to the patient. The provisions of this subsection do not prohibit the facility from requiring a person who has legal control over the income or other resources of the patient to enter into a contract, without incurring personal liability, for the payment of fees charged by the facility for services provided to the patient.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74425 Admission of patient with mental illness or mental retardation. (NRS 449.037)
1. On or after September 27, 1999, a facility for skilled nursing shall not admit a patient with a mental illness or with mental retardation unless the Division of Mental Health and Developmental Services of the Department of Health and Human Services has determined, based on an independent evaluation of the physical and mental health of the patient, that he requires:
(a) The level of services provided by a facility for skilled nursing; and
(b) Specialized services that the facility is able to provide.
2. The independent evaluation required by subsection 1 must be performed by a person or organization other than the Division of Mental Health and Developmental Services.
3. As used in this section:
(a) “Mental illness” has the meaning ascribed to it in NRS 433.164.
(b) “Mental retardation” has the meaning ascribed to it in NRS 433.174.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74427 Agreement with hospital for transfer of patients. (NRS 449.037)
1. A facility for skilled nursing shall have in effect an agreement with at least one licensed hospital that provides for the transfer of patients from the facility to the hospital. The agreement must provide that:
(a) A patient transferred from the facility will be admitted to the hospital in a timely manner if the transfer is medically appropriate as determined by the patient’s attending physician; and
(b) Medical and other information required for the care and treatment of the patient is transferred with the patient. Such information may include information for determining whether the patient may be cared for adequately in a setting that is less expensive than the facility or the hospital.
2. A facility for skilled nursing that does not have such an agreement in effect but has attempted in good faith to enter into such an agreement with a hospital sufficiently close to the facility to make transfers feasible shall be deemed to have such an agreement.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74429 Transfer or discharge of patient. (NRS 449.037)
1. A facility for skilled nursing may transfer or discharge a patient from the facility only if:
(a) The facility can no longer provide for the needs of the patient and the transfer or discharge is necessary for the patient’s welfare;
(b) The health of the patient has improved sufficiently so that the patient no longer requires the services provided by the facility;
(c) The health or safety of other persons in the facility is endangered if the patient remains in the facility;
(d) The charges for services provided to the patient by the facility have not been paid after the facility has given notice of those charges; or
(e) The facility ceases to operate.
2. Before a facility for skilled nursing may transfer or discharge a patient from the facility, the facility shall:
(a) Record the reasons for the transfer or discharge in the medical records of the patient. If a patient is transferred or discharged under the circumstances described in:
(1) Paragraph (a) or (b) of subsection 1, the reasons for the transfer or discharge must be recorded by the patient’s physician.
(2) Paragraph (c) of subsection 1, the reasons for the transfer or discharge must be recorded by any physician.
(b) Give notice of the transfer or discharge to the patient and, if known, to the legal representative of the patient or a member of the patient’s family. The notice must:
(1) Be in writing;
(2) Be in a language that is understood by the patient and his legal representative or a member of his family;
(3) Except as otherwise provided in subsection 3, be given at least 30 days before the effective date of the transfer or discharge;
(4) Include the reasons for the transfer or discharge;
(5) Include the effective date of the transfer or discharge;
(6) Specify the location to which the patient will be transferred or discharged;
(7) Include a statement that the patient has a right to appeal the transfer or discharge;
(8) Include the name, address and telephone number of the advocates for residents of facilities for long-term care appointed pursuant to chapter 427A of NRS; and
(9) If the patient is developmentally disabled or mentally ill, include the name, address and telephone number of persons who advocate for and are responsible for the protection of such persons.
3. The notice required by paragraph (b) of subsection 2 may be given less than 30 days before the effective date of the transfer or discharge if:
(a) The health or safety of other persons in the facility is endangered if the patient remains in the facility;
(b) The health of the patient has improved sufficiently to allow a more immediate transfer or discharge of the patient;
(c) The medical needs of the patient require a more immediate transfer or discharge; or
(d) The patient has not resided in the facility for at least 30 days.
4. Upon admission of a patient to a facility for skilled nursing and at the time the facility transfers the patient for hospitalization or therapeutic leave, the facility shall provide to the patient and to the legal representative of the patient or to a member of the patient’s family, in writing:
(a) The time within which the patient may resume his residency in the facility without waiting for readmission; and
(b) The policy of the facility for readmitting a patient whose hospitalization or therapeutic leave exceeds the time within which he may resume his residency in the facility without waiting for readmission upon the first availability of a bed in a semiprivate room.
5. A facility for skilled nursing shall prepare a patient for his transfer or discharge in such a manner as to ensure the safe and orderly transfer or discharge of the patient from the facility.
6. As used in this section, “transfer” or “discharge” means the movement of a patient to a location outside of a facility for skilled nursing, whether or not that location is within the same physical area of the facility. The term does not include the movement of a patient to a bed located within the facility for skilled nursing.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74431 Summary of discharge. (NRS 449.037)
1. A facility for skilled nursing shall prepare a summary of discharge for each patient discharged from the facility.
2. A summary of discharge must include:
(a) A summary of the pertinent information relating to the patient’s stay at the facility;
(b) A final summary of the patient’s physical, mental and psychosocial health at the time of discharge, including, without limitation, the information required to be included in a comprehensive assessment of the patient pursuant to subsection 2 of NAC 449.74433; and
(c) A plan of care for the patient after his discharge that assists the patient in adjusting to his new living environment. The plan of care must be developed with the participation of the patient and members of his family.
3. A facility for skilled nursing may release a summary of discharge to persons and under the circumstances approved by the patient who is the subject of the summary or his legal representative.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
Assessment of Patients and Plan of Care
NAC 449.74433 Comprehensive assessment of needs of patient. (NRS 449.037)
1. A facility for skilled nursing shall conduct a comprehensive assessment of the needs of each patient in the facility using the assessment instrument specified by the Bureau.
2. A comprehensive assessment must include, without limitation:
(a) Demographic and other pertinent information required to identify the patient;
(b) The customary routine of the patient;
(c) The cognitive patterns of the patient;
(d) An analysis of the communication skills of the patient;
(e) An analysis of the vision of the patient;
(f ) The mood and behavior patterns of the patient;
(g) An analysis of the psychosocial well-being of the patient;
(h) Any problems related to the functional or structural physical condition of the patient;
(i) The patient’s pattern of continence;
( j) The physical condition of the patient, including the diagnosis of any diseases which the patient may have;
(k) An analysis of the nutritional needs of the patient;
(l) The dental condition of the patient;
(m) The condition of the patient’s skin;
(n) Activities in which the patient is interested;
(o) Medications required to be taken by the patient;
( p) Any special treatments and procedures required by the patient;
(q ) The probability of discharging the patient from the facility and any other information related to the discharge of the patient from the facility;
(r) Documentation of summary information relating to any additional assessment performed in accordance with the patient’s assessment protocols; and
(s) Documentation of the patient’s participation in the assessment.
3. The information to be included in a comprehensive assessment must be obtained from the direct observation of and communication with the patient and from communications with the members of the staff who care for the patient.
4. A comprehensive assessment must be conducted:
(a) Within 14 days after the patient’s admission to the facility. The provisions of this paragraph do not require a comprehensive assessment of a patient who is readmitted to the facility following a temporary absence from the facility for hospitalization or therapeutic leave if there is not a significant change in the physical or mental condition of the patient.
(b) Within 14 days after there has been a significant decline or improvement in the physical or mental condition of the patient that:
(1) Requires intervention by a member of the facility’s staff or further medical treatment;
(2) Has affected more than one aspect of the patient’s health; and
(3) Requires review by an interdisciplinary team or a revision of the patient’s plan of care, or both.
(c) At least once every 12 months, but in no event later than 365 days after the completion of the most recent comprehensive assessment.
5. A comprehensive assessment must accurately reflect the physical, mental and psychosocial health of the patient.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74435 Quarterly assessment of patient. (NRS 449.037)
1. A facility for skilled nursing shall, not less than every 3 months, conduct an assessment of each patient in the facility using the quarterly assessment instrument approved by the Bureau.
2. Each quarterly assessment must accurately reflect the physical, mental and psychosocial health of the patient.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74437 Conduct of assessments. (NRS 449.037)
1. The assessments required by NAC 449.74433 and 449.74435 must be conducted by a registered nurse or coordinated by a registered nurse with the participation of other appropriate health care professionals. Each person who completes a portion of the assessment shall certify the accuracy of that portion. The registered nurse shall certify that the assessment is completed.
2. A facility for skilled nursing shall coordinate the assessments required by NAC 449.74433 and 449.74435 with other screening programs required to be conducted upon the patient’s admission to the facility to the extent practicable to avoid the duplication of efforts.
3. Each assessment required by NAC 449.74433 and 449.74435 must be:
(a) Maintained in the medical record of the patient for at least 15 months after the assessment is conducted.
(b) Used to develop, review and revise the patient’s plan of care.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74439 Comprehensive plan of care. (NRS 449.037)
1. A facility for skilled nursing shall develop for each patient in the facility a comprehensive plan of care.
2. A comprehensive plan of care must include:
(a) Measurable objectives and timetables to meet the physical, mental and psychosocial needs of the patient that are identified in the comprehensive assessment required by NAC 449.74433;
(b) A description of the services that will be provided to the patient to attain or maintain his highest practicable physical, mental and psychosocial well-being; and
(c) A description of the services that would otherwise be provided to the patient, but will not be provided because of the patient’s refusal to accept those services.
3. A comprehensive plan of care must be:
(a) Developed within 7 days after the completion of the initial comprehensive assessment required by NAC 449.74433 and periodically reviewed and revised after each subsequent assessment; and
(b) Prepared by an interdisciplinary team that includes the patient’s attending physician, a registered nurse who is responsible for the care of the patient and such other members of the staff of the facility as are appropriate to provide services in accordance with the needs of the patient. To the extent practicable, the patient, his legal representative and members of his family must be allowed to participate in the development of the plan of care.
4. Services provided to a patient in a facility for skilled nursing must:
(a) Comply with the professional standards of quality applicable to those services; and
(b) Be provided by qualified persons in accordance with the patient’s plan of care.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
Medical Records
NAC 449.74441 Maintenance. (NRS 449.037)
1. A facility for skilled nursing shall maintain medical records for each patient in the facility in accordance with accepted professional principles.
2. A medical record must be:
(a) Complete;
(b) Accurate;
(c) Organized; and
(d) Readily accessible to those persons who are authorized to review the records.
3. A medical record must include:
(a) Sufficient information to identify the patient;
(b) A record of the assessments of the patient conducted pursuant to NAC 449.74433 and 449.74435;
(c) The patient’s plan of care and the services provided to the patient;
(d) The results of any assessment of the patient conducted by a state agency before his admission to the facility; and
(e) Periodic progress notes prepared by appropriate members of the staff.
4. A facility for skilled nursing shall maintain the medical records of a patient:
(a) For at least 5 years after the discharge of the patient, unless state law requires otherwise; and
(b) For at least 3 years after the patient reaches 18 years of age if the patient is a minor.
5. A facility for skilled nursing shall ensure that:
(a) Information contained in a medical record is not lost, destroyed or used in an unauthorized manner.
(b) No person willfully and knowingly falsifies or causes another person to falsify information contained in a medical record.
6. Information contained in a medical record is confidential and must not be released without the written consent of the patient except:
(a) As required by law;
(b) Under a contract involving a third-party payor; or
(c) As required upon the transfer of the patient to another medical facility.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74443 Inspection. (NRS 449.037)
1. A patient in a facility for skilled nursing or his legal representative may submit an oral or written request to the facility to inspect all records relating to the patient maintained by the facility. The facility shall, within 24 hours after the receipt of such a request, excluding weekends and holidays, allow the patient or his legal representative to inspect the patient’s records.
2. Upon request, the facility shall furnish to the patient or his legal representative a copy of the records or any portion thereof at the cost of obtaining records from a provider of health care set forth in NRS 629.061. The copy must be furnished within 48 hours after the receipt of the request, excluding weekends and holidays.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
Rights of Patients
NAC 449.74445 Generally. (NRS 449.037)
1. A facility for skilled nursing shall protect and promote the rights of each patient in the facility.
2. In addition to the rights set forth in NRS 449.710 and 449.720, a patient in a skilled nursing facility has the right to:
(a) Receive care in a manner and environment that maintains and enhances each patient’s dignity with respect to each patient’s individuality.
(b) Exercise his rights without the threat of interference, coercion, discrimination or reprisal.
(c) Choose his attending physician.
(d) Be fully informed, in a language that the patient understands, of his total health status, including, without limitation, his medical condition.
(e) Participate in decisions relating to his health care, unless he is unable to do so because he is incompetent or incapacitated.
(f ) Receive services with reasonable accommodation for his individual needs and preferences, unless the health or safety of the patient or other patients would be endangered.
(g) Privacy in relation to his accommodations, personal care, written and oral communications and meetings with other persons. The provisions of this paragraph do not require a facility for skilled nursing to provide a private room to each patient.
(h) File grievances with the facility without the threat of discrimination or reprisal and to the prompt resolution of those grievances. Such grievances include, without limitation, complaints relating to treatment that has been furnished or not furnished and the behavior of other patients.
(i) Use a telephone where calls can be made without being overheard.
( j) Retain and use personal possessions as space allows, including, without limitation, furniture and clothing, unless to do so would infringe upon the rights or threaten the health and safety of other patients.
(k) Share a room with his or her spouse if both spouses reside in the facility and consent to the arrangement.
(l) Manage his financial affairs.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74447 Communications with other persons; examination of records by advocate. (NRS 449.037)
1. A facility for skilled nursing shall not prohibit a patient in the facility from contacting, receiving information from or speaking to:
(a) A representative of the Bureau.
(b) The patient’s physician.
(c) Any person who advocates for the rights of the patients of the facility, including, without limitation:
(1) Advocates for residents of facilities for long-term care appointed pursuant to chapter 427A of NRS; and
(2) Persons who advocate for and are responsible for the protection of persons with developmental disabilities or who are mentally ill.
(d) Any person who provides health care, social, legal or other services to the patient.
(e) The relatives of the patient.
(f ) Any other persons with whom the patient wishes to visit.
2. The provisions of this section do not prohibit a facility for skilled nursing from adopting reasonable restrictions relating to the visitation of patients.
3. A facility for skilled nursing shall not prohibit an advocate for residents of facilities for long-term care appointed pursuant to chapter 427A of NRS from examining the medical records of a patient of the facility in accordance with state law and with the permission of the patient or the patient’s legal representative.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74449 Notice to patients of rights, services and charges. (NRS 449.037)
1. A facility for skilled nursing shall give notice to each patient admitted to the facility of:
(a) His rights as a patient and of the policies of the facility relating to the conduct and responsibilities of patients in the facility; and
(b) The services available at the facility and the charges for those services, including, without limitation, charges for services that are not covered by the facility’s per diem rate.
2. The notice required by subsection 1 must be given:
(a) Orally and in writing;
(b) In a language that the patient understands; and
(c) Before or upon admission of the patient to the facility and periodically during the patient’s stay at the facility.
3. The written notice of the patient’s rights must include, without limitation:
(a) A summary of the provisions of NAC 449.74461 and 449.74463;
(b) The names, addresses and telephone numbers of:
(1) The Bureau;
(2) Advocates for residents of facilities for long-term care appointed pursuant to chapter 427A of NRS;
(3) The Medicaid Fraud Control Unit within the Office of the Attorney General; and
(4) Any other persons who advocate for the rights of patients in the facility; and
(c) A statement that the patient may file a complaint with the Bureau concerning the abuse or neglect of any patient or the misappropriation of any patient’s money.
4. The patient must acknowledge in writing the receipt of each notice provided.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74451 Charges to be consistent with notice of charges. (NRS 449.037) Any amount charged for services provided by a facility for skilled nursing must be consistent with the notice of charges provided by the facility pursuant to NAC 449.74449.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74453 Notice to patients of programs available for assistance in payment of services. (NRS 449.037) A facility for skilled nursing shall:
1. Provide to applicants for admission to the facility and to the patients in the facility oral and written information concerning state and federal programs that are available to assist patients in the payment of services provided by the facility, including, without limitation, Medicaid and Medicare; and
2. Display in a prominent place within the facility the written information provided pursuant to subsection 1.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74455 Discrimination prohibited. (NRS 449.037)
1. A patient in a facility for skilled nursing shall not be segregated or restricted in the enjoyment of an advantage or privilege enjoyed by other patients, or provided with any assistance, service or other benefit which is different or provided in a different manner from that provided to other patients, on the ground of race, color, religion, national origin or disability.
2. A facility for skilled nursing shall adopt and maintain policies and procedures for the transfer and discharge of, and the provision of services to, patients in the facility which do not discriminate against a patient based on the source of payment for the services provided.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74457 Policies and procedures for advance directives by patient; information to be furnished regarding physicians. (NRS 449.037)
1. A facility for skilled nursing shall adopt written policies and procedures authorizing the patients in the facility to establish advance directives for their treatment.
2. The policies and procedures must require that written information be given to adult patients concerning their right to accept or refuse treatment and to establish advance directives for their treatment.
3. A facility for skilled nursing shall inform each patient in the facility of the name and specialty of the physician responsible for his care and the manner in which the physician may be contacted.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74459 Examination by patient of survey of facility and plan of correction. (NRS 449.037)
1. A patient of a facility for skilled nursing may examine the results of the most recent survey of the facility conducted by the Bureau or a federal regulatory agency and any plan of correction required to be carried out by the facility as a result of the survey.
2. A facility for skilled nursing shall:
(a) Make such surveys and plans of correction available for examination at a place that is readily accessible to the patients of the facility; and
(b) Post in a prominent location within the facility a notice of the places where the surveys and plans of correction are available for examination.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74461 Finances of patient: System for maintenance and accounting. (NRS 449.037)
1. A facility for skilled nursing:
(a) Shall not require a patient to deposit any amount of money with the facility to be held by the facility on behalf of the patient.
(b) Shall hold, safeguard, manage and account for money deposited with the facility on behalf of a patient if requested to do so in writing by the patient, in accordance with the provisions of this section and NAC 449.74463.
2. If money held by a facility for skilled nursing on behalf of a patient is greater than $50, the money must be maintained in a financial institution in an account that:
(a) Bears interest;
(b) Is separate from the facility’s operating accounts; and
(c) Credits all interest earned on the money in the account to the account.
3. If money held by a facility for skilled nursing on behalf of a patient is not more than $50, the money must be maintained in:
(a) A financial institution in an account that bears interest;
(b) A financial institution in an account that does not bear interest; or
(c) A petty cash fund.
4. A facility for skilled nursing shall establish and maintain a system that provides a complete and separate accounting of the money held by the facility on behalf of a patient that is prepared according to generally accepted principles of accounting. The system must prohibit the commingling of the patient’s money with the facility’s money or the money of any person other than another patient. An accounting must be made available to the patient on a quarterly basis and upon the request of the patient or his legal representative.
5. A facility for skilled nursing shall obtain a surety bond or provide to the Bureau other assurances that are satisfactory to the Bureau to ensure the security of all money held by the facility on behalf of its patients.
6. A facility for skilled nursing shall, within 30 days after the death of a patient who has deposited money with the facility to hold on his behalf, deliver the money and a final accounting to the proper court or person administering the patient’s estate.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74463 Finances of patient: Authorization to withhold money. (NRS 449.037)
1. A facility for skilled nursing shall not withhold from money held by the facility on behalf of a patient any amount for:
(a) Services related to the maintenance of the patient’s room or bed;
(b) Supplies and services for routine personal hygiene that are required by the patient, including, without limitation:
(1) Shampoo, a comb and a brush;
(2) Bath soap, disinfecting soap or specialized cleansing agents required to treat the medical condition of the patient or to treat infection;
(3) A razor and shaving cream;
(4) A toothbrush, toothpaste, denture adhesive, dental cleaner and dental floss;
(5) Moisturizing lotion;
(6) Tissues, cotton balls and cotton swabs;
(7) Deodorant;
(8) Supplies and services for incontinence;
(9) Sanitary napkins and related supplies;
(10) Towels and washcloths;
(11) Hospital gowns;
(12) Nonprescription drugs;
(13) Supplies and services for the patient’s nails; and
(14) Supplies and services for the patient’s laundry; and
(c) Medically-related social services required by NAC 449.74523.
2. Except as otherwise provided in subsection 3, a facility for skilled nursing may withhold from money held by the facility on behalf of a patient amounts for the following items and services:
(a) A telephone;
(b) A television and radio for the patient’s personal use;
(c) Personal comfort items, including, without limitation, smoking materials, notions, novelties and confections;
(d) Cosmetic and grooming items and services that are not required for routine personal hygiene;
(e) Clothing;
(f ) Reading material;
(g) Gifts purchased on behalf of the patient;
(h) Flowers and plants;
(i) Items for social events and entertainment that are in addition to the program of activities required by NAC 449.74495;
( j) Special services required for the care of the patient, including, without limitation, the services of a private nurse or aide;
(k) A private room, unless a private room is required because of the medical condition of the patient; and
(l) Food that is specially prepared for the patient or requested in lieu of food that is regularly prepared by the facility as required by NAC 449.74525.
3. A facility for skilled nursing shall not:
(a) Charge a patient any amount for an item or service that has not been requested by the patient.
(b) Require a patient or his representative to request an item or service as a condition of the patient being admitted to or remaining in the facility.
4. If an item or service is requested by a patient or his representative for which there will be a charge, a facility for skilled nursing shall inform the patient or representative of the amount of the charge.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74465 Sending and receiving mail. (NRS 449.037) A facility for skilled nursing shall not prohibit a patient in the facility from:
1. Sending and promptly receiving mail. A patient’s mail must not be opened by the facility.
2. Obtaining stationery, postage and writing instruments at the patient’s expense.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74467 Performance of services for facility by patient. (NRS 449.037)
1. A facility for skilled nursing shall not require a patient in the facility to perform services for the facility.
2. A patient may perform services for the facility only if:
(a) The facility has included in the patient’s plan of care his need or desire to perform services for the facility;
(b) The plan of care describes the nature of the services to be performed and the compensation, if any, to be paid for those services;
(c) The compensation to be paid for the services is at or above the prevailing wage; and
(d) The patient agrees to perform the services described in the plan of care.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
Quality of Care
NAC 449.74469 Standards of care. (NRS 449.037) A facility for skilled nursing shall provide to each patient in the facility the services and treatment that are necessary to attain and maintain the patient’s highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment conducted pursuant to NAC 449.74433 and the plan of care developed pursuant to NAC 449.74439.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74471 Administration of drugs. (NRS 449.037)
1. A facility for skilled nursing shall not administer a drug to a patient in the facility:
(a) In excessive doses, including duplicate drug therapy;
(b) For an excessive duration;
(c) Without monitoring the patient properly;
(d) Without adequate indications for the use of the drug; or
(e) If there are any adverse reactions which indicate that the dosage should be reduced or discontinued.
2. Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433, a facility for skilled nursing shall ensure that a patient who:
(a) Has not used an antipsychotic drug is not given such a drug unless it is required to treat a condition of the patient that has been diagnosed and documented in the medical record of the patient.
(b) Uses an antipsychotic drug receives gradual reductions in the dosage, in conjunction with behavioral intervention, in an attempt to discontinue the use of the drug, unless the medical condition of the patient requires otherwise.
3. A facility for skilled nursing shall ensure that patients are not subjected to significant errors in their medication and that the rate of error in the administration of medication is less than 5 percent.
4. A facility for skilled nursing shall not prohibit a patient from administering medication to himself if the interdisciplinary team responsible for the care of the patient determines that this practice is safe.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74473 Program for control of infections. (NRS 449.037)
1. A facility for skilled nursing shall establish and maintain a program for the control of infections within the facility.
2. The program must:
(a) Be designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of disease and infection.
(b) Include procedures for the investigation, control and prevention of infections in the facility.
(c) Establish the procedures that will be followed if a patient becomes infectious, including, without limitation, the circumstances under which a patient may be isolated. A facility shall isolate any patient if required to prevent the spread of infection.
(d) Provide for the maintenance of records of infections and the corrective actions taken when infections occurred.
3. A facility shall ensure that:
(a) An employee with a communicable disease or an infected skin lesion does not come into direct contact with patients in the facility or their food if such contact may result in the transmission of the disease.
(b) Employees wash their hands after any direct contact with a patient if required by accepted professional practices.
4. Linens must be handled, stored, processed and transported in a manner which prevents the spread of infection.
5. The medical records of each patient in the facility must include documentation that the patient has been tested for tuberculosis in accordance with the provisions of NAC 441A.380.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74475 Vision and hearing. (NRS 449.037) A facility for skilled nursing shall:
1. Ensure that each patient in the facility receives proper treatment and devices for his vision and hearing.
2. Assist a patient, if necessary, in making appointments for the treatment of his vision and hearing.
3. If necessary, arrange transportation for a patient to visit a practitioner for the treatment of his vision or hearing or to obtain devices needed for his vision or hearing.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74477 Pressure sores. (NRS 449.037) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433, a facility for skilled nursing shall ensure that a patient:
1. Who is admitted to the facility without pressure sores does not develop pressure sores unless the development of pressure sores is unavoidable because of the medical condition of the patient; and
2. With pressure sores receives the services and treatment needed to promote healing, prevent infection and prevent new sores from developing.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74479 Urinary problems. (NRS 449.037) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433, a facility for skilled nursing shall ensure that a patient:
1. Who is admitted to the facility without an indwelling catheter is not required to use a catheter unless catheterization is unavoidable because of the medical condition of the patient; and
2. Who is incontinent receives the services and treatment needed to prevent the infection of his urinary tract and restore the normal function of his bladder.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74481 Range of motion. (NRS 449.037) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433, a facility for skilled nursing shall ensure that:
1. The range of motion of a patient admitted to the facility is not reduced unless the reduction is unavoidable because of the medical condition of the patient; and
2. A patient with a limited range of motion receives the services and treatment needed to increase his range of motion and to prevent any further loss in his range of motion.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74483 Mental or psychosocial behavior. (NRS 449.037) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433, a facility for skilled nursing shall ensure that a patient:
1. Who is having difficulty adjusting to his environment and is exhibiting abnormal mental or psychosocial behavior receives the services and treatment needed to correct the assessed problem; and
2. Whose assessment does not indicate any difficulty adjusting to his environment or abnormal mental or psychosocial behavior does not become withdrawn, angry or depressed or decrease his social interaction unless such behavior is unavoidable because of the medical condition of the patient.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74485 Nasogastric tubes. (NRS 449.037) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433, a facility for skilled nursing shall ensure that a patient who is:
1. Able to feed himself with or without assistance is not fed with a nasogastric tube unless a nasogastric tube is unavoidable because of the medical condition of the patient; and
2. Fed with a nasogastric tube receives the services and treatment needed to:
(a) Prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers; and
(b) Restore, if possible, normal eating skills.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74487 Nutritional health; hydration. (NRS 449.037)
1. Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433, a facility for skilled nursing shall ensure that:
(a) The nutritional health of the patient is maintained, including, without limitation, the maintenance of his weight and levels of protein, unless the nutritional health of the patient cannot be maintained because of his medical condition.
(b) The patient receives a therapeutic diet if such a diet is required by the patient.
2. A facility for skilled nursing shall provide each patient in the facility with sufficient fluids to maintain proper hydration and health.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74489 Physical or chemical restraint of patients. (NRS 449.037)
1. A facility for skilled nursing shall not use physical or chemical restraints on a patient to discipline the patient or for the convenience of members of the staff.
2. Physical or chemical restraints may be used only if required to treat a patient’s medical symptoms.
3. As used in this section:
(a) “Chemical restraints” means a psychopharmacologic drug that is not required to treat the medical symptoms of a patient, but is used to discipline a patient or for the convenience of members of the staff of a facility for skilled nursing.
(b) “Physical restraints” means any manual method or physical or mechanical device, material or equipment attached or adjacent to a patient’s body that cannot be removed easily by the patient and restricts the freedom of movement of the patient or normal access to the patient’s body.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74491 Prohibition of certain practices regarding patients; investigation of certain violations and injuries to patients; unfit employees. (NRS 449.037)
1. A facility for skilled nursing shall adopt and carry out written policies and procedures that prohibit:
(a) The mistreatment and neglect of the patients in the facility;
(b) The verbal, sexual, physical and mental abuse of the patients in the facility;
(c) Corporal punishment and involuntary seclusion; and
(d) The misappropriation of the property of the patients in the facility.
2. A facility for skilled nursing shall adopt procedures which ensure that all alleged violations of the policies adopted pursuant to subsection 1 and injuries to patients of unknown origin are reported immediately to the administrator of the facility, to the Bureau and to other officials in accordance with state law, and are thoroughly investigated. The procedures must ensure that further violations are prevented while the investigation is being conducted.
3. The results of any investigation must be reported:
(a) To the administrator of the facility or his designated representative and to the Bureau within 5 working days after the alleged violation is reported.
(b) In the manner prescribed in NRS 200.5093 and 432B.220 and chapter 433 of NRS.
Ê The administrator of the facility shall take appropriate action to correct any violation.
4. A facility for skilled nursing:
(a) Shall not employ a person if:
(1) He has been convicted of abusing, neglecting or mistreating a patient; or
(2) A finding that he has abused, neglected, mistreated or misappropriated the property of a patient has been entered in the state nursing assistants registry maintained by the State Board of Nursing.
(b) Shall report to the State Board of Nursing, the Bureau or another appropriate occupational licensing board any judicial action taken against an employee or former employee of the facility which would indicate that the employee is unfit to be employed as a member of the staff of a facility for skilled nursing.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74493 Notification of changes or condition of patient. (NRS 449.037)
1. A facility for skilled nursing shall immediately notify a patient, the patient’s legal representative or an interested member of the patient’s family, if known, and, if appropriate, the patient’s physician when:
(a) The patient has been injured in an accident and may require treatment from a physician;
(b) The patient’s physical, mental or psychosocial health has deteriorated and resulted in medical complications or is threatening the patient’s life;
(c) There is a need to discontinue the current treatment of the patient because of adverse consequences caused by that treatment or to commence a new type of treatment;
(d) The patient will be transferred or discharged from the facility;
(e) The patient will be assigned to another room or assigned a new roommate; or
(f ) There is any change in federal or state law that affects the rights of the patient.
2. A facility for skilled nursing shall maintain in its records and periodically revise the address and telephone number of a patient’s legal representative and interested members of the patient’s family.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74495 Development of program of activities. (NRS 449.037)
1. A facility for skilled nursing shall provide for each patient in the facility a program of activities that is developed in accordance with the comprehensive assessment of the patient conducted pursuant to NAC 449.74433.
2. The program of activities must be directed by a member of the staff who:
(a) Is a therapeutic recreational specialist or activities specialist and is eligible for certification by an organization for accrediting such specialists;
(b) Within the preceding 5 years, has at least 2 years of experience working in a social or recreational program, 1 year of which was as a full-time employee in a patient activities program in a health care setting;
(c) Is a licensed occupational therapist or occupational therapy assistant; or
(d) Has completed a course of training for directing programs of activities for patients in a health care setting.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74497 Daily activities of patient. (NRS 449.037)
1. Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433, a facility for skilled nursing shall ensure that:
(a) The patient’s ability to carry out his daily activities does not diminish unless such diminution is unavoidable because of the medical condition of the patient;
(b) The patient receives the services and treatment needed to maintain or improve his ability to carry out his daily activities; and
(c) The patient receives the services needed to maintain his grooming and personal and oral hygiene, and to ensure good nutrition, if the patient is unable to carry out his daily activities.
2. As used in this section, “daily activities” includes, without limitation:
(a) Bathing, dressing and grooming oneself;
(b) The ability to be ambulatory;
(c) Using the toilet without assistance;
(d) Feeding oneself; and
(e) Using speech, language and other communication systems.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74499 Participation in activities. (NRS 449.037)
1. A facility for skilled nursing shall not prohibit a patient in the facility from:
(a) Participating in activities and maintaining a schedule that are consistent with his interests, assessments and plan of care;
(b) Making choices relating to his health care that are consistent with his plan of care;
(c) Interacting with persons inside and outside of the facility;
(d) Participating in social, religious and community activities that do not interfere with other patients in the facility; and
(e) Making such other choices relating to his activities within the facility that are of significance to the patient.
2. A patient in a facility for skilled nursing may organize and participate in groups formed to interact with other patients in the facility and with the members of their families. A facility for skilled nursing shall provide a private area within the facility in which the members of such a group may meet.
3. A member of the staff of the facility or a visitor to the facility may attend a meeting of such a group if granted permission to do so by the members of the group.
4. A facility for skilled nursing shall designate a member of its staff to provide assistance for and respond to the requests of such a group.
5. The administrator of a facility for skilled nursing shall ensure that any grievances or recommendations submitted by the members of such a group relating to the operation of the facility are given consideration and acted upon appropriately.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
Staff and Attending Physicians
NAC 449.74511 Personnel policies; personnel records. (NRS 449.037)
1. A facility for skilled nursing shall adopt written policies for the personnel employed at the facility.
2. The written policies must:
(a) Include the duties and responsibilities of, and the qualifications required for, each position at the facility;
(b) Include the conditions of employment for each position at the facility;
(c) Include the policies and objectives of the facility related to training while on the job and requirements for continuing education; and
(d) Be periodically reviewed and made available to each employee of the facility.
3. A current and accurate personnel record for each employee of the facility must be maintained at the facility. The record must include, without limitation:
(a) Evidence that the employee has obtained any license, certificate or registration, and possesses the experience and qualifications, required for the position held by the employee;
(b) Such health records as are required by chapter 441A of NAC which include evidence that the employee has had a skin test for tuberculosis in accordance with NAC 441A.375; and
(c) Documentation that the facility has not received any information that the employee has been convicted of a crime listed in paragraph (a) of subsection 1 of NRS 449.188.
4. A facility shall make its personnel records available to the Bureau for inspection upon request.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74513 Medical director. (NRS 449.037)
1. A facility for skilled nursing shall employ a medical director who is licensed to practice medicine in this State.
2. The medical director shall:
(a) Carry out the policies of the facility related to the medical care of its patients; and
(b) Coordinate the medical care provided by the facility.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74515 Physicians. (NRS 449.037)
1. A patient may be admitted to a facility for skilled nursing only upon the written approval of a physician. Upon a patient’s admission to the facility, the facility shall ensure that orders for the immediate care of the patient have been received from the patient’s attending physician.
2. Each patient admitted to a facility for skilled nursing must remain under the care of a physician.
3. A facility for skilled nursing shall ensure that:
(a) The medical care of each patient in the facility is supervised by a physician; and
(b) A physician other than the attending physician of a patient supervises the care of that patient when the attending physician is not available.
4. A patient in a facility for skilled nursing must be visited by a physician at least once every 30 days for the first 90 days after his admission to the facility, and at least once every 60 days thereafter. For the purposes of this subsection, a visit from a physician shall be deemed to be timely if it occurs not later than 10 days after the date on which the visit is required. Except as otherwise provided in this section, each visit required by this subsection must be made by the physician.
5. At each visit to a patient required by subsection 4:
(a) The patient’s plan of care must be reviewed, including, without limitation, the medications and treatments prescribed for the patient;
(b) Progress notes of the visit must be prepared, signed and dated; and
(c) Any orders for the treatment of the patient must be signed and dated.
6. After the initial visit to a patient is made by a physician, every other visit to the patient may be made by a physician assistant, nurse practitioner or clinical nurse specialist on behalf of the physician if the physician assistant, nurse practitioner or clinical nurse specialist is acting:
(a) Within the authorized scope of his practice and under the supervision of the physician; and
(b) In accordance with state law and the policies of the facility for skilled nursing.
7. A facility for skilled nursing shall provide or arrange for the provision of physicians’ services 24 hours a day in the case of an emergency.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74517 Nursing staff. (NRS 449.037)
1. A facility for skilled nursing shall ensure that there is a sufficient number of members of the nursing staff on duty at all times to provide nursing care to and attain and maintain the highest practicable physical, mental and psychosocial well-being of each patient in the facility in accordance with his plan of care.
2. A facility for skilled nursing shall employ a full-time registered nurse to act as the chief administrative nurse. The chief administrative nurse must have:
(a) At least 3 years of experience providing nursing care in a hospital or facility for long-term care; and
(b) Experience supervising other employees.
3. A licensed practical nurse must be designated on each shift as the nurse in charge. The chief administrative nurse may be designated as the nurse in charge only if the facility has an average daily occupancy of not more than 60 patients.
4. A registered nurse must be on duty at a facility for skilled nursing for at least 8 consecutive hours per day, 7 days a week.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74519 Nursing assistants and nursing assistant trainees. (NRS 449.037)
1. A facility for skilled nursing shall not employ a person as a nursing assistant trainee, full time, temporarily or under contract:
(a) Until the facility obtains from the training program required for certification as a nursing assistant in which the person is enrolled, verification that the person has completed 16 hours of instruction in the classroom or is awaiting the results of a certification examination.
(b) For more than 4 months.
2. A facility for skilled nursing shall ensure that each nursing assistant employed by the facility is able to demonstrate competency in skills and techniques that are necessary to care for the patients in the facility in accordance with each patient’s plan of care.
3. A performance review must be completed for each nursing assistant employed by a facility for skilled nursing at least annually. Based on the results of the review, a facility shall provide training to a nursing assistant to ensure his competency. The training must:
(a) Comply with any requirements for training adopted by the State Board of Nursing pursuant to chapter 632 of NRS;
(b) Be at least 12 hours per year;
(c) Address any areas of weakness indicated in the review and may address the special needs of the patients in the facility as determined by the personnel of the facility; and
(d) If the nursing assistant provides services to patients with cognitive impairments, address the care of such patients.
4. A facility for skilled nursing shall not employ a nursing assistant if, for a period of 24 consecutive months after his completion of the training program required for certification as a nursing assistant, he has not provided nursing services or services related to nursing for monetary compensation.
5. As used in this section:
(a) “Nursing assistant” has the meaning ascribed to it in NRS 632.0166.
(b) “Nursing assistant trainee” has the meaning ascribed to it in NRS 632.0168.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74521 Other health care professionals. (NRS 449.037)
1. A facility for skilled nursing shall employ full time, part time or as consultants such health care professionals as are necessary to provide adequate care for each patient in the facility and to carry out the provisions of NAC 449.744 to 449.74549, inclusive.
2. A health care professional employed by a facility for skilled nursing shall comply with accepted professional standards applicable to the services provided by the health care professional.
3. If a facility for skilled nursing does not employ a person to furnish a service required by the facility, the facility shall obtain that service from a qualified outside source. An agreement for obtaining such services must specify, in writing, that the facility assumes responsibility for:
(a) Obtaining services that comply with accepted professional standards applicable to the services being obtained; and
(b) The timely delivery of such services.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74522 Employees of facility which provides care to persons with dementia. (NRS 449.0357, 449.037)
1. Except as otherwise provided in subsection 4, each person who is employed by a facility for skilled nursing which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, who has direct contact with and provides care to persons with any form of dementia and who is licensed or certified by an occupational licensing board must complete the following number of hours of continuing education specifically related to dementia:
(a) In his first year of employment with a facility for skilled nursing, 8 hours which must be completed within the first 30 days after the employee begins employment; and
(b) For every year after the first year of employment, 3 hours which must be completed on or before the anniversary date of the first day of employment.
2. The hours of continuing education required to be completed pursuant to this section:
(a) Must be approved by the occupational licensing board which licensed or certified the person completing the continuing education; and
(b) May be used to satisfy any continuing education requirements of an occupational licensing board and do not constitute additional hours or units of required continuing education.
3. Each facility for skilled nursing shall maintain proof of completion of the hours of continuing education required pursuant to this section in the personnel file of each employee of the facility who is required to complete continuing education pursuant to this section.
4. A person employed by a facility for skilled nursing which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, is not required to complete the hours of continuing education specifically related to dementia required pursuant to subsection 1 if he has completed that training within the previous 12 months.
5. As used in this section, “continuing education specifically related to dementia” includes, without limitation, instruction regarding:
(a) An overview of the disease of dementia, including, without limitation, dementia caused by Alzheimer’s disease, which includes instruction on the symptoms, prognosis and treatment of the disease;
(b) Communicating with a person with dementia;
(c) Providing personal care to a person with dementia;
(d) Recreational and social activities for a person with dementia;
(e) Aggressive and other difficult behaviors of a person with dementia; and
(f ) Advising family members of a person with dementia concerning interaction with the person with dementia.
(Added to NAC by Bd. of Health by R067-04, eff. 8-4-2004)
REVISER’S NOTE.
The regulation of the Board of Health filed with the Secretary of State on August 4, 2004 (LCB File No. R067-04), the source of this section (section 3 of the regulation), contains the following provisions not included in NAC:
“1. Each person who on August 4, 2004, is employed by a facility for skilled nursing which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, and who is required to complete the hours of continuing education specifically related to dementia required pursuant to section 3 of this regulation [NAC 449.74522], shall complete at least 8 hours of continuing education specifically related to dementia within 12 months after August 4, 2004, unless the person has completed the training within the 12 months before August 4, 2004.
2. Evidence that such a person has completed the training required pursuant to subsection 1 must be included in his personnel file and must be kept at the facility.”
Provision of Services
NAC 449.74523 Social services. (NRS 449.037)
1. A facility for skilled nursing shall provide medically-related social services that are designed to assist the patients in the facility in enhancing or restoring their ability to function physically, socially and economically.
2. The social services provided must:
(a) Identify and meet the social and emotional needs of each patient in the facility.
(b) Assist each patient and the members of his family in adjusting to the effects of the patient’s illness or disability, to his treatment and to his stay in the facility.
(c) Include adequate planning upon the patient’s discharge from the facility to ensure that appropriate community and health resources are used.
3. A facility for skilled nursing shall employ full time or under contract an adequate number of social workers and other personnel who are appropriately trained, experienced and qualified to plan, provide and evaluate the social services provided to the patients in the facility. Each social worker employed by the facility must be licensed to engage in social work as a social worker pursuant to chapter 641B of NRS. The facility shall adopt and carry out a plan requiring any social worker employed by the facility who has not completed at least 1 year of training or experience related to providing social services to patients in a facility for skilled nursing to consult with a social worker with such training or experience.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74525 Dietary services. (NRS 449.037)
1. A facility for skilled nursing shall employ full time, part time or as a consultant, a person who is registered as a dietitian by the Commission on Dietetic Registration of the American Dietetic Association. If a registered dietitian is not employed full time, the facility shall designate a person to serve as the director of food service who receives frequently scheduled consultations from a registered dietitian.
2. A facility shall employ an adequate number of qualified and competent personnel to provide food service to the patients in the facility.
3. Menus must be planned in advance and followed to meet the nutritional needs of the patients in the facility in accordance with the recommended dietary allowances of the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences.
4. A facility shall provide to each patient in the facility:
(a) Food that is prepared to conserve the nutritional value and flavor of the food.
(b) Food that is nourishing, palatable, attractive and served at the proper temperature.
(c) A well-balanced diet that meets the daily nutritional and special dietary needs of the patient.
(d) Who refuses the food that is regularly served by the facility, a substitute of similar nutritional value.
5. A therapeutic diet served to a patient by a facility must be prescribed by the attending physician of the patient.
6. A facility shall serve to each patient in the facility at least three meals daily, at such times as are comparable to regular mealtimes within the community in which the facility is located. A snack must be offered to each patient daily at bedtime. Except as otherwise provided in this subsection, breakfast must be served not more than 14 hours after the previous evening meal. If a nourishing snack is served at bedtime, breakfast may be served not more than 16 hours after the previous evening meal if approved by a group of patients organized pursuant to NAC 449.74499.
7. A facility shall provide special eating equipment and utensils to each patient who requires them.
8. A facility shall:
(a) Comply with the applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto and obtain such permits as are necessary from the Bureau of Health Protection Services of the Health Division for the preparation and service of food;
(b) Maintain a report of each inspection concerning the sanitation of the hospital for at least 1 year after the date of the inspection;
(c) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (b) for at least 1 year after the date of the corrective action;
(d) Procure food from sources that are approved or considered satisfactory by federal, state and local authorities;
(e) Store, prepare and serve food under sanitary conditions; and
(f ) Dispose of refuse and garbage properly.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R067-04, 8-4-2004)
NAC 449.74527 Specialized rehabilitative services. (NRS 449.037)
1. A facility for skilled nursing shall provide to a patient in the facility, according to his plan of care, specialized rehabilitative services, including, without limitation, physical therapy, speech pathology, occupational therapy and services for mental illness and mental retardation. Such services must be provided by the facility or obtained from qualified outside sources pursuant to NAC 449.74521.
2. Specialized rehabilitative services may be provided to a patient in a facility only upon the written order of a physician.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74529 Dental services. (NRS 449.037) A facility for skilled nursing shall:
1. Provide or obtain from qualified outside sources pursuant to NAC 449.74521, routine and emergency dental services required to meet the needs of each patient in the facility;
2. Assist patients in the facility with obtaining routine and emergency dental care by:
(a) Making appointments; and
(b) Arranging for transportation to and from a dentist’s office; and
3. Promptly refer a patient with lost or damaged dentures to a dentist.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74531 Pharmaceutical services. (NRS 449.037)
1. A facility for skilled nursing shall provide such pharmaceutical services, including, without limitation, acquiring, receiving, dispensing and administering drugs and biologicals, as are required to meet the needs of the patients in the facility. The facility shall provide such drugs and biologicals as are needed or obtain them from qualified outside sources pursuant to NAC 449.74521.
2. A facility for skilled nursing shall employ or otherwise obtain the services of a registered pharmacist. The registered pharmacist shall:
(a) Provide consultations on all matters relating to the pharmaceutical services provided by the facility;
(b) Establish a system of records for the receipt and disposition of all controlled substances in the facility in sufficient detail to ensure an accurate reconciliation; and
(c) Ensure that those records are in order and that an account of all controlled substances in the facility is maintained and periodically reconciled.
3. The regimen of drugs for each patient in the facility must be reviewed at least once each month by a registered pharmacist. The pharmacist shall report any irregularities he discovers to the patient’s attending physician and the chief administrative nurse of the facility. The physician and chief administrative nurse shall take such actions as they deem necessary in response to the report.
4. Drugs and biologicals used by a facility must be:
(a) Labeled in accordance with state and federal law and accepted professional standards. Each label must include the appropriate accessory and cautionary instructions and the expiration date, if applicable.
(b) Stored in accordance with state and federal law in locked compartments with proper controls for the temperature. Only authorized personnel may have access to the keys to unlock the compartments. Substances listed as schedule II controlled substances pursuant to chapter 453 of NRS and other drugs that have the potential for abuse must be stored separately in a locked compartment that is immovable, unless the facility uses a system to distribute the substances or drugs in single-unit packages, the quantity stored is minimal and a dosage that is missing can be readily detected.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74533 Laboratory services. (NRS 449.037)
1. A facility for skilled nursing shall provide laboratory services to meet the needs of the patients in the facility or contract with a laboratory to obtain such services.
2. If a facility for skilled nursing has its own laboratory, it must be a licensed clinical laboratory under the provisions of chapter 652 of NRS and comply with the provisions of 42 C.F.R. Part 493. The provisions of this subsection do not prohibit a licensed nurse from performing laboratory tests pursuant to NRS 652.217.
3. If the facility contracts with a laboratory for its services, that laboratory must be:
(a) A licensed clinical laboratory under the provisions of chapter 652 of NRS; and
(b) Certified in the specialties and subspecialties required by the facility in accordance with the provisions of 42 C.F.R. Part 493.
4. A facility for skilled nursing shall:
(a) Provide or obtain only such laboratory tests as are ordered by the attending physician of a patient in the facility;
(b) Promptly notify the attending physician of the results of those tests;
(c) Arrange transportation for a patient to obtain laboratory tests ordered by the patient’s attending physician, if the patient requires such assistance; and
(d) Include in the medical records of a patient all reports of the results of laboratory tests ordered for the patient. The reports must include:
(1) The date on which the tests were performed; and
(2) The name and address of the laboratory performing the tests.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74535 Radiological and other diagnostic services. (NRS 449.037)
1. A facility for skilled nursing shall provide radiological and other diagnostic services to meet the needs of the patients in the facility or contract with qualified outside sources to obtain such services.
2. If a facility for skilled nursing provides radiological and other diagnostic services, it shall comply with applicable state law related to the provision of such services.
3. A facility for skilled nursing shall:
(a) Provide or obtain only such radiological and other diagnostic tests as are ordered by the attending physician of a patient in the facility;
(b) Promptly notify the attending physician of the results of those tests;
(c) Arrange transportation for a patient to obtain radiological and other diagnostic tests ordered by the patient’s attending physician, if the patient requires such assistance; and
(d) Include in the medical records of a patient all reports of the results of radiological and other diagnostic tests ordered for the patient. The reports must:
(1) Include the date on which the tests were performed; and
(2) Be signed by the person performing the tests.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74537 Special services. (NRS 449.037) A facility for skilled nursing shall ensure that a patient in the facility receives the following special services if needed:
1. Injections.
2. Parenteral and enteral fluids.
3. Colostomy, ureterostomy and ileostomy care.
4. Tracheostomy care.
5. Tracheal suctioning.
6. Respiratory care.
7. Foot care.
8. Prostheses.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
Physical Environment
NAC 449.74539 General requirements. (NRS 449.037) A facility for skilled nursing shall:
1. Provide a safe, functional, sanitary and comfortable environment for the patients in the facility, the members of its staff and members of the general public;
2. Care for each patient in the facility in a manner that promotes the dignity of the patient and his quality of life;
3. Ensure that the environment of the facility is free of hazards that would cause accidents;
4. Ensure that each patient in the facility receives adequate supervision and devices to prevent accidents;
5. Provide such housekeeping and maintenance services as are necessary to maintain a sanitary, orderly and comfortable environment;
6. Adopt procedures to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water;
7. Equip corridors with firmly secured handrails on each side;
8. Provide adequate and comfortable levels of lighting in all areas of the facility;
9. Provide comfortable levels of sound in all areas of the facility;
10. Maintain an effective program to control pests in order to ensure that the facility is free from pests and rodents;
11. Have adequate outside ventilation by means of windows or mechanical ventilation, or both; and
12. Provide safe and comfortable levels of temperature in the facility. The temperature of the facility must be maintained at a level that is not less than 71 degrees Fahrenheit and not more than 81 degrees Fahrenheit.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99)
NAC 449.74543 Design, construction, equipment and maintenance: General requirements; prerequisites to approval of facility for licensure. (NRS 449.037)
1. A facility for skilled nursing must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the facility and members of the general public.
2. Except as otherwise provided in this section:
(a) A facility for skilled nursing shall comply with the provisions of NFPA 101: Life Safety Code, adopted by reference pursuant to NAC 449.0105.
(b) Any new construction, remodeling or change in use of a facility for skilled nursing must comply with the Guidelines for Design and Construction of Hospital and Health Care Facilities, adopted by reference pursuant to NAC 449.0105, unless the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting the area, replacing the flooring, repairing windows, or replacing window and wall coverings.
3. A facility for skilled nursing shall be deemed to be in compliance with the provisions of subsection 2 if:
(a) The facility is licensed on January 1, 1999, the use of the physical space in the facility is not changed and there are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the public health and welfare; or
(b) The facility has submitted building plans to the Bureau before February 1, 1999, and:
(1) The Bureau determines that the plans comply with standards for construction in effect before December 11, 1998;
(2) The facility is constructed in accordance with those standards;
(3) Construction of the facility is begun before August 1, 1999; and
(4) There are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the public health and welfare.
4. Except as otherwise provided in subsection 5, a facility for skilled nursing shall comply with all applicable:
(a) Federal and state laws;
(b) Local ordinances, including, without limitation, zoning ordinances; and
(c) Life safety, environmental, health, fire and local building codes,
Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply.
5. A facility for skilled nursing which is inspected and approved by the State Public Works Board in accordance with the provisions set forth in chapter 341 of NRS and chapter 341 of NAC is not required to comply with any applicable local building codes related to the construction and maintenance of the facility.
6. A facility for skilled nursing shall submit building plans for new construction or remodeling to the entity designated to review such plans by the Health Division pursuant to NAC 449.0115. The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the facility. Before the construction or remodeling may begin, the plans for the construction or remodeling must be approved by the Health Division. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R076-01, 10-18-2001; R067-04, 8-4-2004)
NAC 449.74549 Patients’ rooms. (NRS 449.037)
1. A patient’s room within a facility for skilled nursing must be designed and equipped in a manner that allows adequate nursing care to be provided and provides comfort and privacy for the patient.
2. A facility for skilled nursing shall provide to each patient in the facility:
(a) A separate bed of proper size and height for the convenience of the patient;
(b) A clean, comfortable mattress;
(c) Bedding that is appropriate for the weather and climate;
(d) Clean linens for his bed and bath that are in good condition; and
(e) Furniture that is appropriate for the patient’s needs.
(Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R067-04, 8-4-2004)
NURSING POOLS
General Provisions
NAC 449.747 Definitions. (NRS 449.037) As used in NAC 449.747 to 449.7481, inclusive, unless the context otherwise requires:
1. “License” means a document issued by the Health Division permitting the operation of a nursing pool.
2. “Licensee” means a person to whom a license has been issued.
3. “Nursing pool” has the meaning ascribed to it in NRS 449.0153.
(Added to NAC by Bd. of Health, eff. 1-31-90; A 8-1-91; R044-97, 10-30-97)
Licensing
NAC 449.7471 License required. (NRS 449.037) No person, state or local government, or agency thereof, may establish, conduct or maintain in this State a nursing pool without first obtaining a license from the Health Division.
(Added to NAC by Bd. of Health, 1-31-90, eff. 7-1-90)
NAC 449.7473 Location to which license applies; persons named in license; restrictions on use of license. (NRS 449.037)
1. Each license is separate and distinct and is issued to a specific person to operate a nursing pool at a specific location. A nursing pool must be operated and conducted under the name and within the area of service designated on the license. The name of the person who is designated as responsible for its conduct must appear on the face of the license.
2. A separate license is required for each nursing pool owned and controlled by a central organization, corporate entity or home office, but operated and directed by governing and administrative bodies separate from the central organization or any other unit owned and controlled by the central organization.
(Added to NAC by Bd. of Health, eff. 1-31-90; A by R044-97, 10-30-97)
NAC 449.7474 Duties of licensee or applicant for license. (NRS 449.037)
1. A licensee or applicant for a license shall:
(a) Designate a person who is responsible for the conduct of the nursing pool; and
(b) Disclose the ownership of the nursing pool to the Health Division.
2. A licensee or applicant for a license is responsible for:
(a) Compliance by the nursing pool with all applicable local, state and federal laws, regulations and similar requirements.
(b) Periodic administrative and professional evaluations of the nursing pool. The licensee or applicant shall receive, review and take action on recommendations made by the evaluating groups and maintain a record of that action.
(c) The appointment of a qualified administrator and the delegation of his responsibility and authority. The licensee or applicant shall ensure that the administrator has sufficient freedom from his other responsibilities to permit his adequate attention to the overall direction and management of the nursing pool.
(d) The appointment of a director of professional services.
3. A licensee or applicant for a license shall adopt policies, including policies relating to the care of patients, and bylaws for the nursing pool. The bylaws must be written, revised as needed and made available to the Health Division. The bylaws must contain not less than the following:
(a) A description of the persons to whom responsibilities for the administration and supervision of the program and the evaluation of practices may be delegated, and the methods by which the licensee or applicant will hold those persons responsible.
(b) A provision requiring the establishment of personnel policies.
(c) A statement of the objectives of the nursing pool.
(Added to NAC by Bd. of Health, eff. 1-31-90)
Administration and Personnel
NAC 449.7475 Administrator: Qualifications and duties. (NRS 449.037)
1. The administrator of a nursing pool must be a physician or professional registered nurse, licensed to practice in this State, or a person having at least 1 year of supervisory or administrative experience in a field related to the provision of health care.
2. The administrator of a nursing pool shall represent the licensee in the daily operation of the nursing pool and appoint a person to exercise his authority in his absence. The administrator’s responsibilities include:
(a) Keeping the licensee fully informed of the activities of the nursing pool through regularly written reports;
(b) Employing qualified personnel and arranging for their orientation and continuing education;
(c) Developing and implementing an accounting and reporting system that reflects the fiscal experience and current financial position of the nursing pool;
(d) Negotiating for services provided by contract in accordance with legal requirements and established policies of the nursing pool;
(e) Holding periodic meetings to maintain a liaison between the licensee and members of the staff of the nursing pool; and
(f ) Performing such other duties as may be assigned.
(Added to NAC by Bd. of Health, eff. 1-31-90)
NAC 449.7476 Director of professional services: Qualifications and duties. (NRS 449.037)
1. The director of professional services must be a physician, or a professional registered nurse, who is licensed to practice in this State. The director must be readily available through the office of the nursing pool to advise members of the staff of the nursing pool.
2. The director of professional services shall:
(a) Direct, supervise and coordinate the skilled nursing services provided by the nursing pool;
(b) Develop and revise written objectives, policies and procedural manuals for the care of patients;
(c) Assist in the development of descriptions of jobs;
(d) Assist in the recruitment and selection of personnel;
(e) Recommend to the administrator the number and levels of members of the nursing staff;
(f ) Plan and conduct orientations and continuing education for members of the staff engaged in the care of patients;
(g) Evaluate the performance of the nursing staff; and
(h) Assist in planning and budgeting for the provision of services.
(Added to NAC by Bd. of Health, eff. 1-31-90)
NAC 449.7477 Personnel policies: Maintenance and availability. (NRS 449.037) A nursing pool shall maintain written policies concerning the qualifications, responsibilities and conditions of employment for each category of personnel, including licensure when required by law. The written policies must be reviewed as needed, made available to the members of the staff of the nursing pool and provide for:
1. Wages and hours;
2. Eligibility for vacations, sick leave and other benefits;
3. Maintenance of a current record of the health of each member of the staff;
4. Orientation of all health personnel to the policies and objectives of the nursing pool, training while on the job and continuing education;
5. Periodic evaluations of the performance of members of the staff;
6. Descriptions of jobs for each category of personnel which are specific and include the types of activities each category may perform; and
7. Maintenance of current personnel records which confirm that the policies are followed.
(Added to NAC by Bd. of Health, eff. 1-31-90)
NAC 449.7478 Requirements for contracts to provide nursing services. (NRS 449.037) If a nursing pool provides nursing services under a contract with another entity, other than a licensed medical facility, the services must be furnished in accordance with the terms of a written contract. The contract must:
1. Provide for retention by the nursing pool of responsibility for and control of the services.
2. Designate the services to be provided, including the setting and geographical area to be served. Services provided must be within the scope and limitations set forth in a physician’s plan of treatment for his patient, and must not be altered with regard to type, amount, frequency or duration, unless the patient suffers an adverse reaction to that treatment.
3. Describe the means of supervision of the personnel performing the services.
4. Describe the method of coordinating the services with the nursing pool.
5. Specify the method of determining charges by and reimbursement of the nursing pool for specific services provided under the contract. Only the nursing pool may bill or collect for services rendered.
6. Specify the period the contract will be effective and the frequency with which the contract will be reviewed. The contract must be reviewed not less than annually.
7. Ensure that the personnel and services which are the subject of the contract meet the requirements of NAC 449.747 to 449.7481, inclusive, including those requirements concerning licensure, qualifications, medical examinations, functions, supervision, orientation and continuing education.
8. Provide that only the nursing pool may accept patients for nursing services.
9. Ensure that the personnel and services which are the subject of the contract will provide treatment to referred patients without regard to race, creed or national origin.
(Added to NAC by Bd. of Health, eff. 1-31-90; A by R044-97, 10-30-97)
NAC 449.7479 Referral of patients when services not available; provision of services; bonding of staff. (NRS 449.037)
1. If services needed by a patient are not available from a nursing pool, it must assist in directing the patient to other resources in the community.
2. Services must be provided only by qualified personnel under the supervision of a physician who is licensed to practice in this State. Necessary qualifications include licensure, registration, certification or the equivalent, as required by state and federal law, for professional registered nurses, practical nurses and nursing assistants.
3. A nursing pool must secure an appropriate bond for each member of its staff who provides care directly to patients.
(Added to NAC by Bd. of Health, eff. 1-31-90)
NAC 449.748 Duties of registered nurse; provision of nursing care by practical nurse or nursing assistant. (NRS 449.037)
1. A registered nurse employed by a nursing pool shall:
(a) Provide nursing guidance and care to patients;
(b) If care is to be provided to a patient at his home, evaluate the home regarding its suitability for the provision of that care;
(c) Teach patients and those who provide them with care regarding the appropriate methods of providing that care;
(d) Supervise and evaluate the care given to patients on a continuing basis; and
(e) Provide any necessary professional nursing care.
2. A practical nurse or nursing assistant employed by a nursing pool may provide nursing care if he is authorized to practice in this State and supervised by a registered nurse.
(Added to NAC by Bd. of Health, eff. 1-31-90)
NAC 449.7481 Annual evaluation of nursing pool by licensee. (NRS 449.037)
1. A licensee shall perform an overall evaluation of the nursing pool annually. The purpose of the evaluation is to audit the financial condition of the nursing pool, to review its policies and procedures, to recommend additions or changes to those policies and procedures, and to ensure compliance with those policies and with applicable regulations.
2. A committee shall:
(a) Review the medical and personnel policies of the nursing pool to see that they are being fulfilled and that necessary additions or changes are effected; and
(b) Submit its report to the licensee, together with any recommendations for changes and any pertinent observations it deems necessary.
(Added to NAC by Bd. of Health, eff. 1-31-90)
HOME HEALTH AGENCIES
General Provisions
NAC 449.749 Definitions. (NRS 449.037) As used in NAC 449.749 to 449.800, inclusive, unless the context otherwise requires:
1. “Branch office” means an office, other than the home office, from which a home health agency provides services.
2. “Home health agency” means an agency to provide nursing in the home as defined in NRS 449.0015.
3. “Home health aide” means a nursing assistant as defined in NRS 632.0166.
4. “Home office” means the central administrative office of a home health agency.
5. “Subunit agency” means an agency owned and controlled by a central organization, corporate entity or home office, but operated and directed by governing and administrative bodies separate from the central organization or any other unit owned and controlled by the central organization.
[Bd. of Health, Home Health Agencies Part I Chap. II, eff. 1-10-74]—(NAC A 11-13-96)
Licensing and Inspection
NAC 449.752 License required. (NRS 449.037) No person, state, local government or any agency thereof may establish, conduct or maintain in this State a home health agency without first obtaining a license issued by the Health Division.
[Bd. of Health, Home Health Agencies Part II Chap. I § A, eff. 1-10-74]
NAC 449.758 Applicability of license; coverage against certain liabilities. (NRS 449.037)
1. Each license is separate and is issued to a specific person to operate a home health agency at a specific location. The home health agency must be operated and conducted in the name designated on the license with the designated service area and the name of the person responsible for its operation also appearing on the face of the license. The license is not transferable.
2. A separate license is required for each subunit agency.
3. Copies of the original license must be issued for each agency or branch of an agency which is maintained on separate premises under the same management.
4. Each home health agency must have proof that it is adequately covered against liabilities resulting from claims incurred in the course of operation.
[Bd. of Health, Home Health Agencies Part II Chap. I § D; Part II Chap. II, eff. 1-10-74]—(NAC A 11-13-96; R044-97, 10-30-97; R121-05, 11-17-2005)
NAC 449.761 Periodic inspections. (NRS 449.037) Every home health agency for which a license has been issued will be periodically inspected by an authorized representative of the Health Division. Reports of each inspection in which deficiencies were found will be prepared by the representative conducting the inspection. A copy of the report will be provided to the administrator of the home health agency within 10 days after the representative who conducted the inspection has conferred with the agency concerning the deficiencies found during the inspection. The administrator shall prepare a plan to correct the deficiencies set forth in the report and submit the plan to the Health Division within 10 days after receipt of the report from the Health Division.
[Bd. of Health, Home Health Agencies Part II Chap. I § E, eff. 1-10-74]—(NAC A 11-13-96)
NAC 449.767 Action to enjoin operation without license. (NRS 449.037)
1. The Health Division may bring an action in the name of the State to enjoin any person, partnership, corporation or association, or any state or local governmental unit or agency thereof, from establishing or maintaining a home health agency:
(a) Without first obtaining a license therefor; or
(b) After his license has been revoked or suspended by the Health Division.
2. It is sufficient in the action to allege that the defendant did, on a certain date and in a certain place, operate and maintain an agency without a license.
[Bd. of Health, Home Health Agencies Part II Chap. I §§ H & I, eff. 1-10-74]
NAC 449.768 Applicant or licensee to maintain home office in Nevada. (NRS 449.037) A person who applies for a license to operate a home health agency or a person who holds such a license shall maintain a home office in this State.
(Added to NAC by Bd. of Health, eff. 11-13-96)
Administration and Personnel
NAC 449.770 Governing body; bylaws. (NRS 449.037)
1. A home health agency must have an organized governing body or designated person who is legally responsible for the conduct of the agency.
2. The ownership of the home health agency must be disclosed to the Health Division. The governing body is responsible for compliance with all applicable local, state and federal laws and regulations.
3. The governing body shall appoint an advisory group of professional personnel, including one or more members who are practicing physicians, one or more professional registered nurses and representatives from other professional disciplines as indicated by the scope of the agency’s program.
4. The governing body is responsible for periodic administrative and professional evaluations of the agency.
5. The governing body shall receive, review and take action on recommendations made by the evaluating groups and document those actions.
6. The governing body shall adopt bylaws or an acceptable equivalent in accordance with legal requirements. The bylaws must be written, revised as needed, and made available to all members of the governing body, the Health Division and the advisory group. The terms of the bylaws must include at least the following:
(a) The basis upon which members of the governing body are selected, their terms of office and their duties and responsibilities.
(b) A provision specifying to whom responsibilities for the administration and supervision of the program and the evaluation of practices may be delegated, and the methods established by the governing body for holding those persons responsible.
(c) A provision specifying the frequency of board meetings and requiring that minutes be taken at each meeting.
(d) A provision requiring the establishment of personnel policies.
(e) The agency’s statements of objectives.
7. The governing body shall adopt policies for the agency including policies relating to admissions, care and discharge of patients.
8. The governing body is legally responsible for the appointment of a qualified administrator and the delegation of responsibility and authority.
9. The governing body shall ensure that the administrator has sufficient freedom from other responsibilities to permit adequate attention to the direction and management of the agency.
[Bd. of Health, Home Health Agencies Part II Chap. III §§ A & B, eff. 1-10-74]—(NAC A 11-13-96)
NAC 449.773 Administrator: Qualifications; duties. (NRS 449.037)
1. The administrator must be a professional registered nurse or licensed physician, either of whom must be licensed in this State, or a person with training or experience in health administration. The administrator must have at least 1 year of supervisory or administrative experience in a field related to health.
2. The administrator shall represent the governing body in the daily operation of the agency. His responsibilities include:
(a) Keeping the governing body fully informed of the conduct of the agency through regularly written reports and by attendance at meetings of the governing body.
(b) Employing qualified personnel and arranging for their orientation and continuing education.
(c) Developing and implementing an accounting and reporting system that reflects the fiscal experience and financial position of the agency.
(d) Negotiating for services provided by contract in accordance with legal requirements and established policies of the agency.
(e) Holding periodic meetings to maintain a liaison between the governing body, the advisory groups and the members of the staff.
(f ) Other duties as may be assigned.
3. The administrator shall appoint a person authorized to act in his absence. The person appointed by the administrator must possess the qualifications set forth in subsection 1.
[Bd. of Health, Home Health Agencies Part II Chap. III § C, eff. 1-10-74]—(NAC A 11-13-96)
NAC 449.776 Director of professional services. (NRS 449.037)
1. The director of professional services must be a physician or a registered professional nurse licensed to practice in this State who is readily available through the agency’s office to advise the members of the staff.
2. The director of professional services shall:
(a) Direct, supervise and coordinate the skilled nursing services and other therapeutic services provided by the agency.
(b) Develop and revise written objectives for the care of patients, policies and procedure manuals.
(c) Assist in the development of descriptions of jobs.
(d) Assist in the recruitment and selection of personnel.
(e) Recommend to the administrator the number and levels of members of the nursing staff.
(f ) Plan and conduct orientations and continuing education for members of the staff engaged in the care of patients.
(g) Evaluate the performance of the nursing staff.
(h) Assist in planning and budgeting for the provision of services.
(i) Assist in establishing criteria for the admission and discharge of patients.
[Bd. of Health, Home Health Agencies Part II Chap. III § D, eff. 1-10-74]
NAC 449.779 Professional advisory group. (NRS 449.037)
1. The professional advisory group must be appointed by the governing body and shall assist in establishing written policies covering skilled nursing, other therapeutic services and other aspects of professional health. These policies must be reviewed at least annually and revised as necessary, and must cover the following:
(a) The scope of services offered;
(b) Administrative records;
(c) Personnel qualifications and responsibilities; and
(d) The evaluation of programs.
2. The professional advisory group must include at least one member who is a licensed practicing physician, one professional registered nurse, representatives from other professional disciplines as indicated by the scope of the agency’s program and two members who are representatives of the general public served by the agency. At least one member of the advisory group may not be an owner or employee of the agency. The administrator or his designee shall attend all meetings of the advisory group.
3. The advisory group shall meet at regular intervals, but at least once a year. Dated minutes must reflect an evaluation of overall agency performance, including the availability of services, the utilization of services and the quality of services. Recommendations must be forwarded to the governing body.
4. The advisory group must be available to advise the governing body on policies issued and the evaluation of programs.
5. The advisory group shall participate in a continuing program to acquaint the community with the established policies and the scope and availability of services provided by the agency and to promote appropriate utilization.
6. The member of the advisory group who is a physician shall interpret the established policies to the local medical society and to other physicians.
7. Brochures and pamphlets describing the home health services of the agency must be prepared with the advice of the advisory group and distributed to other community resources and the general public.
[Bd. of Health, Home Health Agencies Part II Chap. III § E, eff. 1-10-74]—(NAC A 11-13-96)
NAC 449.782 Personnel policies. (NRS 449.037) A home health agency shall establish written policies concerning the qualifications, responsibilities and conditions of employment for each type of personnel, including licensure if required by law. The written policies must be reviewed as needed and made available to the members of the staff and the advisory groups. The personnel policies must provide for:
1. Wage and hour policies;
2. Eligibility for vacation, sick leave and other fringe benefits;
3. The orientation of all health personnel to the policies and objectives of the agency, training while on the job, and continuing education;
4. Periodic evaluation of employees’ performances;
5. Job descriptions for each category of personnel which are specific and include the type of activity each may carry out;
6. The maintenance of employee records which confirm that personnel policies are followed; and
7. The maintenance of a health record for each employee as required by NAC 441A.375.
[Bd. of Health, Home Health Agencies Part II Chap. III § F subsec. 1, eff. 1-10-74]—(NAC A 11-13-96; R121-05, 11-17-2005)
NAC 449.785 Contracts for home health services. (NRS 449.037) If a home health agency provides home health services under a contract with another agency, person or nonprofit agency, it must require that such services be furnished in accordance with the terms of the written contract. The contract must:
1. Provide for retention by the primary agency of responsibility for and control of the services.
2. Designate the services which are to be provided, the setting and the geographical area served. Services provided must be within the scope and limitations set forth in the plan of treatment and may not be altered in type, amount, frequency or duration, except in the case of adverse reaction.
3. Describe how the contracted personnel are to be supervised.
4. Describe how services are coordinated with the primary agency.
5. Provide for the reporting of clinical notes and observations by contracted personnel for inclusion in the records of the primary home health agency to facilitate planning and evaluating patient care and to document the care given. Periodic progress notes by appropriate members of the staff must be submitted at least every 14 days and more often if warranted by the patient’s condition.
6. Specify the method of determining charges and reimbursement by the primary agency for specific services provided under contract. Only the primary agency may bill for or collect for services.
7. Specify the period of time the contract is to be in effect and how frequently it is to be reviewed. The contract must be reviewed annually.
8. Assure that personnel and services contracted for, meet the requirements specified in NAC 449.749 to 449.800, inclusive, for home health agency personnel and services, including licensure, personnel qualifications, medical examination, functions, supervision, orientation, in-service education and case conferences.
9. Provide for the acceptance of patients for home health service only by the primary home health agency. Patients may not be admitted for home health service by any person without an appropriate review of the case and acceptance of the patient by the agency.
10. Assure that personnel and services contracted for will provide treatment to referred patients without regard to race, creed or national origin.
[Bd. of Health, Home Health Agencies Part II Chap. III § F subsec. 2, eff. 1-10-74]
NAC 449.787 Duty to provide skilled nursing care and home health aide services; inclusion of additional services. (NRS 449.037) A home health agency is directly responsible for providing skilled nursing care and home health aide services, and may include other services such as physical therapy, occupational therapy, speech therapy, medical-social services, nutritional guidance, pharmaceutical services, appliances and equipment services.
(Added to NAC by Bd. of Health, eff. 11-13-96; A by R121-05, 11-17-2005)
NAC 449.788 Services to patients. (NRS 449.037)
1. If needed patient services are not available within the agency, the agency must assist in directing the patient to other community resources.
2. Services must be supplied only by qualified personnel and under the supervision of a physician licensed to practice in this State. Qualifications include licensure, registration, certification or their equivalent, as required by state or federal law, for each of the following disciplines:
(a) The professional registered nurse must hold a state license.
(b) The practical nurse must hold a state license.
(c) The home health aide must hold a certificate as a nursing assistant issued by the State Board of Nursing.
(d) The physical therapist must be registered in this State.
(e) The occupational therapist must meet the requirements of the American Occupational Therapy Association or the equivalent thereof.
(f ) The speech therapist must hold a certificate from the American Speech-Language-Hearing Association or the equivalent thereof.
(g) The social worker must be licensed pursuant to chapter 641B of NRS.
(h) The nutritionist must have a bachelor of science degree in home economics in foods and nutrition or the equivalent thereof.
(i) The inhalation therapist must be registered by the American Association of Inhalation Therapists or the equivalent thereof.
3. The agency is responsible for bonding all personnel.
[Bd. of Health, Home Health Agencies Part II Chap. III § G subsecs. 1-3, eff. 1-10-74]—(NAC A 11-13-96)
NAC 449.791 Duties of personnel. (NRS 449.037)
1. A registered nurse shall:
(a) Provide nursing guidance and care to patients at home.
(b) Evaluate the home for its suitability for the patient’s care.
(c) Teach the patient and those in the home who nurse him how his care is to be given.
(d) Supervise and evaluate the patient’s care on a continuing basis.
(e) Provide necessary professional nursing care.
2. A licensed practical nurse may perform certain nursing procedures under the supervision of the registered nurse.
3. The certified home health aide must be trained to function as a member of the health services team. Under the supervision of a registered nurse, he may:
(a) Give the patient personal care, including assistance in the activities of daily living.
(b) Perform certain household services to ensure that the patient’s nutritional needs are met and to maintain a safe and clean environment for him.
4. The social worker shall:
(a) Help the medical team to understand the social and emotional factors affecting the patient and his family.
(b) Help the patient and his family to understand the medical team’s activities.
(c) Assess the social and emotional impact of the program on the patient and his family.
5. The physical therapist shall:
(a) Assist the physician in the evaluation of the patient by giving functional ability tests.
(b) With the physician, help to develop and implement a plan for physical therapy for the patient.
(c) Instruct members of the health care team, the patient and his family in the procedures and techniques needed for his physical rehabilitation and maintenance.
6. The occupational therapist shall:
(a) Assist the physician in his evaluation of the patient’s level of function and ability to perform activities of daily living.
(b) Help to develop and implement the patient’s care plan.
(c) Instruct members of the health care team and family who participate in the patient’s occupational therapy.
[Bd. of Health, Home Health Agencies Part II Chap. III § G subsec. 4, eff. 1-10-74]—(NAC A 11-13-96)
NAC 449.793 Evaluation by governing body; periodic review of contracts, operations, policies and procedures. (NRS 449.037)
1. The governing body of an agency is responsible for providing for an evaluation of the agency once a year. The purpose of the evaluation is to audit, review policies and procedures, recommend additions or changes and ensure that the policies and regulations are being met.
2. A committee shall review all contracts and charters held by the agency to ascertain that:
(a) Existing contracts are legal and up to date.
(b) The existing contracts meet the needs of all parties involved.
3. A committee shall review the management and office procedures of the agency to ascertain that:
(a) The agency is being operated in the most effective and economical means while still giving quality service.
(b) All office procedures are up to date, filing is correctly done and bookkeeping is meeting accepted accounting procedures and is current.
(c) Equipment is in good repair and adequately meets operational needs.
4. The committee shall submit a report to the governing body with any recommendations for changes and pertinent observations as it deems necessary.
5. A committee shall review the medical and personnel policies to ensure that the policies are being fulfilled and necessary changes or additions are effected.
6. The governing body shall provide for a quarterly review of 10 percent of the records of patients who have received services during the preceding 3 months in each service area. The members of the committee must include an administrative representative, a physician, a registered nurse and a clerk or librarian who keeps records. The clerk or librarian shall review the clinical records to ensure that they are complete, that all forms are properly filled out and that documentation complies with good medical practices. The committee shall determine whether the services have been provided to the patients in an adequate and appropriate manner by all levels of service. The committee shall record any deficiencies and make necessary recommendations to the administrator. If the branch offices are small, two or more offices may establish one committee to review cases from each area. Each subunit agency must establish a committee to review cases within its area. Minutes of the committee’s meetings must be documented and available for review.
[Bd. of Health, Home Health Agencies Part II Chap. III § J, eff. 1-10-74]—(NAC A 11-13-96)—(Substituted in revision for NAC 449.803)
Medical Services and Medical Records
NAC 449.794 Clinical records: General requirements. (NRS 449.037)
1. Clinical records must be kept for all patients who are receiving services directly from a home health agency or by contract with other health agencies or therapists. The records must contain pertinent past and current medical, nursing, social and therapeutic data.
2. The clinical records of patients who are receiving services must be kept on file in the home office and in each subunit agency and branch office and may not be removed except for activities relating to their utilization and review.
3. Clinical records must be kept on file for 5 years after the discharge of a patient from service.
[Bd. of Health, Home Health Agencies Part II Chap. III § H subsecs. 1-3, eff. 1-10-74]—(NAC A 11-13-96)
NAC 449.797 Contents of clinical records. (NRS 449.037) Clinical records must contain:
1. The name, address and telephone number of the person who will be notified in an emergency involving the patient.
2. Information as to whether home health services are after hospitalization in a hospital, skilled nursing facility or other health service facility and, if so, the dates of admission and discharge from these facilities.
3. A clinical summary from the hospital, skilled nursing facility or other health service facility from which the patient is transferred to the home health agency.
4. A plan for patient care which includes:
(a) Objectives and approaches for providing services.
(b) Diagnoses of all medical conditions relevant to a plan of treatment.
(c) Physical traits pertinent to the plan for care.
(d) Nursing services required and the level of care and frequency of visits, special care which is required, such as dressing and catheter changes, and specific observations to be brought to the physician’s attention.
(e) Requirements of therapy, such as physical, speech, occupational or inhalation therapy with specific instructions for each.
(f ) Requirements of activity, such as the degree allowed and any assistance required.
(g) Medical appliances needed, such as crutches, walkers, braces or equipment for respiratory care.
(h) Nutritional needs.
(i) Medical supplies needed, such as dressings or irrigation sets.
( j) The degree of participation of the family in the care.
5. A copy of:
(a) The patient’s durable power of attorney for health care, if the patient has executed such a power of attorney pursuant to NRS 449.800 to 449.860, inclusive; and
(b) A declaration governing the withholding or withdrawal of life-sustaining treatment, if the patient has executed such a declaration pursuant to NRS 449.600.
6. Nurses’ notes that follow a good medical format, including pertinent observations regarding a patient’s physical and mental status, procedures done, examinations, dietary status and recommendations.
7. Therapists’ notes, if applicable, stating the rehabilitative procedures, progress and the types, duration and frequency of the modalities rendered.
8. A written evaluation for services made at the time the patient is admitted for care. Regular written reevaluations for services and assessments of patients made on a continuing basis.
9. A report given to the attending physician, written or by phone, whenever unusual findings occur. A written progress note must be submitted to the physician at least every 62 days.
10. A record of the termination of services, including the date and reason for termination and the time when the physician was notified of the termination.
[Bd. of Health, Home Health Agencies Part II Chap. III § H subsec. 4, eff. 1-10-74]—(NAC A 11-13-96)
NAC 449.800 Medical orders. (NRS 449.037)
1. A complete diagnosis must be included with the medical orders as well as any relevant problems.
2. Initial medical orders, renewals and changes of orders for skilled nursing and other therapeutic services submitted by telephone must be recorded before they are carried out. All medical orders must bear the signature of the physician who initiated the order within 20 working days after the receipt of the oral order.
3. Orders must be specific regarding the level of care and the service given.
4. Medication orders must include:
(a) The name of the drug.
(b) The exact dosage in units, milligrams, grams or other measurements.
(c) Frequency.
(d) The duration of treatment.
(e) The method of administration.
(f ) Any special precautions, including requests for doctor’s orders for the use of adrenaline for possible anaphylaxis.
5. The agency must have an established policy regarding the administration of injectable narcotics and other drugs subject to the drug abuse law. If the policy allows the administration of injectable narcotics and other dangerous drugs subject to drug abuse law, they must be prescribed according to state regulations.
6. Specific orders must be given for:
(a) Rehabilitative and restorative care such as physiotherapy;
(b) Skilled nursing and home health aide care;
(c) Nutritional needs;
(d) The degree of activity permitted;
(e) Dressings and the frequency of change;
(f ) The instruction of a member of the family in technical nursing procedures; and
(g) Any other items necessary to complete a specific plan of treatment for the patient.
7. All orders must be renewed in writing by the physician at least every 62 days.
8. New orders are required when there is a change in diagnosis, a change in orders, a change of physician or following hospitalization.
[Bd. of Health, Home Health Agencies Part II Chap. III § I, eff. 1-10-74]—(NAC A 11-1-88; 11-13-96)
FINANCIAL REPORTING
NAC 449.951 Definitions. (NRS 449.460) As used in NAC 449.951 to 449.969, inclusive, unless the context otherwise requires, the words and terms defined in NRS 449.450 have the meanings ascribed to them in that section.
(Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 1-2-90; 10-20-93)
NAC 449.953 Annual fee for insurers: Amount; notice; administrative fine for failure to pay. (NRS 449.460, 449.465)
1. Each admitted health insurer shall pay an annual fee to cover the costs of carrying out the provisions of NRS 449.450 to 449.530, inclusive, and for the support of the Legislative Committee on Health Care. For each fiscal year, the total amount authorized by the Legislature for this purpose in the biennial budget for that fiscal year must be divided by the number of admitted health insurers on the first day of that fiscal year, pursuant to the records of the Commissioner of Insurance, to determine the amount owed by each insurer for all purposes, including the $50 fee for the support of the Legislative Committee on Health Care.
2. The Department will prepare and mail a notice to each insurer subject to the fee specified in subsection 1. The notice must include:
(a) The amount of the fee and a statement identifying that portion of the fee which is used for the support of the Legislative Committee on Health Care;
(b) The day on which payment of the fee is due, which must not be less than 30 days after receipt of the notice; and
(c) The penalty for failure to pay the fee as specified in subsection 3.
3. Failure to pay the fee subjects the insurer to an administrative fine not to exceed $500 for each day that the fee remains unpaid after it is due.
(Added to NAC by Dep’t of Human Resources, eff. 1-2-90; A 9-16-92; 10-20-93)
NAC 449.957 Hospitals to file certain reports; certification; exception; extension. (NRS 449.460)
1. Except as otherwise provided in subsection 3, every hospital shall file with the Department the following reports:
(a) A copy of the hospital’s Medicare Cost Report within 120 days after the close of the hospital’s Medicare fiscal year;
(b) A copy of the hospital’s proposed operating budget for the fiscal year within 30 days after the beginning of the fiscal year;
(c) A copy of any report made by an independent auditor concerning a financial audit of the hospital’s operations within 30 days after the receipt of the report by the hospital; and
(d) An annual report including such information as the Department deems necessary. The information in a report filed pursuant to this paragraph must be certified by an independent auditor.
2. Each report filed pursuant to subsection 1 must be certified by a responsible officer of the hospital to be accurate and complete to the best of the officer’s knowledge and belief.
3. Each hospital which has less than 200 beds or which is subject to the provisions of chapter 450 of NRS shall submit to the Department each year a copy of an annual audit conducted by an independent auditor.
4. An extension of the deadline for filing a report pursuant to this section may be granted to a hospital if the hospital certifies before the report is due that the information required for the report is not available on the required reporting date for reasons beyond the control of the hospital.
(Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 10-20-93)
NAC 449.960 Hospitals to submit quarterly financial and utilization report; certification; extension. (NRS 449.460)
1. Each hospital shall submit for each calendar quarter a completed financial and utilization report on a form prepared and distributed by the Department. This report must be submitted no later than 30 days after the last day of the calendar quarter covered by the report.
2. The Department will adopt forms and instructions for the quarterly reports required pursuant to subsection 1.
3. Each quarterly report must be certified by a responsible officer of the hospital to be accurate and complete to the best of the officer’s knowledge and belief.
4. An extension of the deadline for filing a quarterly report pursuant to this section may be granted to a hospital if the hospital submits to the Department before the report is due an acceptable reason for granting the extension. The Department will not grant an extension unless the request for an extension includes a proposed date for submission of the report.
(Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 10-20-93)
NAC 449.962 Facility for intermediate care or facility for skilled nursing to submit quarterly financial and utilization report; certification; extension. (NRS 449.460)
1. Each facility for intermediate care or facility for skilled nursing shall submit for each calendar quarter a completed financial and utilization report on a form prepared and distributed by the Department. This report must be submitted no later than 30 days after the last day of the calendar quarter covered by the report.
2. The Department will adopt forms and instructions for the quarterly reports required pursuant to subsection 1.
3. Each quarterly report must be certified by a responsible officer of the facility for intermediate care or facility for skilled nursing to be accurate and complete to the best of the officer’s knowledge and belief.
4. An extension of the deadline for filing a quarterly report pursuant to this section may be granted to a facility for intermediate care or facility for skilled nursing if the facility submits to the Department before the report is due an acceptable reason for granting the extension. The Department will not grant an extension unless the request for an extension includes a proposed date for submission of the report.
(Added to NAC by Dep’t of Human Resources, eff. 10-20-93)
NAC 449.9625 Institution to submit quarterly financial and utilization report; certification; extension; exception. (NRS 449.460)
1. Except as otherwise provided in subsection 5, each institution shall submit for each calendar quarter a completed financial and utilization report on a form prepared and distributed by the Department. This report must be submitted no later than 30 days after the last day of the calendar quarter covered by the report.
2. The Department will adopt forms and instructions for the quarterly reports required pursuant to subsection 1.
3. Each quarterly report must be certified by a responsible officer of the institution to be accurate and complete to the best of the officer’s knowledge and belief.
4. An extension of the deadline for filing a quarterly report pursuant to this section may be granted to an institution if the institution submits to the Department before the report is due an acceptable reason for granting the extension. The Department will not grant an extension unless the request for an extension includes a proposed date for submission of the report.
5. This section does not apply to a hospital that submits quarterly reports pursuant to NAC 449.960 or to a facility for intermediate care or a facility for skilled nursing that submits quarterly reports pursuant to NAC 449.962.
(Added to NAC by Dep’t of Human Resources, eff. 10-20-93)
NAC 449.963 Information concerning discharged patients: Submission; limitation on disclosure. (NRS 449.460, 449.485)
1. Each hospital shall prepare and submit to the Department, for each patient discharged by the hospital during each month, a copy of the UB-82 form specified by the Centers for Medicare and Medicaid Services. The hospital shall submit the required forms for each month within 45 days after the last day of the month, and include the following information on each form:
(a) UB-82 field number 3, the Patient Control Number (Patient ID);
(b) UB-82 field number 4, Type of Bill;
(c) UB-82 field number 8, Medical Number (Hospital ID);
(d) UB-82 field number 11, Patient Address (ZIP code only will be used by the Department in its data system);
(e) UB-82 field number 12, Birth Date;
(f ) UB-82 field number 13, Sex;
(g) UB-82 field number 14, Marital Status;
(h) UB-82 field number 15, Admission Date;
(i) UB-82 field number 17, Admission Type;
( j) UB-82 field number 18, Admission Source;
(k) UB-82 field number 21, STAT (Discharge Status);
(l) UB-82 field number 22, Discharge Date;
(m) UB-82 field number 27, Admitting Diagnosis (Principal Diagnosis Code-ICD-9-CM);
(n) UB-82 field numbers 51a through 51w, inclusive, Revenue Codes;
(o) UB-82 field numbers 52a through 52w, inclusive, Service Units;
( p) UB-82 field numbers 53a through 53w, inclusive, Total Charges;
(q ) UB-82 field numbers 57A through 57C, inclusive, Payer (including the 5-digit Payer Classification Code Number);
(r) UB-82 field number 68, patient social security number (only last six digits will be used in the Department’s data system);
(s) UB-82 field number 77, Principal Code (Principal Diagnosis Code-ICD-9-CM);
(t) UB-82 field numbers 78 through 81, inclusive, Other Diagnosis Codes (ICD-9-CM);
(u) UB-82 field number 84a, Principal Procedure CD (Procedure Code-ICD-9-CM);
(v) UB-82 field numbers 85A through 86A, inclusive, Other Procedure Codes (ICD-9-CM);
(w) UB-82 field number 92, Attending Physician ID; and
(x) UB-82 field number 93, Other Physician ID.
2. The Department and any person with whom the Department may contract for the development and operation of its UB-82 data system shall not disclose any information from the data system which may be used to identify any patient of a hospital.
3. A hospital with more than 200 beds which submits the information required by this section by means other than a magnetic tape shall pay the costs of entering the data into the data system. The Department will prepare a bill for such entry on a quarterly basis and submit it to the hospital. The hospital shall pay the bill within 30 days after receipt of the bill.
4. As used in this section, “hospital” has the meaning ascribed to it in NRS 449.012.
(Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 1-2-90; 9-16-92; 10-20-93; A by Bd. of Health by R051-02, eff. 7-24-2002)
NAC 449.966 Notice of insufficiency of submitted information. (NRS 449.460)
1. If the Department determines that the information submitted by an institution is insufficient, it will notify the institution, by mail, of the insufficiency.
2. The institution shall submit the required information to the Department within 30 days after receipt of the notice of insufficiency.
(Added to NAC by Dep’t of Human Resources, eff. 4-29-86)
NAC 449.969 Administrative fine for failing to meet deadlines. (NRS 449.460, 449.490) Unless an extension is granted, an institution which fails to submit a report or information required pursuant to NAC 449.957 to 449.963, inclusive, by the deadline for submission is subject to an administrative fine not exceeding $500 for each day the report or information is delinquent.
(Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 10-20-93)
MOBILE UNITS
NAC 449.970 Definitions. (NRS 449.037) As used in NAC 449.970 to 449.97042, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.9701 to 449.97018, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.9701 “Independent facility” defined. (NRS 449.037) “Independent facility” means the owner or operator of a mobile unit who:
1. Is not a parent facility; and
2. Uses the mobile unit to operate a medical facility specified in subsections 1 to 13, inclusive, of NRS 449.0151.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97012 “Mobile unit” defined. (NRS 449.037) “Mobile unit” has the meaning ascribed to it in NRS 449.01515.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97014 “Parent facility” defined. (NRS 449.037) “Parent facility” means a medical facility that is:
1. Specified in subsections 1 to 13, inclusive, of NRS 449.0151; and
2. Licensed pursuant to NRS 449.001 to 449.240, inclusive.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97016 “Service site” defined. (NRS 449.037) “Service site” means the location where a mobile unit is parked when providing a service to a patient.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97018 “Staging area” defined. (NRS 449.037) “Staging area” means any location that serves as a base for maintaining a mobile unit.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.9702 Applicability of provisions. (NRS 449.037) The provisions of NAC 449.970 to 449.97042, inclusive, do not apply to:
1. A mobile unit that provides services only:
(a) Relating to conducting a mammography in accordance with a certificate of authorization to operate a radiation machine for mammography issued pursuant to NRS 457.185;
(b) Using a radiation machine which is registered in accordance with NAC 459.150; or
(c) For which a license is not required pursuant to NRS 449.001 to 449.240, inclusive; or
2. A motor vehicle that is designed and used solely for transportation by a medical facility.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97022 Licensure. (NRS 449.037)
1. The Health Division may issue a license to operate a mobile unit only to:
(a) A parent facility; or
(b) An independent facility.
2. A parent facility or independent facility shall obtain a license for each mobile unit that it operates.
3. In addition to the information required to be included in a license pursuant to NRS 449.085, each license to operate a mobile unit issued by the Health Division must set forth:
(a) The name of the operator of the mobile unit;
(b) The address of the parent facility or independent facility that is issued the license; and
(c) Each staging area that the parent facility or independent facility designates for the mobile unit.
4. A parent facility or independent facility that is issued a license to operate a mobile unit shall:
(a) Maintain the original of the license in the mobile unit for which the license is issued; and
(b) Post a copy of the license in a conspicuous location at the parent facility or independent facility.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97024 Application for licensure. (NRS 449.037) An application for a license to operate a mobile unit must include:
1. The information required by NRS 449.040 and NAC 449.011;
2. A copy of the certificate of registration issued pursuant to chapter 482 of NRS for the mobile unit; and
3. A statement indicating:
(a) Whether the applicant is a parent facility or independent facility;
(b) If the applicant is an independent facility, the type of medical facility, as specified in subsections 1 to 13, inclusive, of NRS 449.0151, that the applicant wishes to operate as a mobile unit;
(c) Each proposed service and procedure that the mobile unit will provide;
(d) Each proposed service site for the mobile unit; and
(e) The manufacturer of the mobile unit.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97026 Design, construction, equipment, maintenance and parking. (NRS 449.037)
1. Except as otherwise provided in subsection 5, a parent facility or independent facility which is issued a license to operate a mobile unit shall ensure that the mobile unit complies with the provisions entitled “Mobile, Transportable and Relocatable Units” set forth in section 12 of the Guidelines for Design and Construction of Hospital and Health Care Facilities, adopted by reference pursuant to NAC 449.0105.
2. Except as otherwise provided in subsection 4, before any new construction of a mobile unit or any remodeling of an existing mobile unit is begun:
(a) The parent facility or independent facility that applies for the license to operate the mobile unit or that has been issued the license to operate the mobile unit must submit a copy of the building plans for the new construction or remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115; and
(b) The building plans must be approved by the Health Division.
3. The building plans submitted for review and approval as required pursuant to subsection 2 must be drawn to scale and include a statement indicating:
(a) The services and procedures that will be provided at the mobile unit; and
(b) Each staging area designated by the parent facility or independent facility for the mobile unit.
4. A parent facility or independent facility is not required to submit plans for remodeling to the entity designated to review such plans by the Health Division pursuant to the provisions of NAC 449.0115 if the remodeling is limited to refurbishing an area within a mobile unit, including, without limitation, painting the area, replacing the flooring in the area, repairing the windows in the area, and replacing window or wall coverings in the area.
5. A parent facility or independent facility which is issued a license to operate a mobile facility shall ensure that the mobile unit for which the license is issued:
(a) Complies with any applicable zoning regulation for each staging area designated for the mobile unit;
(b) Is of sufficient size and is arranged in a manner that is appropriate to provide the services for which the mobile unit is licensed;
(c) Is furnished with the appropriate equipment to provide for the comfort and safety of each patient who receives services at the mobile unit;
(d) Is maintained in good repair and in a clean and sanitary manner; and
(e) During any period in which the operator of the mobile unit provides services at the mobile unit:
(1) Is located and illuminated in such a manner that each patient who receives services at the mobile unit may safely and comfortably enter and exit the mobile unit; and
(2) Complies with any applicable statute, ordinance or regulation relating to the parking of the mobile unit.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002; A by R076-04, 8-5-2004)
NAC 449.97028 Staging areas; disposal of biohazards and waste. (NRS 449.037)
1. Each parent facility or independent facility shall designate at least one staging area for each mobile unit for which the parent facility or independent facility is issued a license. A staging area designated by a parent facility or independent facility pursuant to this section must:
(a) Provide for the cleaning and sanitizing of the mobile unit and its equipment before and after the mobile unit is used; and
(b) Include a clean and sanitary area for the storage of supplies used for the mobile unit.
2. If any biohazard or any solid or liquid waste located at the site of the mobile unit will be disposed of at the staging area, the parent facility or independent facility shall ensure that the staging area is designed and maintained to provide for such disposal.
3. If any biohazard or any solid or liquid waste located at the site of the mobile unit will not be disposed of at the staging area, the parent facility or independent facility shall provide for such disposal in a manner and location approved by the Bureau.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.9703 Compliance with certain statutes and regulations. (NRS 449.037) A parent facility or independent facility which is issued a license to operate a mobile unit shall ensure that the mobile unit is operated in compliance with:
1. Any applicable statute or regulation relating to the registration of the mobile unit as a motor vehicle and the licensing of each driver of the mobile unit;
2. The applicable provisions of chapter 461 or 489 of NRS; and
3. The applicable provisions of NRS 449.001 to 449.240, inclusive, and the standards and regulations adopted pursuant to those provisions.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97032 Compliance with regulations relating to evaluation of quality of services. (NRS 449.037) A parent facility or independent facility which is issued a license to operate a mobile unit shall:
1. Ensure that the mobile unit complies with any regulation which applies to the parent facility or independent facility relating to the evaluation of the quality of services provided by the mobile unit; and
2. Review each service provided by the mobile unit to ensure compliance with subsection 1.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97034 Written policies for operation of unit; agreement with hospital or medical facility for transfer of patients during emergencies. (NRS 449.037)
1. A parent facility or independent facility which is issued a license to operate a mobile unit must, before operating the mobile unit, establish written policies for the operation of the mobile unit. The written policies must be established in consultation with any other appropriate provider of health care as determined by the parent facility or independent facility and must include, without limitation, provisions relating to:
(a) The care of patients;
(b) The orientation, training and supervision of employees;
(c) The scope of services and the evaluation of the quality of those services;
(d) The criteria for selecting patients to receive services at the mobile unit;
(e) The procedure for:
(1) Performing each service provided at the mobile unit;
(2) Storing and handling any medication provided to a patient of the mobile unit; and
(3) Collecting, storing and disposing of any biohazard or liquid or solid waste from the mobile unit;
(f ) The control of any infectious disease or organism in the mobile unit;
(g) The preparation and maintenance of any statement, log, document or other record relating to any service provided to a patient of the mobile unit;
(h) The transportation of a patient of the mobile unit, including, without limitation:
(1) The manner in which the patient must be transported;
(2) Any equipment that must be used to transport the patient; and
(3) The appropriate protection required for the patient during inclement weather;
(i) The manner in which the mobile unit must be evacuated during an emergency and the services that the mobile unit must provide during the emergency, including, without limitation, a plan for coordinating the evacuation and the provision of those services with the parent facility or independent facility of the mobile unit; and
( j) The identification of any specific requirements for the mobile unit necessary to provide any service at a service site for the mobile unit.
2. A parent facility or independent facility that establishes written policies for the operation of a mobile unit which include the provisions required by paragraph (i) of subsection 1 shall ensure that each employee and patient of the mobile unit understands those provisions.
3. Each parent facility or independent facility specified in subsection 1 shall maintain a written agreement with at least one hospital or other medical facility for the transfer of the patients of a mobile unit of the parent facility or independent facility during an emergency. The written agreement must include, without limitation, provisions relating to:
(a) The manner in which the hospital or medical facility must communicate with the mobile unit during the emergency;
(b) The transfer of each patient of the mobile unit to or from the hospital or medical facility;
(c) The number of persons required to assist in the transfer of a patient; and
(d) Any requirements of the mobile unit or a patient of the mobile unit to conduct the transfer of a patient.
4. A parent facility or independent facility that establishes written policies for the operation of a mobile unit pursuant to this section shall ensure that the written policy is consistent with any other policy or procedure of the parent facility or independent facility relating to the provision of services to a patient of the mobile unit.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97036 Rights of patients. (NRS 449.037)
1. In addition to complying with the requirements set forth in NRS 449.700 to 449.730, inclusive, a parent facility or independent facility that is issued a license to operate a mobile unit shall ensure that each patient who receives services at the mobile unit is:
(a) Treated with respect, consideration and dignity;
(b) Provided appropriate privacy;
(c) Informed of:
(1) His rights as a patient in accordance with NRS 449.730;
(2) Before admission to the mobile unit, each service that is available at the mobile unit and the estimated cost of the service; and
(3) Any supplies, medication or equipment that the patient may require after receiving the service; and
(d) Allowed to participate in any decision relating to any health care he receives at the mobile unit, unless he is unable to participate in that decision because of his medical condition.
2. If a patient of a mobile unit is unable to understand any information relating to his rights as a patient provided to him pursuant to subsection 1, the person who is responsible for the provision of services at the mobile unit shall provide that information to an appropriate person who is responsible for the patient. For each patient who is informed of his rights as a patient pursuant to this section, the person who is responsible for the provision of services at the mobile unit shall:
(a) Prepare a written statement indicating that he informed the patient of those rights; and
(b) Include the statement in the medical record of the patient that is maintained by the mobile unit.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97038 Maintenance of schedule and records; supplies and equipment; diagnostic radiological services; laboratory services. (NRS 449.037)
1. A parent facility or independent facility which is issued a license to operate a mobile unit shall:
(a) On or before the first day of each month, prepare and maintain a schedule setting forth the proposed dates of use for each service site for the mobile unit for that month;
(b) Prepare and maintain a record of each service provided to a patient of the mobile unit, including, without limitation:
(1) The name, age and sex of the patient;
(2) The chart or identification number of the patient;
(3) The date, time and service site where the service was provided to the patient; and
(4) The duration of any procedure performed for the patient at the mobile unit;
(c) In addition to the record of services required by paragraph (b), prepare and maintain a clinical record of each patient who receives any service at the mobile unit in accordance with the requirements of the parent facility or independent facility of the mobile unit; and
(d) Ensure that a sufficient amount of supplies and equipment is available at the mobile unit to provide services to each patient of the mobile unit.
2. If a diagnostic radiological service is required to provide services for a patient of a mobile unit, the parent facility or independent facility shall ensure that the diagnostic radiological service is provided:
(a) In accordance with the requirements prescribed by the parent facility or independent facility; and
(b) Using equipment that is registered pursuant to NAC 459.150.
3. If a laboratory service is required to provide services for a patient of a mobile unit, the parent facility or independent facility shall ensure that the laboratory service is provided:
(a) In accordance with chapters 652 of NRS and 652 of NAC and any applicable federal law; and
(b) In the manner prescribed by the parent facility or independent facility for providing the laboratory service.
4. A parent facility or independent facility which is issued a license to operate a mobile unit shall ensure that each record of a patient of the mobile unit which is maintained by the parent facility or independent facility is available for use by the mobile unit. If the patient ceases to receive services at the mobile unit, the parent facility or independent facility shall maintain the records of the patient at the parent facility or independent facility, or at any other location where the records are available for inspection by the Bureau.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.9704 Occupancy; fire safety; exits; use and maintenance of equipment; telecommunications device. (NRS 449.037) A parent facility or independent facility which is issued a license to operate a mobile unit shall:
1. Limit the occupancy of patients in the mobile unit to not more than five patients at any time;
2. Equip the mobile unit with at least two fire extinguishers having a minimum rating of 2A-20BC, and provide any other equipment for fire safety for the mobile unit that is required by the fire authority having jurisdiction;
3. Ensure that the mobile unit has at least two exits from the mobile unit, at least two of which must be doors if the mobile unit provides a service to a patient at the mobile unit who is unable to exit the mobile unit without assistance;
4. Ensure the existence of a corridor for each exit from the mobile unit that is of sufficient size to provide access to that exit;
5. Ensure that the equipment in the mobile unit is used and maintained in accordance with the instructions of the manufacturer of the equipment;
6. Prepare and maintain a record of any maintenance or procedure for calibration of the equipment that is performed in accordance with the instructions of the manufacturer of the equipment pursuant to subsection 5; and
7. Provide a telecommunications device for the mobile unit.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
NAC 449.97042 Restrictions on operation; office of independent facility; operation pursuant to contract. (NRS 449.037)
1. A hospital shall not operate a mobile unit as a primary source for providing a service specified in NRS 449.012 except during an emergency.
2. A parent facility or independent facility that is issued a license to operate a mobile unit shall not use the mobile unit to provide any service for which the mobile unit is not licensed, regardless of whether the mobile unit is operated by a person other than the parent facility or independent facility.
3. An independent facility that is issued a license to operate a mobile unit shall:
(a) Maintain an office in this State;
(b) Ensure that the office remains open during normal business hours;
(c) Ensure that any schedule, record or other information that the independent facility or mobile unit is required to maintain pursuant to NAC 449.970 to 449.97042, inclusive, is maintained at the office of the independent facility; and
(d) Not use the office of the independent facility to provide any service for which the mobile unit is licensed, unless the owner or operator of the independent facility is a physician licensed pursuant to chapter 630 of NRS and uses the office to provide medical services to his patients.
4. If a mobile unit is operated pursuant to a contract, the parent facility or independent facility of the mobile unit:
(a) Is liable for any failure by the operator of the mobile unit to comply with any provision of NRS 449.001 to 449.240, inclusive, or the standards and regulations adopted by the State Board of Health concerning the operation and maintenance of the mobile unit;
(b) Shall maintain on the premises of the parent facility or independent facility a record satisfactory to the Health Division setting forth the services provided by the mobile unit pursuant to the contract and the name of each person who is responsible for the provision of services at the mobile unit;
(c) Shall ensure that any procedure conducted or service provided by the mobile unit is conducted or provided in accordance with the standard of acceptable practice for the procedure or service; and
(d) Shall ensure that the owner or operator of the mobile unit makes the mobile unit available for inspection by the Health Division pursuant to NRS 449.150, 449.230 and 449.235.
(Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002)
SURGICAL CENTERS FOR AMBULATORY PATIENTS
General Provisions
NAC 449.971 Definitions. (NRS 449.037) As used in NAC 449.971 to 449.996, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.9715 to 449.9743, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9715 “Allied health profession” defined. (NRS 449.037) “Allied health profession” has the meaning ascribed to it by NRS 450.006.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.972 “Ambulatory surgical center” defined. (NRS 449.037) “Ambulatory surgical center” has the meaning ascribed to “surgical center for ambulatory patients” by NRS 449.019.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.9725 “Division” defined. (NRS 449.037) “Division” means the Health Division of the Department of Health and Human Services.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.973 “Governing body” defined. (NRS 449.037) “Governing body” means the person or persons designated by the licensee as responsible for the total operation of the ambulatory surgical center.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.9735 “Licensee” defined. (NRS 449.037) “Licensee” means the person or public agency that is licensed by the Division in accordance with the provisions of NRS 449.001 to 449.240, inclusive, and NAC 449.971 to 449.996, inclusive.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.974 “Patient” defined. (NRS 449.037) “Patient” means a natural person who is undergoing diagnostic procedures or treatment by surgery in the ambulatory surgical center.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.9741 “Physician” defined. (NRS 449.037) “Physician” means a person who is licensed to practice medicine pursuant to chapter 630 of NRS or to practice osteopathic medicine pursuant to chapter 633 of NRS.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99)
NAC 449.9742 “Registered nurse” defined. (NRS 449.037) “Registered nurse” means a person who is licensed to practice professional nursing pursuant to chapter 632 of NRS.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99)
NAC 449.9743 “Surgery” defined. (NRS 449.037) “Surgery” means the treatment of a human being by a physician using one or more of the following procedures:
1. Cutting into any part of the body using a scalpel, electrocautery or any other means for diagnosis or the removal or repair of diseased or damaged tissue, organs, tumors or foreign bodies.
2. The reduction of a fracture or the dislocation of a bone, joint or bony structure.
3. The repair of a malformation of the body resulting from an injury, a birth defect or another cause, that requires cutting and manipulation or a suture.
4. An instrumentation of the uterine cavity of a woman for diagnostic or therapeutic purposes, including the procedure commonly known as dilation and curettage.
5. Any instrumentation of, or injection of a substance into, the uterine cavity of a woman to terminate a pregnancy.
6. Any procedure to sterilize a human being.
7. An endoscopic procedure.
8. A laproscopic procedure.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99)
Licensing
NAC 449.9745 Compliance with requirements by accreditation. (NRS 449.037) The operator of an ambulatory surgical center shall be deemed by the Division to have complied with the requirements for licensing contained in NAC 449.971 to 449.996, inclusive, if:
1. The center is currently accredited by the Joint Commission on Accreditation of Health Care Organizations, the Accreditation Association for Ambulatory Health Care or the American Association for Accreditation for Ambulatory Surgery Facilities;
2. The operator provides the Division with evidence of the accreditation; and
3. The standards for accreditation applied by the accrediting organization are at least as stringent as the requirements of NAC 449.971 to 449.996, inclusive.
(Added to NAC by Bd. of Health, eff. 12-15-88; A 6-7-90; R049-99, 9-27-99)
NAC 449.9755 Investigation of applicant and inspection of center. (NRS 449.037) After it receives a properly completed and notarized application, accompanied by the appropriate fee, the Division shall conduct an investigation of the applicant and inspect the proposed center.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.978 Effect of expiration of license. (NRS 449.037) If a license authorizing an ambulatory surgical center expires, patients must not occupy the center.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R044-97, 10-30-97)
NAC 449.9785 Conformance with regulations required. (NRS 449.037) During the term of his license, the licensee shall continuously maintain the ambulatory surgical center in conformance with the provisions of NAC 449.971 to 449.996, inclusive. Any violation of these provisions may result in the suspension or revocation of the license.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
Administration
NAC 449.979 Governing body required. (NRS 449.037) Except as otherwise provided by NAC 449.9835, each ambulatory surgical center must have a governing body, chaired by a principal in the organization of the licensee, with legal authority for the operation of the center.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.9795 Duties of governing body. (NRS 449.037) The governing body shall:
1. Adopt a set of rules which include provisions concerning:
(a) The criteria by which the members and officers of the governing body are selected, their terms of office and their duties;
(b) The frequency of its meetings; and
(c) The annual revision and approval of the rules by the governing body.
2. Arrange for minutes of its meetings to be taken to record the business conducted. These minutes must be available to all members.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.980 Responsibilities of governing body. (NRS 449.037) The governing body shall ensure that:
1. Each patient of the center is under the care of a physician.
2. Each patient admitted to the center receives a presurgical evaluation conducted by a physician within the 7 days immediately preceding the date of his surgery.
3. A physician is on the premises of the ambulatory surgical center and immediately available at all times when there are patients in the operating rooms or the recovery room of the center. As used in this subsection, “immediately available” means the physician is sufficiently free from other duties to be able to respond rapidly to an emergency.
4. An annual operating budget and a plan for capital expenditures are established.
5. The center is adequately staffed and equipped.
6. There is documentation in the files of the center of the qualifications of all persons under contract with the center.
7. The center adopts, enforces and annually reviews written policies and procedures required by NAC 449.971 to 449.996, inclusive, including an organizational chart. These policies and procedures must:
(a) Be approved annually by the governing body.
(b) Provide that a surgical procedure may be performed on a patient only with the consent of the patient or his legal representative, except in an emergency.
(c) Include procedures for the isolation or immediate transfer of a patient with a communicable disease.
(d) Include procedures for the periodic review and amendment, as deemed appropriate, of the scope of the procedures performed at the center.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9801 Procedures for granting privileges to members of medical staff. (NRS 449.037)
1. The governing body shall:
(a) Adopt criteria for granting privileges to members of the medical staff based upon the size and complexity of the services provided by the center.
(b) Ensure that an application to be accorded privileges or for the renewal of those privileges is processed in an expeditious manner.
(c) Adopt procedures for verifying information contained in an application to be accorded privileges or for the renewal of those privileges. The procedures may include a requirement for the applicant to sign a statement granting immunity from liability to the center for actions taken to verify the information and attesting to the accuracy and completeness of the information contained in the application.
2. The procedures for granting privileges to members of the medical staff must be approved by the governing body.
3. An application to be accorded privileges at an ambulatory surgical center must include, without limitation:
(a) Information related to the educational and professional training of the applicant;
(b) An evaluation conducted by the applicant’s peers concerning the quality of care provided by the applicant;
(c) Evidence that the applicant is licensed or certified to provide in this State the professional services for which the privileges are being requested;
(d) Evidence of any license required to be obtained by the applicant from the Drug Enforcement Administration;
(e) A description or list of the privileges being requested;
(f ) Information obtained from the National Practitioner Data Bank as may be required by federal law; and
(g) Such other information as may be required by the governing body, including, without limitation, information relating to:
(1) Any claims filed against the applicant for professional liability;
(2) The revocation, suspension or voluntary relinquishment of the applicant’s license or certification to practice in this State, any other disciplinary action that has been taken against the applicant in his professional capacity and any limitations or conditions placed on the applicant’s license or certification to practice in this State;
(3) Complaints or reports of any adverse action filed against the applicant with a local, state or national professional society or occupational board;
(4) Insurance for professional liability maintained by the applicant, including any circumstance under which an insurer has refused to issue such insurance to the applicant or cancelled the applicant’s insurance;
(5) The denial, suspension, limitation, termination or refusal to renew privileges accorded to the applicant at another medical facility;
(6) The suspension or revocation of a license issued to the applicant by the Drug Enforcement Administration;
(7) Any conviction for a criminal offense, other than a minor traffic violation; and
(8) Any physical or mental condition of the applicant that would interfere with his ability to provide professional services, including alcohol or drug abuse.
4. A member of the medical staff who is applying for the renewal of his privileges must provide evidence that he is in compliance with the provisions of subsection 3 on the date of the application.
5. The ambulatory surgical center shall maintain a record of the privileges accorded to each member of the medical staff of the center. The record must include, without limitation:
(a) The application to be accorded privileges at the center;
(b) Each application for the renewal of those privileges;
(c) Evidence of the verification of the information contained in the applications;
(d) The privileges granted; and
(e) Such other information as may be required by the governing body.
6. Privileges accorded to a member of the medical staff must be:
(a) Consistent with his professional experience and authorized scope of practice;
(b) For a limited time as specified by the governing body or a person or committee designated by the governing body; and
(c) Be reviewed periodically and revised as appropriate.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99)
NAC 449.9805 Establishment of policy for authentication. (NRS 449.037) The governing body shall establish a policy for authentication that:
1. Authorizes the use of rubber stamps and prohibits the use of any stamp by any person other than the person whose signature the stamp represents;
2. Approves a method for identifying the person making an entry in any record or chart; and
3. Requires that the professional title of the person making such an entry and the date of that entry is included with the entry.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.981 Appointment and responsibilities of administrator. (NRS 449.037)
1. The governing body shall appoint a qualified administrator for the center who is responsible to the governing board for the performance of his duties.
2. The administrator must:
(a) Be at least 21 years of age;
(b) Possess one of the following qualifications:
(1) Be a physician;
(2) Be a registered nurse;
(3) Have a bachelor’s or postgraduate degree in administration or a field related to health care; or
(4) Have at least 1 year of administrative experience in a health care setting;
(c) Have experience in the administration and supervision of personnel; and
(d) Possess such knowledge of the practice of medicine as to enable him to be conversant in surgical protocols.
3. The governing body shall develop and maintain a written job description for the administrator that includes the duties and responsibilities of the administrator. The job description must be made available for review upon the request of the Division.
4. The administrator is responsible for:
(a) The daily operation of the center;
(b) Serving, along with any committee appointed for the purpose, as a liaison between the governing body, the members of the medical staff and all the departments of the center;
(c) Reporting the pertinent activities concerning the center to the governing body at regular intervals; and
(d) Appointing a person responsible for the center in his absence. The person so appointed must possess the same qualifications as are required of the administrator.
5. The administrator shall:
(a) Ensure that the center complies with all applicable federal and state laws and local ordinances and the policies and procedures approved by the governing body;
(b) Annually develop, evaluate, revise and carry out policies and procedures for the center;
(c) Ensure that there is an adequate number of qualified and competent members of the staff to provide for the needs of the patients at the center;
(d) Develop and maintain a clear and complete job description for each member of the staff;
(e) Review each incident or accident report filed with the administrator, take appropriate action in response thereto and maintain a record of the action taken;
(f ) Enter into contracts with such persons as are necessary to obtain any services required by the center; and
(g) Establish a program for quality assurance as required by NAC 449.9812.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9812 Program for quality assurance. (NRS 449.037)
1. The administrator of an ambulatory surgical center shall establish a program for quality assurance for the center.
2. The program for quality assurance must include, without limitation:
(a) Periodic reviews of the clinical responsibilities and authority of the members of the staff.
(b) Periodic evaluations of members of the staff that are conducted by their peers.
(c) Procedures for the supervision of the professional and technical activities of the members of the staff.
(d) Periodic evaluations that are conducted to determine whether the clinical and administrative policies of the center are cost-effective. The evaluations required by this paragraph must not be limited to the cost-effectiveness of the administrative policies of the center.
(e) Procedures for identifying and correcting any problems or concerns that provide an opportunity for all members of the staff who are health care practitioners to participate in the program for quality assurance.
(f ) Techniques for self-assessment that are required to be used by the members of the staff and provide for an examination of the manner in which care has been, is and will be provided and the quality of the care provided.
(g) Procedures for identifying and addressing any problems or concerns related to the care provided to patients using the medical records of the center and any other sources of data that may be useful to identify previously unrecognized concerns, and for assessing the frequency, severity and sources of suspected problems and concerns. The procedures must include, without limitation, procedures for assessing:
(1) The clinical performances of members of the staff who are health care practitioners;
(2) The standards used for the maintenance of medical records;
(3) The procedures used to control the quality of radiological, pathological, laboratory and pharmaceutical services provided by the center;
(4) The procedures used to control the quality of other professional and technical services provided by the center;
(5) The care and services provided by the extended recovery unit, if such a unit is operated by the center;
(6) The procedures used to control infection; and
(7) The satisfaction of patients who have been treated at the center.
(h) The maintenance of a record of all fires and deaths that have occurred at the center and the transfer of all patients from the center to a hospital.
(i) Procedures for assessing any actions taken to correct identified problems or concerns and for determining whether the actions taken have achieved or sustained the desired result and, if not, why not.
3. The members of the professional and administrative staffs of the center shall:
(a) Understand, support and participate in the program for quality assurance; and
(b) Participate in the resolution of any problems and concerns identified pursuant to the procedures required by subsection 2.
4. The members of the staff who are health care practitioners shall participate in the development and application of the criteria used to evaluate the care provided at the center and the evaluation of any problems and concerns identified pursuant to the procedures required by subsection 2.
5. Activities conducted pursuant to the program for quality assurance must be reported to the appropriate members of the staff and to the governing body. The administrator of the center shall establish procedures for carrying out any recommendations of the governing body.
6. As used in this section, “health care practitioner” means a person who is licensed or certified to provide health care services in this State, including, without limitation, a physician, dentist, podiatrist, and registered or licensed practical nurse.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99)
NAC 449.9813 Committee for quality assurance. (NRS 449.037)
1. The governing body shall establish a committee for quality assurance.
2. The committee must be composed of members of the staff who represent the various clinical and medical services provided by the center.
3. The committee shall carry out the program for quality assurance established pursuant to NAC 449.9812.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99)
NAC 449.9815 Maintenance. (NRS 449.037) The administrator shall ensure that the person in charge of maintenance at the center:
1. Has a written program of maintenance of all of the equipment used at the center.
2. Has written service contracts with vendors that require the inspection and repair of equipment as needed.
3. Maintains written records of the inspections of the equipment used at the center.
4. Keeps the temperature in the center at a comfortable level.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.982 Sanitation and housekeeping. (NRS 449.037) The administrator shall ensure that the sanitation and housekeeping staff of the center:
1. Maintains a clean and sanitary environment in the center with particular regard for:
(a) The sanitary disposal of pathological and infectious waste;
(b) Methods for handling contaminated linen or substitutes for linen; and
(c) An effective program to control pests.
2. Keeps the center free of offensive odors, dirt and hazards.
3. Has suitable equipment and supplies for the routine cleaning of all surfaces in the center and keeps the equipment in a sanitary condition.
4. Uses methods of cleaning that minimize the spread of pathogenic organisms.
5. Cleans all floors in the center on a daily basis.
6. Maintains all toilet facilities and storage areas in a sanitary and orderly manner on a daily basis.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.983 Protection from fire and other disasters. (NRS 449.037)
1. The administrator shall ensure that the center, members of the staff and patients are adequately protected from fire or other disasters. He shall prepare a written plan describing all actions to be taken by the members of the staff and patients in the case of any such incident. This plan must be approved by the governing body and the local fire department and must include provisions for:
(a) Evacuation routes and procedures that are posted in the center.
(b) The assignment of personnel to specific tasks and responsibilities.
(c) Instruction on the use of alarm stations and the location of signals.
(d) Instruction concerning methods of containing a fire.
(e) Procedures for the notification of appropriate persons.
(f ) The location of equipment for fighting fires.
(g) The conduct of fire drills not less frequently than once each quarter for each shift of employees and requirements for a dated, written report and an evaluation of each drill.
(h) The maintenance of records showing that all employees have been trained in the execution of the plan at the beginning of their employment and annually thereafter.
(i) A rehearsal and a review of the plan at least once each year with a separate rehearsal for other disasters at least once each year. A written report and evaluation of each rehearsal must be on file.
2. An ambulatory surgical center must be equipped with an automatic sprinkler system that is in good working condition and is approved by the State Fire Marshal.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9835 Exemption from requirements for governing body and administrator. (NRS 449.037)
1. If a licensee is a physician operator, the ambulatory surgical center operated by the licensee is not required to have a governing body or an administrator. In such a case, in the absence of a governing body or an administrator, the physician operator is responsible for complying with all the provisions of NAC 449.971 to 449.996, inclusive.
2. As used in this section, “physician operator” means a physician, a podiatric physician licensed pursuant to chapter 635 of NRS or a dentist licensed pursuant to chapter 631 of NRS who is operating an ambulatory surgical center for the purpose of performing surgery only upon his patients.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9837 Restrictions on operation of ambulatory surgical center; maintenance of records. (NRS 449.037)
1. An ambulatory surgical center:
(a) May be operated only for the purpose of providing surgical services to patients who do not require care for more than 24 hours.
(b) Except as otherwise provided in subsection 2, may not be operated in:
(1) Conjunction with any other medical facility; or
(2) A common area with any other medical facility during its hours of operation.
2. The provisions of subsection 1 do not prohibit an ambulatory surgical center from:
(a) Being located in the same building as a physician’s office or clinic if the center is physically separated from the office or clinic by at least one fire wall that is rated to withstand a fire for at least 1 hour.
(b) Sharing a lobby with another medical facility.
3. The records of an ambulatory surgical center must be maintained separately from the records of any other medical facility.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99)
NAC 449.9843 Compliance with certain standards, laws, ordinances and codes; submission and approval of building plans; prerequisites to approval of center for licensure. (NRS 449.037)
1. An ambulatory surgical center shall comply with the provisions of NFPA 99: Standard for Health Care Facilities concerning medical gases, adopted by reference pursuant to NAC 449.0105, and the provisions of NFPA 101: Life Safety Code, adopted by reference pursuant to NAC 449.0105.
2. Any new construction, remodeling or change in the use of an ambulatory surgical center must comply with the Guidelines for Design and Construction of Hospital and Health Care Facilities, adopted by reference pursuant to NAC 449.0105, unless the remodeling is limited to refurbishing an area within the center, including, without limitation, painting the area, replacing flooring in the area, repairing windows in the area and replacing window or wall coverings in the area.
3. An ambulatory surgical center shall be deemed to be in compliance with the provisions of subsection 2 and subsection 2 of NAC 449.983 if:
(a) The center is licensed on February 1, 1999, the use of the physical space in the center is not changed and there are no deficiencies in the construction of the center that are likely to cause serious injury, harm or impairment to the public health and welfare; or
(b) The center has submitted building plans to the Bureau before February 1, 1999, and:
(1) The Bureau determines that the plans comply with standards for construction in effect before December 11, 1998;
(2) The center is constructed in accordance with those standards;
(3) Construction of the center is begun before August 1, 1999; and
(4) There are no deficiencies in the construction of the center that are likely to cause serious injury, harm or impairment to the public health and welfare.
4. An ambulatory surgical center shall comply with all applicable:
(a) Federal and state laws;
(b) Local ordinances, including, without limitation, zoning ordinances; and
(c) Life safety, environmental, health, fire and local building codes.
Ê If there is a difference between state and local requirements, the more stringent requirements apply.
5. An ambulatory surgical center shall submit building plans for new construction or remodeling to the entity designated to review such plans by the Health Division pursuant to NAC 449.0115. The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the center. Before the construction or remodeling may begin, the plans for the construction or remodeling must be approved by the Health Division. The Bureau shall not approve a center for licensure until all construction is completed and a survey is conducted at the site of the center.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99; A by R076-01, 10-18-2001; R077-04, 8-5-2004)
Personnel
NAC 449.9855 Policies and requirements for personnel. (NRS 449.037)
1. An ambulatory surgical center shall have written policies for the personnel employed at the center. These policies must be provided to each employee in the form of a manual and must include provisions concerning hours of work, grievances in connection with termination, vacation, sick leave and leaves of absence.
2. Each employee of the center must:
(a) Have a skin test for tuberculosis in accordance with NAC 441A.375. A record of each test must be maintained at the center.
(b) Within 10 days after the date of his employment, and periodically thereafter, be instructed in the control of infections, the prevention of fires, the safety of the patients, preparation in case of disaster, and the policies and procedures of the center.
3. A current and accurate personnel record for each employee of the center must be maintained at the center. The record must include, without limitation:
(a) A job description that:
(1) Includes the duties and responsibilities of, and the qualifications required for, the position held by the employee; and
(2) Is signed by the employee;
(b) Evidence that the employee has obtained any license, certificate or registration, and possesses the experience and qualifications, required for the position held by the employee;
(c) An annual evaluation of the employee that is signed by the employee and his supervisor; and
(d) Such health records as are required by chapter 441A of NAC.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9865 Medical staff. (NRS 449.037)
1. The medical staff of an ambulatory surgical center is answerable to the governing body for the quality of medical care provided to patients and for the ethical and professional practices of its members.
2. The governing body, or a person or committee designated by the governing body, shall appoint the members of the medical staff and grant, deny and withdraw the privileges to be accorded members of the medical staff as it deems appropriate. Appointments to the medical staff must be made in writing and must be documented in the records of the center.
3. Each member of the medical staff must be qualified for the position to which he is appointed and the privileges which he is accorded.
4. A roster of the surgical privileges of each member of the medical staff must be kept in the files of the operating room, specifying the privileges accorded him.
5. The governing body shall establish procedures for disciplining a member of the medical staff who fails to comply with the policies and procedures of the center.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.988 Nursing staff. (NRS 449.037)
1. Each ambulatory surgical center must have a department of nursing under the direction of a chief nurse who is a registered nurse.
2. A sufficient number of members of the nursing staff must be on duty at all times to ensure that proper care is provided to each patient. A sufficient number of registered nurses must be on duty at all times to ensure the immediate availability of a registered nurse for the care of any patient. A person who is not a registered nurse may be assigned to care for a patient to the extent consistent with his education, experience and authorized scope of practice.
3. A surgical technician or licensed practical nurse may be permitted to serve as a scrub technician only under the direct supervision of a registered nurse.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
Medical Records, Services and Facilities
NAC 449.9885 Medical records: Maintenance. (NRS 449.037)
1. An employee shall oversee the completion, filing and retention of each medical record.
2. Records must be maintained for each patient admitted for care in the center in accordance with accepted professional principles.
3. Only authorized personnel may have access to medical records. Information contained in a medical record must not be released without the written consent of the patient or his guardian except:
(a) As required by law;
(b) Under a contract involving a third-party payor; or
(c) As otherwise provided by the agreement on admission.
4. A medical record may be microfilmed if the record can be legibly reproduced.
5. A licensee who ceases operations shall notify the Division of the arrangements made for access to and the safe preservation of medical records.
6. Medical records must not be removed from the center except upon the issuance of an order by a court of competent jurisdiction.
7. The records of each patient discharged from the center must be completed within 30 days after the date of his discharge.
8. An index of medical records must be maintained. The medical records of each patient must be indexed, within 6 months after discharge, according to the surgery performed and the physician attending the patient.
9. Each record must be protected against loss, destruction or unauthorized use.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.989 Medical records: Contents. (NRS 449.037) The medical record of each patient must be complete, authenticated, accurate and current, and must include the following information:
1. A complete identification of the patient, including information on his next of kin and on the person or agency legally or financially responsible for him.
2. A statement concerning the admission and diagnosis of the patient.
3. The medical history of the patient.
4. Documentation that the patient has been given a presurgical evaluation conducted by a physician within the 7 days immediately preceding the date of the patient’s surgery.
5. Evidence of any informed consent given for the care of the patient.
6. Any clinical observations of the patient, such as the notes of a physician, a nurse or any other professional person in attendance. Such an entry must be signed by the person making the entry and include the title of that person.
7. Reports of all studies ordered, including laboratory and radiological examinations.
8. Confirmation of the original diagnosis, or the diagnosis at the time of discharge.
9. A report of any operation performed on the patient, prepared by the surgeon.
10. A description of the procedure followed in any administration of anesthesia to the patient.
11. A recovery report for the patient.
12. A summary of discharge, including, without limitation, the disposition of the patient and any recommendations and instructions given to the patient.
13. Documentation that a member of the nursing staff interviewed the patient within 72 hours after the patient was discharged from the center to determine the condition of the patient and whether the patient was satisfied with the services provided, and to receive any complaints or problems the patient may have.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9895 Sterilization. (NRS 449.037)
1. All surgical instruments, sutures and drains used in the care of patients must be sterile.
2. If these materials are sterilized on the premises, the process of sterilization must be supervised by a person who has received specialized training in the operation of that process, including training in methods of testing to verify the efficiency of the process.
3. Instructions for operating any autoclave or sterilizer must be posted near the equipment, and this equipment must be maintained in a safe operating condition.
4. The efficiency of the method of sterilization used must be checked not less frequently than once each month by bacteriological tests. Records of the results of these tests must be maintained by the center for at least 1 year.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.990 Medication and treatment. (NRS 449.037)
1. Any medication or treatment may be given only upon the written or oral order of a person lawfully authorized to prescribe that medication or treatment. This order must be authenticated by the prescriber and the person administering the medication. An oral order must be recorded and authenticated within 24 hours after it is made.
2. Medications prepared by one nurse may not be administered by another nurse.
3. At the time the medication is administered, the patient must be identified and the medication must be identified as being ordered for that patient and recorded in the medical record of the patient.
4. Records must be maintained for any substance listed as a schedule II controlled substance pursuant to chapter 453 of NRS. Any such record must indicate the name of the patient, the name of the prescriber, the name of the controlled substance, the strength and dose administered, and the balance of the controlled substance remaining. A count must be made of all such controlled substances at the change of each nursing shift by a nurse from each shift. The count must be authenticated by both nurses.
5. Transfusions of blood or intravenous medications may be administered only by persons who have been specially trained and are authorized for that duty. An ambulatory surgical center shall adopt policies and procedures for the administration of blood.
6. Any suspected adverse reaction to a transfusion or medication must be reported by members of the nursing staff to the physician attending the patient. The nursing staff shall note the reaction in the medical record of the patient. Any suspected reaction to a transfusion must also be reported to the service that furnished the blood.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9902 Emergency equipment and supplies required. (NRS 449.037)
1. An ambulatory surgical center must be equipped with:
(a) A cardiac defibrillator;
(b) A tracheostomy set; and
(c) Such other emergency medical equipment and supplies as are specified by the members of the medical staff.
2. A person trained in the use of emergency equipment and in cardiopulmonary resuscitation must be on the premises of the ambulatory surgical center and immediately available at all times when there is a patient in the center. As used in this subsection, “immediately available” means that the person is sufficiently free from other duties to be able to respond rapidly to an emergency.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99)
NAC 449.9905 Pharmacist required; records, storage and administration of drugs. (NRS 449.037)
1. A pharmacist must be on the staff of each ambulatory surgical center or under contract with the center. He is responsible for all matters pertaining to the use of drugs in the center. If the center employs a part-time pharmacist by contract, he shall visit the center not less frequently than once each month. These visits must be documented.
2. Records of all transactions must be in writing and maintained so the receipt and disposition of any drug may be readily traced.
3. Drugs requiring refrigeration must be stored in a locked refrigerator or a refrigerator in a locked room. Food must not be stored in this refrigerator except for food used as a vehicle for the administration of drugs.
4. In the absence of a full-time pharmacist, the director of nursing must be designated in writing as responsible for the control of dangerous drugs and controlled substances. Substances listed as schedule II controlled substances pursuant to chapter 453 of NRS must be stored in a storage area with two locks. If a box is used, it must be securely fastened and immovable.
5. Drugs may not be kept in stock after the expiration date on the label. Obsolete, contaminated or deteriorated drugs must be destroyed.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.991 Laboratory services. (NRS 449.037)
1. Laboratory services must be provided to meet the needs of patients and must be available to each center at all times.
2. If the ambulatory surgical center has its own laboratory, it must be a licensed clinical laboratory under the provisions of chapter 652 of NRS.
3. If the ambulatory surgical center contracts with a laboratory for its services, that laboratory must be certified in accordance with the Clinical Laboratory Improvement Amendments of 1988, Public Law No. 100-578.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.992 Pathological services. (NRS 449.037)
1. Pathology services must be provided by a staff pathologist or by a pathologist used as a consultant by the ambulatory surgical center. The pathologist must be licensed to practice in this State.
2. All material removed from a patient during surgery must be clearly labeled and examined microscopically as required by a pathologist. In the absence of a staff pathologist, written arrangements must be made to send tissues to a pathologist outside the center.
3. A list of tissues that do not routinely require microscopic examination must be approved by a pathologist and made available to the laboratory and the members of the medical staff.
4. Reports of examinations of tissues must be authenticated by the examining pathologist. The original report must be filed in the medical record of the patient.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9925 Procurement, storage and transfusion of blood. (NRS 449.037)
1. If the ambulatory surgical center provides its own service for blood transfusions through its clinical laboratory:
(a) Any arrangement for the procurement, safekeeping or transfusion of blood or derivatives of blood must be under the supervision of a physician.
(b) Any reaction to a transfusion of blood must be investigated.
(c) The storage equipment for blood and derivatives of blood must be protected by an alarm system which is tested each month to check its operation.
(d) Samples of the blood of any patient receiving a transfusion and of each unit of blood used in the center must be retained in accordance with the written policy of the laboratory for at least 7 days for further testing in the event of a reaction to the transfusion.
(e) Blood and derivatives of blood that have exceeded their expiration date may not be used.
2. If the ambulatory surgical center depends on an outside source for blood, there must be in force a written agreement governing the procurement of blood and derivatives of blood that is reviewed annually by the governing body and the staff pathologist or the pathologist used as a consultant by the center.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.993 Diagnostic radiological services. (NRS 449.037)
1. Each ambulatory surgical center shall maintain diagnostic radiological services or have such services immediately available. Whether these services are provided directly or by contract, personnel capable of supervising the performance of the services must be available.
2. If a center provides diagnostic radiological services directly, the center must have a full-time radiologist or a radiologist who works as a part-time consultant available to supervise the department of radiology and to interpret films.
3. Only a person designated as qualified by the radiologist may operate the equipment for X rays. Only a physician may perform a fluoroscopy.
4. A radiological technician must be on duty or available within 15 minutes after being called while the center is open.
5. Examinations by X-ray must be ordered by the physician responsible for the care of the patient, and the order must contain a concise statement of the reason for the examination. Reports of these examinations must be signed by the reporting physician. The original report must be filed in the medical records of the patient, and a copy of the report must be kept in the radiology department.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9935 Operating and recovery rooms; endoscopy suite. (NRS 449.037)
1. The operating and recovery rooms of an ambulatory surgical center must be used exclusively for surgical procedures.
2. Except as otherwise provided in subsection 3, surgical procedures must be conducted in a class A, B or C operating room in accordance with chapter 9 of the Guidelines for Design and Construction of Hospital and Health Care Facilities, adopted by reference pursuant to NAC 449.0105.
3. If an ambulatory surgical center is licensed to perform only endoscopic procedures, such procedures may be conducted in an endoscopy suite in accordance with chapter 9 of the Guidelines for Design and Construction of Hospital and Health Care Facilities, adopted by reference pursuant to NAC 449.0105.
4. A registered nurse experienced in surgical procedures shall supervise the operating room.
5. Only a registered nurse may function as the circulating nurse in the operating room.
6. The operating room must be equipped with:
(a) A system for making emergency calls;
(b) Oxygen;
(c) Mechanical ventilatory assistance equipment, including, without limitation, a manual breathing bag and a ventilator;
(d) Cardiac monitoring equipment;
(e) Laryngoscopes and endotracheal tubes; and
(f ) Suction equipment.
7. If the operating team consists of persons who are not physicians, such as a dentist, a podiatrist or a nurse, a physician must be on the premises and immediately available in case of an emergency. As used in this subsection, “immediately available” means the physician is sufficiently free from other duties to be able to respond rapidly to the emergency.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R077-04, 8-5-2004)
NAC 449.9937 Extended recovery units. (NRS 449.037)
1. An ambulatory surgical center may operate an extended recovery unit.
2. An extended recovery unit must:
(a) Be located in an area of the center that is separate from the other operations of the center;
(b) Provide audio and visual privacy for each patient in the unit;
(c) Be supervised by at least one physician who is recommended for the position by the members of the medical staff and approved by the governing body;
(d) Have at least one physician on the premises or immediately available by telephone at all times when there is a patient in the unit;
(e) Except as otherwise provided in paragraph (f ), have at least one nurse who is trained in advanced cardiac life support on duty for every two patients in the unit;
(f ) Have at least two nurses who are trained in advanced cardiac life support on duty at all times when there is a patient in the unit; and
(g) Be equipped with:
(1) A system for making emergency calls;
(2) Oxygen;
(3) A cardiac defibrillator;
(4) A manual breathing bag;
(5) Suction equipment; and
(6) Such other emergency equipment as is needed to provide care to patients in the unit.
3. A patient must be admitted and discharged from an extended recovery unit only upon the order of the physician of record. If a patient is admitted to the unit, the time he remains in the unit for treatment, when added to the time he remains in any other area of the ambulatory surgical center for treatment, may not exceed 23 hours and 59 minutes.
4. The center shall adopt policies and procedures for the extended recovery unit that include, without limitation:
(a) Clinical criteria for determining a patient’s eligibility for admission into the unit;
(b) Clinical criteria for determining a patient’s eligibility for being discharged from the unit;
(c) Procedures for providing emergency services; and
(d) Procedures for transferring a patient in need of other health care services.
5. An ambulatory surgical center shall provide food to meet the needs of patients in an extended recovery unit. A patient on a special diet must be served food that conforms to the patient’s prescribed diet. If the food is prepared by the center, the center shall:
(a) Comply with the applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto; and
(b) Obtain such permits as are necessary from the Bureau of Health Protection Services of the Health Division to prepare the food.
(Added to NAC by Bd. of Health by R049-99, eff. 9-27-99)
NAC 449.994 Records required before surgery; report of surgery. (NRS 449.037)
1. A presurgical evaluation conducted by a physician and the pertinent past medical history of a patient must be recorded in the chart of the patient before surgery.
2. A properly executed form of consent to surgery must be placed in the medical record of the patient before surgery. A report must be prepared immediately after surgery describing the technique and findings of the surgery.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9945 Administration and record of anesthesia. (NRS 449.037)
1. Anesthetics must be administered in the operating room of an ambulatory surgical center by an anesthesiologist, a qualified physician, a dentist or, under the direction of the operating physician and in accordance with the provisions of chapter 632 of NRS and the regulations adopted pursuant thereto, a certified registered nurse anesthetist.
2. Persons designated to administer anesthetics must be qualified to administer anesthetics based on their credentials and must be approved by the governing body.
3. General anesthesia must not be administered to a patient unless a physician has evaluated the patient immediately before surgery to assess and document the risks of administering the anesthesia relative to the surgical procedure to be performed. A patient who receives general anesthesia must be evaluated by a physician after the patient has recovered from the general anesthesia and before he is discharged from the recovery room.
4. A record of anesthesia must be completed after surgery, and there must be a follow-up on each patient who has received anesthesia with the findings recorded by the person who administered the anesthesia.
5. As used in this section, “certified registered nurse anesthetist” has the meaning ascribed to it in NRS 632.014.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.9955 Informing patient of rights, services and cost. (NRS 449.037) The administrator of an ambulatory surgical center shall ensure that:
1. Each patient admitted to the center is treated with respect, consideration and dignity.
2. Each patient admitted to the center is provided appropriate privacy.
3. Each patient admitted to the center is informed of his rights as a patient in accordance with the provisions of NRS 449.730. He must be informed, at the time of his admission, of the services available and the estimated cost of those services. If a patient is unable to understand his rights, they must be explained to his guardian, next of kin or the agency financially responsible for his care.
4. The records of a patient admitted to the center are kept confidential, except as otherwise provided by law.
5. Each patient admitted to the center is given the opportunity to participate in decisions relating to his health care, unless he is unable to do so because of his medical condition.
6. Information is available to patients and members of the staff concerning:
(a) The policies of the center relating to the conduct and responsibilities of patients;
(b) The care that is available at the center during emergencies and after normal business hours;
(c) The policies of the center related to the payment of fees;
(d) A patient’s right to refuse to participate in experimental research; and
(e) The procedures for filing complaints or grievances at the center.
(Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99)
NAC 449.996 Transfer of patients. (NRS 449.037)
1. Each ambulatory surgical center shall maintain with a licensed general hospital a written agreement concerning the transfer of patients. The agreement must provide for the security of, and the accountability for, the personal effects of the patient.
2. If a patient is transferred, all medical and administrative information relating to the patient must be transferred with him or promptly made available to the licensed center or agency responsible for his continuing care.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.9965 Prohibited locations for construction of center. (NRS 449.037) A new ambulatory surgical center must not be constructed over any underground liquid butane, propane or transmission line for gas, or over any underground high pressure lines, under high voltage electrical lines or near hazardous or hazard-producing plants.
(Added to NAC by Bd. of Health, eff. 12-15-88)
NAC 449.997 Conversion of hazardous building into center prohibited. (NRS 449.037) No building may be converted for use as an ambulatory surgical center if, because of its location, physical condition, state of repair or arrangement of facilities, the building would be hazardous to the health and safety of patients.
(Added to NAC by Bd. of Health, eff. 12-15-88)
RECEIVERS
NAC 449.9981 List of interested and qualified persons. (NRS 449.037) The Health Division may solicit applications from persons interested in being nominated by the Health Division as receivers whenever receivership proceedings are brought. The Health Division shall develop and maintain a list of persons who are interested and qualified to act as receivers for facilities. Persons or organizations appearing on the list must have experience in the delivery of health care services or other relevant experience.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99811 Experience. (NRS 449.037)
1. In recommending a person or organization to serve as a receiver in a case, the Health Division shall, if feasible, nominate a receiver who has experience in the delivery of the type of care, treatment or services provided by the facility for which a receiver is requested.
2. If the primary deficiencies leading to the request for appointment of a receiver are related to the financial stability of the facility, the person or organization recommended must have experience in financial management and, if feasible, in the financial management of health care facilities.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99812 Authority. (NRS 449.037) A receiver appointed pursuant to NAC 449.9981 to 449.99814, inclusive, may exercise such authority as is granted by the court appointing the receiver and as is consistent with the laws governing the authority of a receiver in this State.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99813 Compensation and payment of bond. (NRS 449.037) The compensation of the receiver and the expense of any bond he is required to furnish must be paid from the revenues of the facility for which the receiver is appointed.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99814 Operation of facility. (NRS 449.037)
1. The Bureau shall provide a receiver appointed by the court with a provisional license to operate the facility during the pendency of the receivership.
2. The receiver is responsible to the court for the operation of the facility during the receivership. Any deficiencies concerning the operation during the receivership, if not corrected, must be reported by the Health Division to the court.
(Added to NAC by Bd. of Health, eff. 8-1-91)
ADMINISTRATIVE SANCTIONS
General Provisions
NAC 449.9982 Definitions. (NRS 449.037) As used in NAC 449.9982 to 449.99939, inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.99821 to 449.99841, inclusive, have the meanings ascribed to them in those sections.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R131-99, 11-29-99; R051-02, 7-24-2002)
NAC 449.99821 “Ban on admissions” defined. (NRS 449.037) “Ban on admissions” means a prohibition on the provision of care, treatment or services to recipients who are newly admitted.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99822 “Cluster” defined. (NRS 449.037) “Cluster” means a deficiency that involves the same or similar kinds of care, treatment or services as one or more other deficiencies.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99823 “Compliance” and “substantially correct the deficiency” defined. (NRS 449.037) “Compliance” or “substantially correct the deficiency” means that no major deficiency is present and that effective steps have been taken to resolve all deficiencies.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99824 “Costs” defined. (NRS 449.037)
1. “Costs” means the expenses of implementing and enforcing administrative sanctions and of bringing an action in a court of competent jurisdiction.
2. The term includes, without limitation, filing fees, fees for service of notices or process and all expenses of litigation recoverable as costs pursuant to chapter 18 of NRS.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99825 “De minimis deficiency” defined. (NRS 449.037) “De minimis deficiency” means a deficiency rated at a severity level of one or two and at a scope level of one or two.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.998253 “Division of Health Care Financing and Policy” defined. (NRS 449.037) “Division of Health Care Financing and Policy” means the Division of Health Care Financing and Policy of the Department of Health and Human Services.
(Added to NAC by Bd. of Health by R051-02, eff. 7-24-2002)
NAC 449.998255 “Facility” defined. (NRS 449.037) “Facility” means a medical facility or facility for the dependent.
(Added to NAC by Bd. of Health by R131-99, eff. 11-29-99)
NAC 449.99826 “Immediate family” defined. (NRS 449.037) “Immediate family” means the spouse, parent, child or sibling of a recipient.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99827 “Initial deficiency” defined. (NRS 449.037)
1. “Initial deficiency” means the first occurrence of a deficiency recorded by the Bureau.
2. The term includes any deficiency found during a standard survey, during an extended survey or in response to a complaint.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99828 “Major deficiency” defined. (NRS 449.037) “Major deficiency” means a deficiency with a combined severity and scope rating of five or more.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99829 “Medicaid facility” defined. (NRS 449.037) “Medicaid facility” means a facility that has entered into an agreement to provide care, services or treatment paid under the joint federal-state Medicaid program described in 42 U.S.C. §§ 1396 et seq.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.9983 “Medicare facility” defined. (NRS 449.037) “Medicare facility” means a facility that has entered into an agreement to provide care, services or treatment paid by Medicare pursuant to 42 U.S.C. §§ 1395 et seq.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99832 “Monitor” defined. (NRS 449.037) “Monitor” means to observe, advise or supervise a facility on an as-needed basis to ensure compliance with the plan of correction for the facility
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99833 “New admission” defined. (NRS 449.037) “New admission” means a person who is admitted to the facility on or after the effective date of a ban on admissions and who has not been admitted before or, if previously admitted, has been discharged or left the facility voluntarily more than 30 days before the effective date of the ban.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99834 “Particular kinds of care, treatment or services” defined. (NRS 449.037) “Particular kinds of care, treatment or services” includes discrete areas such as bowel and bladder training, catheter care, restraints, injections, parenteral fluid administration, tube feedings, gastrostomy care, colostomy care, ileostomy care, respiratory therapy, tracheostomy care, suctioning, physical therapy and occupational therapy.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99835 “Plan of correction” defined. (NRS 449.037) “Plan of correction” means a plan developed by the facility and approved by the Bureau that:
1. Describes the actions to be taken by the facility to correct one or more deficiencies; and
2. Specifies the date by which those deficiencies will be corrected.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99836 “Provider agreement” defined. (NRS 449.037) “Provider agreement” means an agreement between a facility and:
1. The Centers for Medicare and Medicaid Services, if the facility is a Medicare facility; or
2. The Division of Health Care Financing and Policy, if the facility is a Medicaid facility.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99837 “Repeated deficiency” defined. (NRS 449.037) “Repeated deficiency” means a deficiency found by the Bureau again within 18 months, including one found at a follow-up survey, an investigation of a complaint or the next annual survey.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99838 “Resurvey” defined. (NRS 449.037) “Resurvey” means a subsequent survey conducted to evaluate compliance with a plan of correction.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99839 “Severity and scope score” defined. (NRS 449.037) “Severity and scope score” means the sum of the numerical levels of severity and scope assigned to a deficiency.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.9984 “Subsequent deficiency” defined. (NRS 449.037) “Subsequent deficiency” means a deficiency found on a resurvey.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99841 “Temporary management” defined. (NRS 449.037) “Temporary management” means the temporary appointment by the Bureau or by a court of competent jurisdiction of a manager or administrator with authority to operate the facility and to hire, terminate or reassign staff, obligate money of the facility, alter procedures and manage the facility to correct the deficiencies found during a survey or visit identifying the deficiencies.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99843 Purposes of administrative sanctions. (NRS 449.037) The purposes of administrative sanctions are to:
1. Safeguard the rights, interests and well-being of recipients, including the protection of recipients from actual or potential harm resulting from deficiencies;
2. Encourage and assist facilities to comply with the requirements of the Health Division, including those imposed by federal law;
3. Promote the efficient use of resources to ensure appropriate care, treatment and services for recipients; and
4. Protect Medicare beneficiaries and Medicaid recipients against health care of substandard quality.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99844 Interpretation of provisions in accordance with federal standards. (NRS 449.037) With respect to facilities governed by the federal Medicare or Medicaid criteria, the provisions of NAC 449.9982 to 449.99939, inclusive, must be interpreted in accordance with applicable federal standards.
(Added to NAC by Bd. of Health, eff. 8-1-91)
Imposition: Generally
NAC 449.9985 Authority of Health Division and Bureau. (NRS 449.037) Administrative sanctions authorized by NRS 449.163 must be imposed by the Health Division through the Bureau.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99851 Requirement for imposition; optional imposition. (NRS 449.037, 449.165) At least one administrative sanction must be imposed for each deficiency in any facility with a severity level of four and for each deficiency in any facility with a combined severity and scope score of six or more. The Bureau may impose sanctions if deficiencies of a severity level three or less or a combined severity and scope score of less than six are identified.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99852 Requirement for imposition; multiple sanctions. (NRS 449.037, 449.165) The Bureau must impose at least one of the sanctions listed in NAC 449.99863 upon any facility that has a deficiency with a severity level of four or a combined severity and scope score of six or more. More than one of these sanctions may be imposed in the discretion of the Bureau.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99853 Imposition of one or more sanctions; criteria for imposition of particular sanction. (NRS 449.037, 449.165) The Bureau may apply one or more sanctions as provided in NAC 449.99863 and 449.99935. If the Bureau chooses to impose a particular sanction, it must be applied according to the severity and scope factors established in NAC 449.99858 to 449.99861, inclusive.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99854 Imposition in lieu of or in addition to recommendation to terminate provider agreement; duration of sanctions. (NRS 449.037, 449.165)
1. The Bureau may apply one or more of the sanctions specified in NAC 449.99863 in lieu of or in addition to a recommendation to the Division of Health Care Financing and Policy or the Centers for Medicare and Medicaid Services to terminate a provider agreement.
2. Sanctions applied pursuant to NAC 449.9982 to 449.99939, inclusive, may be imposed until substantial compliance is achieved or, if compliance is not achieved, until the day before termination of the license or provider agreement becomes effective.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99855 Imposition in emergencies: Authority; notice. (NRS 449.037, 449.165)
1. If necessary to protect the public health and safety, the Bureau may impose such sanctions as are necessary without notice to the facility or by oral notice to the facility.
2. If there is an immediate and serious threat to the health and safety of recipients served by a facility, the Bureau may appoint a temporary manager to remove the threat. A temporary manager may also be appointed without prior written notice on an emergency basis if a facility violates any ban on admissions. If there is an immediate and serious threat to the health and safety of recipients, the times provided for notice contained in this subsection govern. In all other respects, the provisions governing temporary management found in NAC 449.99915 to 449.99921, inclusive, apply.
3. The Bureau may, in an emergency, impose a ban on admissions, a limitation on occupancy of a residential facility or may suspend the license of a facility without notice or upon oral notice as provided in this section.
4. In any case where sanctions are imposed without written notice, the Bureau shall provide written notice that complies with the requirements of NAC 439.345 within 48 hours after the imposition of the sanctions.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R044-97, 10-30-97)
NAC 449.99856 Deficiencies: Basis for imposition of sanctions; reporting; presumption of de minimis deficiency. (NRS 449.037, 449.165)
1. The Bureau may apply one or more sanctions on the basis of deficiencies found during surveys or investigations of complaints conducted by the Bureau.
2. Deficiencies must be reported to the facility and, if applicable, to the Centers for Medicare and Medicaid Services. The notice to the facility must specify the deficiencies found and the severity and scope score for each deficiency determined by the Bureau.
3. Any deficiency for which a severity and scope score is not specified is presumed to be a de minimis deficiency.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99857 Classifications of severity and scope of deficiencies: Use. (NRS 449.037, 449.165) In determining the sanctions to be imposed, the Bureau shall consider the severity and scope of the deficiencies according to the classifications of severity and scope described in NAC 449.99858 to 449.99861, inclusive.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99858 Scope of violations: Evaluation of representative sample of recipients; size of sample. (NRS 449.037, 449.165)
1. In determining the scope of a violation, a survey of a facility must evaluate a representative sample of recipients as described in the protocol for the survey of such a facility. Unless a sample of a different size is required for the survey by federal law, the sample must consist of at least the following size:
|
Number of recipients |
Minimum number of recipients in sample |
|
|
|
|
1 - 9.............................................................................. |
All recipients |
|
10 - 40.......................................................................... |
10 |
|
41 - 75.......................................................................... |
15 |
|
76 - 100........................................................................ |
20 |
|
101 - 175...................................................................... |
25 |
|
176 - 250...................................................................... |
30 |
|
251 - 350...................................................................... |
35 |
|
351 - 450...................................................................... |
40 |
|
451 or more................................................................. |
50 |
2. The sample size used in identifying the scope of a deficiency in a resurvey must not be less than 60 percent of the sample size used in the initial survey.
3. In determining the scope of a violation involving particular kinds of care, treatment or services, the survey must evaluate a representative sample of recipients receiving or requiring the particular kinds of care, treatment or services. Unless a sample of a different size is required for the survey by federal law, the sample must consist of at least the following size:
|
Number of recipients needing or receiving a particular kind of care, treatment or services |
Minimum number of recipients in sample |
|
|
|
|
1 - 9.............................................................................. |
All recipients |
|
10 - 40.......................................................................... |
10 |
|
41 - 75.......................................................................... |
15 |
|
76 - 100........................................................................ |
20 |
|
101 - 175...................................................................... |
25 |
|
176 - 250...................................................................... |
30 |
|
251 - 350...................................................................... |
35 |
|
351 - 450...................................................................... |
40 |
|
451 or more................................................................. |
50 |
4. The Bureau may review more than the minimum number of recipients. If it does so, the determination of scope must be based on the number of recipients actually reviewed.
5. If the Bureau investigates a complaint relating to a recipient, the Bureau may sample only that recipient. The scope of any deficiency cited pursuant to this subsection must be scope level one.
6. As used in this section, “recipient” means a person who:
(a) Is admitted to a licensed bed maintained by the facility at the time the Bureau surveys the facility; or
(b) Received services at the facility within the 30 days immediately preceding the date the Bureau surveys the facility, if the facility is not licensed to maintain beds.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99859 Scope of deficiencies: Use of scope scale; basis for assessment. (NRS 449.037, 449.165)
1. The scope scale must be used to assess the scope of a particular deficiency in or by the facility.
2. The basis for the assessment is the actual or potential harm to recipients as shown by:
(a) The frequency of the deficiency;
(b) The number or percentage of recipients affected;
(c) The number or percentage of staff involved; and
(d) The pattern or lack of pattern of the deficiencies.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.9986 Scope of deficiencies: Criteria for evaluation. (NRS 449.037, 449.165)
1. The scope of the deficiencies must be evaluated using the criteria prescribed in this section.
2. A deficiency of scope level one consists of one or an isolated number of unrelated incidents in the sample surveyed. A deficiency is of this scope if it involves 20 percent or less of the recipients sampled in a facility.
3. A deficiency is scope level two if the Bureau identifies a pattern of incidents at the facility, including any deficiencies involving recipients who require particular kinds of care, treatment or service. The number or percentage of recipients or staff involved in the incidents or the repeated occurrences of incidents in short succession may also establish a pattern by indicating a reasonable degree of predictability of similar incidents. A deficiency is also of this scope if it involves more than 20 percent but not more than 50 percent of the recipients sampled in a facility.
4. A deficiency is of scope level three if it occurs in a sufficient number or percentage of recipients or staff or with sufficient regularity over time that it may be considered systemic or pervasive in or by the facility. A deficiency is also of this scope if it involves more than 50 percent of the recipients sampled in a facility.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99861 Severity of deficiencies: Use of severity scale; basis for assessment; criteria for evaluation. (NRS 449.037, 449.165)
1. The severity scale must be used to assess the severity of a particular deficiency pertaining to the facility. The basis for the assessment must be the actual or potential harm to recipients.
2. Deficiencies of severity level one concern requirements promulgated primarily for administrative purposes. No harm is likely to occur to a recipient. No negative recipient impact has occurred or is likely to occur. The ability of a recipient to achieve the highest practicable physical, mental or psychosocial well-being has not been and is not likely to be compromised.
3. Deficiencies of severity level two indirectly threaten the health, safety, rights, security, welfare or well-being of a recipient. A potential for harm, as yet unrealized, exists. If continued over time, a negative impact on one or more recipients or a violation of one or more recipients’ rights would occur or would be likely to occur or the ability of one or more recipients to achieve the highest practicable physical, mental or psychosocial well-being would be, or would likely be, compromised.
4. Deficiencies of severity level three create a condition or incident in the operation or maintenance of a facility that directly or indirectly threatens the health, safety, rights, security, welfare or well-being of one or more recipients. A negative impact on the health, safety, rights, security, welfare or well-being of one or more recipients has occurred or can be predicted with substantial probability to occur or the ability of recipients to achieve the highest practicable physical, mental or psychosocial well-being has been or is about to be compromised and requires intervention and correction of the deficiency. Violation of a partial or complete ban on admissions imposed on a facility, violation of a limitation on occupancy of a residential facility or failure to implement a directed plan of correction is presumed to be a deficiency of this level of severity.
5. Deficiencies of severity level four create a condition or incident that has resulted in or can be predicted with substantial probability to result in death or serious harm to a recipient. As used in this subsection, “serious harm” includes serious mental harm, serious impairment of bodily functions, serious dysfunction of any bodily organ or part, life-threatening harm or death.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99862 Presumption when same deficiency found on resurvey; imposition of sanction for subsequent deficiency. (NRS 449.037, 449.165) If the same deficiency is found on a resurvey, there is a rebuttable presumption that the deficiency continued through the period between the survey and resurvey. A sanction may be imposed for a subsequent deficiency only if the resurvey is made and the deficiency is again actually found to be present.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99863 Available sanctions. (NRS 449.037) The sanctions available for all facilities include:
1. The imposition of a plan of correction as directed by the Bureau;
2. The issuance of a provisional license as provided by NRS 449.091;
3. The imposition of a limitation on the occupancy of a residential facility;
4. The imposition of a ban on admissions;
5. Monitoring of the facility by the Bureau;
6. The assessment of monetary penalties;
7. The requirement that the facility be managed temporarily by a person appointed by the Bureau; and
8. The denial, suspension or revocation of the license of the facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99864 Determination of appropriate sanction: Procedure. (NRS 449.037, 449.165) To determine the appropriate sanction, the Bureau shall follow the procedure set forth in NAC 449.99864 to 449.99867, inclusive.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99865 Determination of appropriate sanction: Initial assessment. (NRS 449.037, 449.165) The Bureau shall initially assess individual deficiencies or clusters of deficiencies according to the following initial factors:
1. The presence or absence of an immediate and serious threat to the health and safety of residents;
2. The severity of the deficiency; and
3. The scope of the deficiency.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99866 Determination of appropriate sanction: Consideration of secondary factors. (NRS 449.037, 449.165) After the initial assessment, the Bureau shall consider the following secondary factors in determining the sanction to impose:
1. The relationship of one deficiency or cluster or pattern of deficiencies to other deficiencies;
2. The history of previous compliance by the facility generally and specifically with reference to the deficiencies in issue;
3. Whether the deficiencies are directly related to the care, services or treatment received by persons from the facility; and
4. The corrective and long-term compliance outcomes desired.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99867 Determination of appropriate sanction: Basis for selection; presumption. (NRS 449.037, 449.165) The selection of a sanction must be based upon the nature of the deficiencies or cluster of deficiencies and the sanction most likely to correct those deficiencies. Absent evidence to the contrary, restrictions upon service and monetary penalties are presumed to be the most effective sanctions for deficiencies that do not cause an immediate and serious threat to recipients.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
Plan of Correction
NAC 449.9987 Development and submission of plan; authority of Bureau when plan is not acceptable; effect of failure to submit plan. (NRS 449.037, 449.165)
1. The facility shall develop a plan of correction for each deficiency and submit the plan to the Bureau for approval within 10 days after receipt of the statement of deficiencies. The plan of correction must include specific requirements for corrective action, which must include times within which the deficiencies are to be corrected.
2. If the plan is not acceptable to the Bureau, the Bureau may direct the facility to resubmit a plan of correction or the Bureau may develop a directed plan of correction with which the facility must comply.
3. Failure to submit the plan of correction to the Bureau within 10 days constitutes a separate deficiency subject to monetary penalties with severity and scope rated at the same levels as the highest deficiency identified on the notice of deficiencies.
(Added to NAC by Bd. of Health, eff. 8-1-91)
Limitation on Occupancy of Residential Facility
NAC 449.99875 Purpose and scope of limitation; imposition in addition to partial ban on admissions. (NRS 449.037, 449.165)
1. A limitation on the occupancy of a residential unit must be imposed by the Bureau to safeguard the health, safety and well-being of residents currently receiving care, treatment or services and to prevent the admission of persons who cannot adequately be served by the facility. If a limitation on occupancy is imposed, the limitation applies regardless of the source of payment. The Bureau may limit the occupancy of a facility to the number of beds occupied at the time the deficiency occurred. If such a limitation is imposed, priority in new admissions must be given to immediate relatives of persons presently occupying the facility.
2. If the facility contains separately identifiable units and the deficiencies are confined to one or more discrete units, the limitation on occupancy may be limited to those units.
3. A limitation on occupancy may be imposed in addition to a partial ban on admissions if the facility is unable to provide adequate care, treatment or services for persons needing a discrete kind or type of care.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99876 Criteria for imposition. (NRS 449.037, 449.165)
1. If the Bureau imposes a limitation on the occupancy of a residential facility, the limitation must be imposed as provided in this section.
2. For deficiencies with a combined severity and scope score of six or more, a limitation on occupancy must be imposed.
3. For deficiencies with a severity and scope score of less than six, a limitation on occupancy may be imposed if the deficiencies involve direct recipient care, services or treatment or the ability of residents to exit the facility safely in case of a fire or other emergency.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99877 Duration and termination of limitation. (NRS 449.037, 449.165) A limitation on occupancy:
1. Must be imposed for not less than 72 hours.
2. Must be terminated if the facility demonstrates that substantial improvements have been made to correct the deficiencies and that the health, safety and well-being of recipients are adequately safeguarded.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99878 Notice of limitation: General requirements; effect of noncompliance. (NRS 449.037, 449.165)
1. If a limitation on occupancy is imposed, a notice of the limitation must be posted at all public entrances to the facility within 48 hours after the facility receives notice of the limitation. Each notice must be not less than 15 inches by 20 inches in size and include:
(a) The words “NOTICE OF LIMITATION ON OCCUPANCY” printed in boldface type not less than 1 1/2 inches in size;
(b) A statement specifying the number of residents the facility is authorized to serve;
(c) A statement identifying a member of the staff of the facility who will provide additional information relating to the limitation on occupancy; and
(d) The telephone number of the Bureau.
2. Any person contacting the facility in writing or by telephone or any other means of telecommunication relating to a recipient seeking admission to the facility must be:
(a) Notified of the limitation on occupancy; and
(b) Provided with the information required by subsection 1.
3. The failure to post notice of a limitation on occupancy as required by this section, or the removal of such a notice, is a deficiency of severity level three and a scope level of three. The failure to inform an inquirer as to the existence of a limitation on occupancy is a deficiency of severity level two and a scope level of three.
4. In addition to the information required by subsection 1, the content of any notice required to be posted or published pursuant to this section must conform to the requirements set forth by the Bureau in the notice of sanction.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
Ban on Admissions
NAC 449.9988 Purpose and scope of ban. (NRS 449.037, 449.165)
1. A ban on admissions may be imposed by the Bureau on a residential or nonresidential facility to safeguard the health, safety and well-being of recipients receiving care, treatment or services and to prevent the admission of persons who cannot adequately be served by the facility. If a ban is imposed, it applies to all new admissions, regardless of the source of payment.
2. An immediate family member of a resident of a residential facility is not a new admission for the purposes of a ban on admissions unless the deficiencies are such that the health, safety or well-being of the immediate family member will be directly jeopardized.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99881 Criteria for imposition. (NRS 449.037, 449.165)
1. If the Bureau imposes a ban on admissions, the ban must be imposed as provided in this section.
2. For deficiencies of severity level four and scope level two or more, a ban on all new admissions must be imposed.
3. For deficiencies of severity level three and scope level three, a ban on all new admissions must be imposed.
4. For deficiencies of severity level three and scope level two, a complete or partial ban on admissions may be imposed. If the deficiency is related to a discrete type of care, treatment or services, the ban may be limited to new admissions requiring the care, treatment or services for which the deficiency is found.
5. For deficiencies with a severity level of three or four and a scope level of one, the Bureau may impose a partial ban on admissions, limited to persons needing the care, treatment or services affected by the deficiency.
6. For deficiencies with a severity level of two and a scope level of three, a ban on admissions may be imposed if the deficiencies directly affect the care, treatment or services furnished to recipients. The ban may be limited to those persons requiring the kind or type of services affected by the deficiencies.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99882 Duration and termination of ban. (NRS 449.037, 449.165) A ban on admissions:
1. Must be imposed for not less than 72 hours.
2. Must be terminated if the facility demonstrates that substantial improvements have been made to correct the deficiencies and that the health, safety and well-being of recipients are adequately safeguarded.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99883 Notice of ban: General requirements; effect of noncompliance. (NRS 449.037, 449.165)
1. If a ban on admissions is imposed, a notice of the ban must be posted at all public entrances to the facility within 48 hours after the facility receives notice of the ban. Each notice must be not less than 15 inches by 20 inches in size and include:
(a) The words “NOTICE OF BAN ON ADMISSIONS” printed in boldface type not less than 1 1/2 inches in size;
(b) A statement identifying a member of the staff of the facility who will provide additional information relating to the ban on admissions; and
(c) The telephone number of the Bureau.
2. If the facility provides care, treatment or services at a site other than the location of the office of the facility, notice must be provided by publishing an announcement, identified as a “LEGAL NOTICE” and not less than 25 percent of a newspaper page in size, in a newspaper of general circulation in the geographic area served by the facility on two separate occasions. The first publication must occur within 7 days after the facility receives notice of the ban, and the second publication must occur within 14 days after that date. At least one publication must be in a Sunday edition of the publication. Each publication must include the information required by subsection 1.
3. Any person contacting the facility in writing or by telephone or any other means of telecommunication relating to a recipient seeking admission must be:
(a) Notified of the ban; and
(b) Provided with the information required by subsection 1.
4. The failure to post or publish notice of a ban on admissions as required by this section, or the removal of such a notice, is a deficiency of severity level three and a scope of level three. A failure to inform an inquirer as to the existence of the ban is a deficiency of severity level two and a scope of level three.
5. In addition to the information required by subsection 1, the content of any notice required to be posted or published pursuant to this section must conform to the requirements set forth by the Bureau in the notice of sanction.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
Monitoring of Facility
NAC 449.99885 Authority of Bureau. (NRS 449.037, 449.165)
1. The Bureau may monitor the implementation of the plan of correction of the facility to determine whether the facility carries out the plan of correction.
2. The Bureau may also monitor the facility if the scope of the deficiencies identified is difficult to evaluate on a single visit. Such deficiencies include, without limitation, violations of recipients’ rights, inappropriate use of restraints and cases in which the Bureau has reason to question the ongoing compliance of the facility with the requirements of federal or state law.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
Monetary Penalties
NAC 449.99895 Imposition by Bureau; purpose; applicable criteria. (NRS 449.037, 449.165) The Bureau may impose a monetary penalty alone or in addition to other penalties. The purpose of a monetary penalty is to provide a fund for protecting the health, safety, rights, welfare and well-being of recipients and the property of residents in facilities and to deter future deficiencies. If a monetary penalty is imposed, the criteria in NAC 449.99896 must be applied.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99896 Criteria for imposition; imposition of initial and daily penalties. (NRS 449.037, 449.165)
1. Except as otherwise provided in subsection 4 of this section, the Bureau may impose a monetary penalty including interest thereon on any facility that is not in compliance with any participation requirement, regardless of whether the deficiency constitutes an immediate and serious threat.
2. If a monetary penalty is imposed, the initial amount of the penalty must be based on the severity and scope score of the deficiency and must be imposed as provided in NAC 449.99899.
3. In addition to the initial monetary penalty, the Bureau may impose a monetary penalty for each day of noncompliance from the date the noncompliance occurs or is identified until compliance is verified.
4. A facility is not subject to a monetary penalty for a de minimis deficiency.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99897 Imposition of initial penalty pending hearing or appeal; stay of payment of penalties pending appeal. (NRS 449.037, 449.165)
1. The Bureau shall impose an initial monetary penalty pending a hearing or appeal. The payment of the initial penalty must not be stayed during the pendency of any administrative appeal.
2. The payment of any daily monetary penalties or interest that accrue while the facility has a hearing pending on the initial determination of deficiencies leading to the imposition of sanctions must be stayed pending the appeal.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99898 Procedure for imposition; interest on total penalty assessed. (NRS 449.037, 449.165) If the Bureau imposes a monetary penalty, the penalty must be imposed as provided in NAC 449.99899 to 449.99908, inclusive. In imposing the monetary penalty, the total penalty assessed against any facility bears interest at the rate of 10 percent per annum.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99899 Determination of amount of penalties. (NRS 449.037, 449.165)
1. In determining the amount of an initial monetary penalty, the Bureau shall consider the severity alone if the severity level is four. In determining the amount of the monetary penalty where the severity level is less than four, both severity and scope must be considered. In determining whether to impose a daily monetary penalty, the Bureau shall consider the severity and scope and the factors indicated for increased and decreased penalties provided in NAC 449.99902 and 449.99904.
2. For initial deficiencies with a severity level of four, an initial monetary penalty of $1,000 per deficiency must be imposed.
3. For initial deficiencies rated with a severity level of three and a scope level of three, a monetary penalty of $800 per deficiency must be imposed.
4. For initial deficiencies with a severity level of three and a scope level of two or less, an initial monetary penalty of $400 per deficiency must be imposed.
5. For initial deficiencies with a severity level of two and a scope level of three, an initial monetary penalty of $200 per deficiency may be imposed. The payment of this monetary penalty must be suspended if the facility has corrected the deficiencies within the time specified in the plan of correction approved by the Bureau.
6. In addition to any monetary penalty imposed pursuant to this section, the Bureau may impose a monetary penalty of not more than $10 per recipient per day for each day the deficiency continues.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.999 Limitation on principal amount of total daily penalty. (NRS 449.037, 449.165) In no event may the principal amount of the total daily monetary penalty assessed against any facility exceed $1,000 per deficiency per day.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99901 Daily penalty: Computation according to number of recipients. (NRS 449.037, 449.165) If a monetary penalty is assessed on a daily basis according to the number of recipients and the number of recipients fluctuates, the penalty must be computed on the basis of the average daily number of recipients during the 3 months preceding the imposition of the penalty.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99902 Increase in penalty for repeated deficiencies or false compliance. (NRS 449.037, 449.165)
1. Penalties must be increased if deficiencies are repeated or compliance is falsely alleged.
2. For each repeat deficiency present within 18 months after an initial deficiency, the monetary penalty must be computed at the rate of one and one-half times the rate that was or could have been assessed initially for a deficiency of that severity and scope.
3. The Bureau may double the daily monetary penalty that was or could have been assessed if the facility alleges compliance and the Bureau finds on a survey that at the time compliance was alleged the deficiencies continued to exist.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99903 Presumption regarding deficiencies identified on resurvey. (NRS 449.037, 449.165) There is a rebuttable presumption that deficiencies identified on a resurvey were present on each day between the date of the initial deficiency and the date of the resurveyed deficiency.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99904 Reduction of penalty. (NRS 449.037, 449.165) If a facility against which a monetary penalty is imposed:
1. Waives the right to a hearing;
2. Corrects the deficiencies that were the basis for the sanction; and
3. Pays the monetary penalty within 15 days after receipt of the notice of the penalty,
Ê the penalty must be reduced by 25 percent and no interest may be charged.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99905 Daily penalty: Effective beginning date. (NRS 449.037, 449.165) The effective beginning date of a daily monetary penalty is:
1. In the case of an immediate and serious threat, the date the deficiency occurred; or
2. In any other case, the day the deficiency is identified.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99906 Daily penalty: Date and period of computation; notice to facility. (NRS 449.037, 449.165)
1. Daily penalties and interest must be computed after compliance has been verified or the provider has been sent notice of termination of a license or provisional license. A daily monetary penalty must end on the effective date of compliance or termination of the license of the facility.
2. If a provider achieves compliance, the Bureau shall send a separate notice to the facility containing:
(a) The amount of the penalty per day;
(b) The number of days involved;
(c) The due date of the penalty; and
(d) The total amount due.
3. If the license of a facility is to be terminated, the Bureau shall send the information required by subsection 2 in the notice of termination.
4. If the Bureau’s decision of noncompliance is upheld on appeal or the facility waives its right to a hearing, the monetary penalty must be imposed for the number of days between the effective date of the penalty and the date of correction of the deficiencies or, if applicable, the date the license of the facility is terminated.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99907 Termination of daily penalties; failure of Medicaid facility to remove immediate and serious threat after appointment of temporary management. (NRS 449.037, 449.165)
1. The daily accrual of a monetary penalty must end if the facility demonstrates that substantial improvements have been made to correct the deficiencies and that the health, safety and well-being of recipients are adequately protected and safeguarded.
2. A monetary penalty may be imposed on a daily basis for not longer than 6 months, after which the Bureau shall deny, suspend or revoke the license of the facility and, if the facility is a Medicaid facility and major deficiencies remain, request the Division of Health Care Financing and Policy to terminate the Medicaid provider agreement of the facility.
3. If a deficiency in a Medicaid facility presents an immediate and serious threat and continues to exist on the 23rd day after the appointment of temporary management, the Bureau shall request the Division of Health Care Financing and Policy to terminate the Medicaid provider agreement of the facility.
4. If the provider can supply credible evidence that substantial compliance with participation requirements was attained on a date preceding that of the survey, monetary penalties accrue only until that date of correction for which there is credible evidence. As used in this subsection, “credible evidence” means actual documentation that compliance has been achieved.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99908 Time for payment of penalties. (NRS 449.037, 449.165)
1. Initial monetary penalty assessment payments are due within 15 days after the notice of the penalty and must be paid irrespective of any administrative appeal.
2. The daily monetary penalty is due and must be paid within 15 days after compliance is verified or termination of a license is effective and the facility is notified of the amount of the total daily monetary penalty and interest due.
3. If the facility has appealed a decision imposing a monetary penalty, the daily penalty is due and must be paid after the final administrative decision is rendered and 15 days after the facility has been notified of the amount of the total daily penalty and interest due.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99909 Assessment of interest on unpaid balance of penalty. (NRS 449.037, 449.165) Unless it is waived as provided in this chapter, interest at the rate prescribed in NRS 449.163 will be assessed on the unpaid balance of the penalty, beginning on the due date.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.9991 Recovery of costs for collection of penalty. (NRS 449.037, 449.165) Any costs, including attorney’s fees, incurred by the Bureau or the Health Division in the collection of any monetary penalty may be recovered from the facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99911 Failure to pay penalty: Suspension of license of facility. (NRS 449.037, 449.165)
1. If the facility fails to pay a monetary penalty, the Health Division may suspend the license of the facility.
2. The Health Division shall, in accordance with the requirements of NAC 439.345, provide notice of its intention to suspend the license of the facility.
3. If the facility fails to pay the monetary penalty, including any additional costs incurred in collection of the penalty, within 10 days after receipt of the notice, the Health Division shall suspend the license of the facility. The suspension must not be stayed during the pendency of any administrative appeal.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R044-97, 10-30-97)
NAC 449.99912 Disposition of money collected. (NRS 449.037)
1. Unless otherwise required by federal law, money collected by the Health Division as administrative sanctions must be deposited into a separate fund and applied to the protection of the health, safety, well-being and property of recipients, including residents of facilities that the Health Division finds deficient.
2. Any of the following applications of money collected, without limitation, are permissible:
(a) Reimbursement of costs related to the operation of a facility pending correction of deficiencies or closure;
(b) Reimbursement of residents for personal money lost; and
(c) Payment of the cost of relocating residents to other facilities.
(Added to NAC by Bd. of Health, eff. 8-1-91)
Temporary Management
NAC 449.99915 Appointment of temporary manager when there is immediate and serious threat: Notice; effect of failure to accept manager and to remove threat. (NRS 449.037, 449.165, 449.170)
1. If a temporary manager is to be appointed, the Bureau shall orally notify the facility of the appointment. Written notice that complies with the requirements of NAC 439.345 must be mailed within 48 hours after the oral notice.
2. If the facility does not accept the temporary manager or a temporary manager is not available within 10 days after the date of the deficiency, and the immediate and serious threat is not removed, the Bureau shall deny, suspend or revoke the license of the facility and, if applicable, shall recommend to the Division of Health Care Financing and Policy termination or suspension of the Medicaid provider agreement of the facility.
3. If the facility accepts the temporary manager, the Bureau shall:
(a) Notify the facility that, unless it removes the immediate and serious threat, its license will be denied, suspended or revoked pursuant to NRS 449.160; and
(b) If applicable, recommend to the Division of Health Care Financing and Policy that the Medicaid provider agreement of the facility be terminated, effective on the 23rd day after the date of appointment of the temporary manager.
4. If the immediate and serious threat is not removed on or before the 23rd day after the appointment of the temporary manager, the Bureau shall deny, suspend or revoke the license of the facility and, if applicable, recommend to the Division of Health Care Financing and Policy that the Medicaid provider agreement be terminated.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R044-97, 10-30-97; R051-02, 7-24-2002)
NAC 449.99916 Appointment of temporary manager when there is no immediate and serious threat: Notice. (NRS 449.037, 449.170) Appointment of a temporary manager where there is not an immediate and serious threat must be made in conformity with the provisions for notice contained in NAC 439.345.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R044-97, 10-30-97)
NAC 449.99917 Temporary manager: Qualifications. (NRS 449.037)
1. The temporary manager must:
(a) Be a person qualified to operate the facility pursuant to the provisions of chapter 449 of NRS relating to the licensing of the facility;
(b) Demonstrate prior competency as an administrator of a medical facility or a facility for the dependent or have other relevant experience pertinent to the deficiencies identified; and
(c) Have had no disciplinary action taken against him by any licensing board or professional society in any state.
2. The temporary manager may be an employee of the Health Division or a private person or agency that contracts with the Health Division to serve in that capacity.
3. The temporary manager must not be:
(a) An employee of the facility or an affiliated facility; or
(b) A person or agency that has served as a consultant to the facility or an affiliated facility within the 2 years preceding the appointment of the temporary manager.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99918 Temporary manager: Authority. (NRS 449.037, 449.165) The temporary manager may take such action as is required to mitigate the immediate danger at the facility, including, without limitation, providing for the safe transfer of residents or prohibiting the transfer of residents.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99919 Effect of failure to agree to appointment of or to relinquish authority to temporary manager. (NRS 449.037, 449.165) If a facility fails to agree to the appointment of a temporary manager or fails to relinquish authority to the temporary manager, the Health Division shall:
1. Request the Attorney General to bring an action pursuant to NRS 439.565;
2. Deny, suspend or revoke the license of the facility; and
3. If applicable, request the Division of Health Care Financing and Policy to terminate the provider agreement of the facility in accordance with the requirements of the Medicaid program.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.9992 Events requiring termination of management; initiation of judicial proceedings. (NRS 449.037, 449.165)
1. Temporary management of a facility must be terminated if the Bureau determines that:
(a) The facility has substantially corrected the deficiency and has secured management capable of ensuring continued compliance with applicable state and federal statutes, regulations, conditions and standards; or
(b) The license of the facility has been denied, revoked or suspended.
2. If temporary management will be needed for more than 24 days, the Bureau shall request the Attorney General to initiate judicial proceedings as authorized by NRS 439.565.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99921 Payment of costs and expenses. (NRS 449.037, 449.165) The costs and expenses of temporary management, including the compensation of the manager, must be paid by the facility through the Bureau while the temporary manager is assigned to the facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
Closure of Facility and Transfer of Residents
NAC 449.99925 Authority of Bureau. (NRS 449.037) The Bureau shall in an emergency deny, suspend or revoke the license of a facility and, in the case of a residential facility that is no longer licensed to operate, arrange for the appointment of a temporary manager to oversee the timely and orderly transfer of any residents. This sanction may be used only if other less drastic measures are inadequate to prevent or remove a serious threat to the health, safety and well-being of recipients and, in the case of a residential facility, the action is deemed necessary to safeguard and protect the health of residents of the facility.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99926 Requirements for notification. (NRS 449.037)
1. Except as otherwise provided in subsection 2, if the Bureau proposes to close a facility, the Health Division shall, at least 5 days before the transfer, notify or cause to be notified personally or by written or telephonic means:
(a) Each recipient; and
(b) Any person indicated on the record of the recipient as a person to be notified in case of an emergency,
Ê of the nature of the emergency and the proposed transfer.
2. In an acute emergency, residents may be transferred without prior notice. As used in this subsection, “acute emergency” means that action must be taken without prior notice as a result of an immediate and serious threat.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99927 Appointment of temporary manager. (NRS 449.037) If the Bureau denies, revokes or suspends the license of a facility, the Bureau shall appoint a temporary manager to assist in the orderly closure of the facility and, in the case of a residential facility, the transfer of residents.
(Added to NAC by Bd. of Health, eff. 8-1-91)
NAC 449.99928 Bureau to supervise or appoint temporary manager to supervise transfer; imposition of other appropriate sanctions. (NRS 449.037) If a residential facility is to be closed, the Bureau shall supervise, or appoint a temporary manager to supervise, the orderly transfer of residents. The Bureau may also impose other appropriate sanctions as authorized by the regulations of the Health Division.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99929 Determination of appropriate placement of residents. (NRS 449.037) If the residents of a residential facility are to be transferred, the following criteria must be applied by the Bureau or temporary manager responsible for supervising the orderly transfer of residents in the following order to determine the most appropriate placement of each resident:
1. The medical and psychological health of the resident and the suitability of the proposed facility to meet the resident’s medical and psychosocial needs;
2. The facility, if any, where the spouse or immediate family member of the resident is a resident; and
3. The geographical proximity of the proposed facility to the immediate family or regular visitors of the resident.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.9993 Rights of appeal for transferred residents. (NRS 449.037) Except in cases of emergency or termination of the license of a facility, the rights of appeal provided by federal and state statutes or regulations governing the transfer of residents apply to residents who are transferred.
(Added to NAC by Bd. of Health, eff. 8-1-91)
Facilities Participating in Medicaid
NAC 449.99935 Authorized recommendations in addition to available sanctions. (NRS 449.037) For a facility that participates in Medicaid, in addition to imposing any sanction authorized by NAC 449.99863, the Bureau may recommend to the Division of Health Care Financing and Policy:
1. That the provider agreement of the facility be terminated.
2. That Medicaid payment for new admissions be denied.
3. That Medicaid payment for certain diagnostic categories or certain types of specialized care be denied.
4. That all or part of the Medicaid payments to the facility be suspended.
5. That the facility be allowed to continue to participate as a Medicaid facility for 6 months after the date of the survey if:
(a) The Bureau finds that it is more appropriate to impose alternative sanctions than to recommend termination of the facility from the Medicaid program;
(b) The facility has submitted an acceptable plan of correction;
(c) The Bureau approves the plan of correction; and
(d) The facility agrees to repay the Federal Government for any payments received under the Medicare or Medicaid program if timely corrective action is not taken in accordance with the approved plan of correction.
Ê If the facility does not substantially correct the cited deficiencies within 6 months after the last day of the survey, the Bureau shall recommend that the Division of Health Care Financing and Policy terminate the Medicaid agreement of any facility whose participation was continued under these conditions.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99936 Withholding of monetary penalties from payments owed to facility. (NRS 449.037)
1. The amount of any monetary penalty owed by a Medicaid facility, if it has been determined, may be deducted from any money otherwise owed to the facility by the Division of Health Care Financing and Policy.
2. If the facility does not pay a monetary penalty by the date it is due and no extension of time to pay is granted, the Administrator of the Health Division shall notify the Administrator of the Division of Health Care Financing and Policy of the amount of the penalty due and owing and shall request withholding of the amount owed.
3. The Administrator of the Division of Health Care Financing and Policy shall take the appropriate steps to withhold the amount of the monetary penalty owed, including any interest and costs of collection, from the Medicaid payment otherwise due the facility. Money so withheld must be remitted to the Health Division for deposit in the special fund established pursuant to NAC 449.99912. Money withheld for costs of collection must be applied by the Administrator of the Health Division to the account incurring the costs.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99937 Denial of payments for new admissions generally. (NRS 449.037)
1. The Bureau may request the Division of Health Care Financing and Policy to deny Medicaid payment to a facility for new admissions if:
(a) The facility does not substantially correct the deficiencies within 90 days or within the time required by federal Medicaid law after the facility is notified by the Bureau of the deficiencies; or
(b) The Bureau has cited a facility with substandard quality of care (severity score of level three or more and scope of level three) on two of the last three consecutive standard surveys.
2. If the facility achieves and maintains compliance with the requirements, the Bureau shall request the Division of Health Care Financing and Policy to resume payments to the facility prospectively, effective on the date compliance was achieved.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99938 Denial of payments for new admissions who have certain specified diagnoses or special care needs. (NRS 449.037)
1. The Bureau may request the Division of Health Care Financing and Policy to deny payment to a facility for new admissions who have certain specified diagnoses or special care needs if:
(a) The facility is not currently able to provide appropriate care, services or treatment for those persons; or
(b) Caring for those persons will adversely affect care provided to other recipients.
2. If the facility achieves and maintains compliance with the requirements, the Bureau must request the Division of Health Care Financing and Policy to resume payment to the facility prospectively, effective on the date compliance was achieved.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)
NAC 449.99939 Suspension of payments for services furnished to Medicaid recipient on or after date of deficiency. (NRS 449.037)
1. The Bureau may request the Division of Health Care Financing and Policy to suspend all or part of the Medicaid payments to a facility for services furnished to a Medicaid recipient on or after the date of the deficiency, regardless of whether the recipient was admitted before, on or after the date of the deficiency.
2. If the facility achieves compliance with the requirements, the Bureau shall request the Division of Health Care Financing and Policy to resume payments retroactively.
(Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002)