DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Health Facilities and

To view this page ensure that Adobe Flash Player version 9.0.124 or greater is installed.

Please login or register to make a comment!

DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Health Facilities and Emergency Medical Services Division 6 CCR 1011-1 STANDARDS FOR HOSPITALS AND HEALTH FACILITIES (Promulgated by the State Board Of Health) CHAPTER V LONG TERM CARE FACILITIES Last amended 3/18/09, effective 4/30/09 (Definitions, new section 18.8 3 Modifications, and new Part 25 - General Building and Life Safety Code Requirements) CHAPTER V LONG TERM CARE FACILITIES Part 1 - Governing Body Definitions LONG-TERM CARE FACILITY. A long-term care facility is a health facility that holds itself out as a nursing home, nursing facility, nursing care facility or intermediate care facility or a health facility that is planned, organized, operated, and maintained to provide supportive, restorative, and preventive services to persons who, due to physical and/or mental disability, require continuous or regular inpatient care. (a) a long-term care facility is a nursing care facility, or a nursing facility serving residents who require continuous medical and nursing care and supervision.

(b) a long-term care facility is an intermediate care facility serving residents who require regular, but not continuous nursing care and supervision. PLAN REVIEW 3 the review by the Department, or its designee, of new construction, previously unlicensed space, or remodeling to ensure compliance by ... more. less.

the facility with the National Fire Protection Association (NFPA) Life Safety Code and with this Chapter V. Plan review consists of the analysis of construction plans/documents and onsite inspections, where warranted. For the purposes of the National Fire Protection Association requirements, the Department is the authority having jurisdiction for state licensure. STRUCTURAL ELEMENT 3 for the purposes of plan review, means an element relating to load bearing or to the scheme (layout) of a building as opposed to a screening or ornamental element. Structural elements of a building include but are not limited to: floor joists, rafters, wall and partition studs, supporting columns and foundations. 1.1 GOVERNING BODY. The governing body is the individual, group of individuals, or corporate entity that has ultimate authority and legal responsibility for the operation of the long-term care facility. 1.1.1 The governing body shall provide the necessary facilities, qualified personnel, and services to meet the total needs of the facility's residents. 1.1.2 The governing body shall appoint for the facility a full-time administrator, qualified as provided in Section 2.1, and delegate to that officer the executive authority and full responsibility for day-to-day administration of the facility. 1.1.3 The governing body is responsible for the performance of all persons providing services within the facility. 1.2 STRUCTURE. If the governing body includes more than one individual, the group shall be formally organized with written constitution or articles of incorporation and by-laws; hold regular, periodic meetings; and maintain meeting records. 1.2.1 The facility shall disclose its ownership as required in Part 2, chapter II of these regulations. 1.2.2 The governing body shall provide a formal means of obtaining local community involvement and opportunity to communicate with the administrator on issues of residents' rights. The means of community input shall provide opportunity for regular input and such input shall be documented. 1 (a) The input may come through a formally organized community advisory committee that is given the opportunity to comment and advise the governing body on matters of facility policy; is composed of members, a majority of whom reside in the facility's service area, and none of whom are owners or employees of or consultants to the facility. (b) The input may come through membership of at least 25% of the governing body representing citizens in the facility's service area, none of whom are owners or employees of or consultant? to the facility. (c) The facility may request Department approval of an alternative means of obtaining community input on residents' rights. 1.3 QUALITY ASSURANCE. The governing body shall assure that there is an effective quality assurance program to evaluate the availability, appropriateness, effectiveness, and efficiency of resident care, including without limitation, a continuous program of evaluating medical, nursing care, social services, activities, dietary, housekeeping, maintenance, infection control, and pharmacy services. 1.3.1 The quality assurance plan shall be in writing and shall include objectives; personnel involved; responsibility for reviewing critical incidents; methods for monitoring and evaluating care; and methods for monitoring effectiveness of actions taken to improve quality of resident care. 1.3.2 The facility shall maintain evidence of actions taken in response to quality assurance activity and their effectiveness and shall report annually to the governing body. 1.4 EXCEPTIONS TO RULES. The requirements of these regulations do not prohibit the use of alternate concepts, methods, procedures, techniques, equipment, or personnel qualifications or conducting pilot projects. A facility may request waivers or exceptions to these regulations under provisions of Part 4 of Chapter 2. 1.5 POSTING DEFICIENCIES. The facility shall post conspicuously in public view either the statement of deficiencies following its most recent survey or a notice stating the location and times at which the statement can be reviewed. Part 2 - Administration 2.1 ADMINISTRATOR. The administrator is responsible to the governing body for planning, organizing, developing, and controlling the operations of the facility. 2.1.1 The administrator shall be licensed in the State of Colorado. 2.1.2 The administrator's responsibilities: 1) liaison among the governing body, medical staff, and physicians whose patients reside in. the facility, 2) financial and personnel management, 3) providing for appropriate resident care; and 4) maintaining relationships with the community and with other health care facilities, organizations, and services; 5) assuring facility and staff compliance with all regulations; and 6) any responsibilities prescribed by facility policy. 2 2.2 ORGANIZATION. The facility shall be organized formally to carry out its responsibilities with a plan of organization clearly defining the authority, responsibilities, and functions of each category of personnel. 2.3 POLICIES. In consultation with the Medical Advisor and one or more registered nurses and other related health care professionals, the administrator shall develop and at least annually review written resident care policies and procedures that govern resident care in the following areas: nursing, housekeeping, maintenance sanitation, medical, dental, dietary, diagnostic, emergency, and pharmaceutical care; social services; activities; rehabilitation; physical, occupational, and speech therapy; resident admission, transfer, and discharge; notification of physician and family or other responsible party of resident's incidents, accidents and changes of status; disasters; and health records and any other policies the department determines the facility needs based on its characteristics of its resident population. 2.4 FACILITY STAFFING PLAN. The facility shall have a master staffing plan for providing staffing in compliance with these regulations, distribution of personnel, replacement of personnel, and forecasting future personnel needs. 2.5 OCCURRENCE REPORTING. Notwithstanding any other reporting required by state regulation, each facility shall report the following to the department within 24 hours of discovery by the facility. (1) Any occurrence involving neglect of a resident by failure to provide goods and services necessary to avoid the resident 9s physical harm or mental anguish. (2) Any occurrence involving abuse of a resident by the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (3) Any occurrence involving an injury of unknown source where the source of the injury could not be explained and the injury is suspicious because of the extent or location of the injury. (4) Any occurrence involving misappropriation of a resident 9s property including the deliberate misplacement, exploitation, or wrongful use of a resident 9s belongings or money without the resident 9s consent. Part 3 - Admissions 3.1 RESTRICTIONS. The facility shall admit only those persons whose needs it can meet within the accommodations and services it provides. 3.1.1 No resident shall be admitted for inpatient care to any room or area other than one regularly designated and equipped as a resident bedroom. 3.1.2 There shall be no more residents admitted to a bedroom than the number for which the room is designed and equipped. 3.2 BED HOLD POLICIES. 3 The facility shall develop policies for holding beds available for residents who are temporarily absent therefrom, provide a copy of the policy upon admission, and explain these policies to residents upon admission and before each temporary absence. 3.3 RESIDENT IDENTIFICATION. Upon admission, each resident shall have a visible means of identification placed and maintained on his or her person and property. Part 4 - Personnel 4.1 POLICIES. The facility shall maintain written approved personnel policies, job descriptions, and rules prescribing the conditions of employment, management of employees, and quality and quantity of resident care to be provided. 4.1.1 The facility shall provide job-specific orientation to all new employees within 90 days of employment. 4.1.2 All personnel shall be informed of the purpose and objectives of the facility. 4.1.3 All personnel shall be provided access to the facility's personnel policies and the facility shall provide evidence that each employee has reviewed them. 4.2 DEPARTMENTS. Each department of the facility shall be under the direction of a person qualified by training, experience, and ability to direct effective services. 4.2.1 The facility shall provide a sufficient number of qualified personnel in each department to operate the department. 4.2.2 All persons assigned to direct resident care shall be prepared through formal education or on-the-job training in the principles, policies, procedures, and appropriate techniques of resident care. The facility shall provide educational programs for employees to be informed of new methods and techniques. 4.3 STAFF DEVELOPMENT COORDINATOR. The long-term care facility shall employ a staff development coordinator who shall be responsible for coordinating orientation, inservice, on-the-job training, and continuing education programs and for determining that staff have been properly trained and are implementing results of their training. The objective of this standard is that staff be appropriately trained in necessary aspects of resident care to carry out their job responsibilities. 4.3.1 The coordinator shall have experience in and ability to prepare and coordinate inservice education and training programs for adult learners in the area of geriatrics. 4.3.2 The facility shall employ a staff development coordinator for a sufficient amount of time to meet inservice, orientation, training, and supervision needs of staff. The facility shall provide for appropriate staff follow-up. 4.3.3 The facility shall provide annual inservice education for staff in at least the following areas: infection control, fire prevention and safety, accident prevention, confidentiality of 4 resident information, rehabilitative nursing, resident rights, dietary, pharmacy, dental, behavior management, disaster preparedness, and, if it has developmentally disabled residents, developmental disabilities, residents with Alzheimer's conditions, those conditions, or mentally ill residents, mental illness. 4.3.4 The facility shall maintain attendance records with original signatures on inservice programs and course materials or outlines that staff who are unable to attend the program may review. 4.4 RECORDS. The facility shall maintain personnel records on each employee, including an employment application, that includes training and past experience, verification of credentials, references of past work experience, orientation, and evidence that health status is appropriate to perform duties in the employee's job description. 4.5 REFERENCE MATERIALS. The facility shall provide current reference material related to the care that is provided in the facility for use by all personnel. 4.6 STAFF IDENTIFICATION. All facility staff shall wear name and title badges while on duty, except where they may pose a danger to staff or residents due to the nature of resident conditions. Part 5 - Resident Care 5.1 RESIDENT CARE. Residents shall receive the care necessary to meet individual physical, psycho-social, and rehabilitative needs and assistance to achieve and maintain their highest possible level of independence, self-care, and self-worth and well-being. Provision of care shall be documented in the health record. 5.1.1 QUALITY OF LIFE. Residents shall be provided: a safe, supportive, comfortable, homelike environment; freedom and encouragement to exercise choice over their surroundings, schedules, health care, and life activities; the opportunity to be involved with the members of their community inside and outside the nursing home; and treatment with dignity and respect. 5.1.2 DECUBITUS PREVENTION AND CARE. (See also 7.7) (1) For residents whose decubitus ulcers developed while the resident was in the facility, the facility shall have (a) assessed the potential for skin breakdown and (b) provided preventive measures before the ulcer developed to residents identified in the assessment required in Section 5.2 as at risk of decubiti (i.e. a resident exhibiting three or more of the following symptoms: underweight, incontinence, dehydration, disorientation or unconsciousness, or limited mobility). (2) For all residents with decubitus ulcers, the facility shall: 5 (a) have developed an individualized treatment plan (as prescribed by Section 5.7) designed to alleviate the condition; (b) be providing active treatment to improve the condition in accordance with the treatment plan; (c) be evaluating the resident's progress and treatment at least weekly and revising the treatment plan as needed and required by Section 5.7; (d) be providing proper nutrition and hydration to promote healing and prevent further breakdown. 5.1.3 ACCIDENT PREVENTION AND ATTENTION. (1) The facility shall: (a) investigate causes of accidents; (b) monitor the resident's response to the accident, and obtain physician's or mental health evaluation, if needed; (c) have developed and implemented an individualized plan as part of the care plan prescribed by Section 5.7 for prevention of future accidents; (d) evaluate and revise the plan as needed. (2) For residents at high risk for accidents, the facility shall have identified the risk in the care plan and taken reasonable precautions to prevent common accidents before the accident occurred. Residents at high risk of accidents include the blind, the deaf, those with seizure disorders, those with accidents in the last 6 months, the totally confused but ambulatory, new amputees, and residents on psychoactive drugs. 5.1.4 BEHAVIOR PROBLEM CARE. (1) For residents with behavior problems the facility shall: (a) have noted the behavioral problem and evaluated it in the initial assessment required by Section 5.2; (b) develop and implement an individualized treatment plan as part of the care plan prescribed by Section 5.7; (c) develop and implement a behavior management plan as part of the care plan prescribed by Section 5.7; (d) obtain a mental health evaluation in appropriate cases; (e) evaluate the resident's progress and revise the plan, as needed and required by Section 5.7; (2) For residents receiving behavior modification drugs, the facility shall indicate in nurses' notes both positive and/or negative effects of the drug and that alternatives or adjuncts to the drugs in care planning were considered. These evaluations shall meet requirements of Section 7.10.8. 6 5.1.5 CONTRACTURE CARE. (See also 7.7) (1) For residents with contractures upon admission, the facility shall have noted the problem, evaluated it, and undertaken restorative nursing intervention. (2) For residents with contractures that occurred while in the facility, the facility shall have documented that range of motion and/or repositioning was performed before the contracture developed; if the resident refused treatment or preventive measures, the. facility shall have documented that such measures and the consequences of the refusal were explained to the resident. (3) For all other residents with the potential for contracture, the facility shall have developed and be implementing an individualized treatment plan as part of the care plan prescribed in Section 5.7 to prevent or manage contractures and be periodically evaluating the progress. The plan shall be reviewed and revised at least annually as needed. 5.1.6 PROMOTION OF MOBILITY. (See also 7.7) (1) For all residents, the facility shall have assessed each resident's ambulation potential and capability at least monthly, designed a plan of care as part of the care plan prescribed in Section 5.7 to encourage mobility, be implementing the plan, regularly evaluate progress and revise the plan as needed. (2) For residents requiring devices and/or personal assistance to ambulate, the facility shall provide and maintain devices in good repair, assist the resident to obtain appropriate footwear, and provide assistance to residents to move and transfer. (3) For residents physically limited from walking, the medical record shall contain evidence of a monthly review of the need for restraints and evidence that restraints are removed in accordance with Sections 7.11 and 7.12. 5.1.7 INDWELLING CATHETER CARE. (1) For residents with any indwelling catheter, the facility shall have: (a) evaluated appropriateness of continued use at least monthly; (b) assessed the reason for the incontinence; (c) evaluated the potential of bladder retraining, implementing it, if indicated, or documenting reasons if retraining was not indicated; (d) implemented any physician order for irrigation or catheter replacement. (2) For residents exhibiting signs or symptoms of urinary tract infection, the facility shall have notified the physician, obtained orders for treatment and implemented such treatment plan. 5.1.8 WEIGHT CHANGES. The facility shall: (1) evaluate the resident to determine the cause of the weight change; 7 (2) develop and implement an individualized plan of care as part of the care plan prescribed by Section 5.7 (including appropriate intervention by other appropriate disciplines); evaluate resident progress as required by Section 5.7, and revise the plan, as needed; (3) observe food and fluid intake and provide encouragement to residents with eating problems; (4) provide reasonable choices of foods to meet personal preferences and religious needs; (5) if nourishments are provided as part of the care plan, between meals and at bedtime, document the nourishments provided and whether they are consumed; (6) provide assistance in eating or adaptive eating devices and assist residents in obtaining dentures, or dental care, as appropriate to the individual resident; (7) for residents with mouth or gum problems, meet the requirements of part 10. 5.1.9 GROOMING. (1) The facility shall assist the resident to obtain appropriate materials for personal care for the resident, provide personal care in a manner that preserves resident dignity and privacy, and provide social services intervention, if needed. (2) For residents with inappropriate, unclean, or poorly maintained clothing and/or assistive devices, the facility shall assist the residents to obtain clothing, shoes and devices. Such clothing, shoes and devices shall fit properly, be clean, and be in good repair. (3) For residents with poor oral hygiene, the facility shall meet the requirements of Part 10. 5.1.10 EXCORIATION PREVENTION AND CARE. (See also 7.7) (1) For all residents who are incontinent or immobile, have impaired sensation, compromised nutritional or fluid status, or inadequate hygiene, the facility shall: (a) have completed an initial skin evaluation upon admission and re- evaluated the condition at least weekly; (b) be providing measures to prevent the excoriation, including: (1) maintenance of clean, dry well lubricated skin; (2) taking incontinent residents to the bathroom on a regular individualized schedule; (3) evaluating the need for daily baths; (4) determining potential trouble spots where microbial growth may occur (breasts, gluteal folds, skin folds). (2) For residents with excoriations, the facility shall: 8 (a) develop and be implementing an individualized treatment plan as part of the care plan prescribed by Section 5.7 for the excoriation; (b) evaluate the resident's progress at least daily and review and revise the treatment plan as needed; (c) enter a progress note at least weekly in the health record. 5.1.11 FLUID MANAGEMENT. The facility shall provide fluid in quantities needed to maintain hydration and body weight and shall: (1) assess each resident's hydration needs; (2) observe and evaluate food and fluid intake daily and record and report deviations from sufficient food and fluid intake; (3) provide assistance and encouragement to residents requiring assistance to meet their food and fluid requirements; (4) provide self-help adaptive devices and encourage their use. 5.1.12 PERSONAL ENVIRONMENT. The facility shall allow for personalization of rooms through the use of residents' personal furniture, appliances, decorations, plants, and memorabilia. The facility may limit the number of furniture items in resident rooms if to do so is necessary to accommodate roommate preferences, fire codes, housekeeping, or safe movement in the room. 5.1.13 PERSONAL CHOICE. The facility shall: (1) make reasonable efforts to accommodate preferences of roommate, including the right of each resident so requesting to be assigned to a room with non- smokers; (2) allow residents flexibility in times to eat main meals, consistent with requirements of Section 11.2 and with its own reasonable staffing and scheduling requirements; (3) allow residents flexibility in times to bathe, rise and retire, consistent with its own reasonable staffing and scheduling requirements; (4) provide at least one alternative menu choice for each meal of similar nutritive value. The same alternative shall not be used for two consecutive meals. 5.1.14 PROBLEM RESOLUTION. The facility shall inform residents of the resident council and grievance procedures, the name, address, and phone number of the Long-Term Care Ombudsman, and the phone number and address of the Departments of Health and Social Services and the Colorado Foundation for Medical Care. Staff shall assist residents in raising problems to the facility's administration or appropriate outside agencies. 5.2 RESIDENT ASSESSMENT. Within twenty-four hours of admission to the long-term care facility, a licensed nurse shall assess each resident's physical, mental, and functional status, including strengths, impairments, rehabilitative needs, special treatments, capability for self-administration of medications, and dependence and independence 9 in activities of daily living. The initial assessment shall form the basis of the preliminary care plan. Within seven days of admission, the nurse shall also collaborate with social services staff in assessing discharge potential and shall coordinate assessments with social services, dietetic, and activity staff. These assessments shall form the basis of the interdisciplinary care plan prescribed by Section 5.7. 5.2.1 The continuing assessment shall at all times reflect resident status. 5.2.2 The assessment shall be updated at least at three month intervals, but in any event whenever a significant change of resident condition occurs. 5.2.3 The current resident assessment shall be a part of the resident's health record and available for all direct care staff to use. 5.3 NURSING CARE PLANNING. A licensed nurse shall prepare an individualized nursing care plan for each resident based on the resident assessment prescribed by Section 5.2 and applicable physician treatment orders. The purpose of the care plan is to create an individualized tool for carrying out preventive, therapeutic, and rehabilitative nursing care. 5.3.1 Within 24 hours of admission, nursing staff shall prepare and implement a preliminary nursing care plan to meet each resident's immediate needs. 5.3.2 Within one week of admission, nursing staff shall prepare and implement a comprehensive nursing care plan for each resident. 5.3.3 The plan shall meet each resident's unique needs, problems, and strengths by identifying resident strengths, needs, and problems; specifying care interventions to capitalize on the strengths and meet those needs or problems; and defining the frequency of each intervention. 5.3.4 The nursing care plan shall be current and evaluated and revised following each assessment and whenever the resident's condition changes. 5.4 SOCIAL SERVICES CARE PLANNING. Social services staff shall assess social services needs within one week of admission and develop a social services care plan to meet each resident's needs. 5.5 ACTIVITIES CARE PLANNING. Activities staff shall assess activities needs within one week of admission and shall develop an activities care plan to meet each resident's needs. 5.6 NUTRITIONAL CARE PLANNING. (a) The Dietary supervisor or consultant shall prepare an initial nutritional history and assessment for each resident within two weeks of admission that includes special needs, likes and dislikes, nutritional status, and need for adaptive cutlery and dishes and develop a plan of care to meet these needs. (b) In the event the facility elects to utilize paid feeding assistants or feeding assistant volunteers pursuant to Part 11.001 of this Chapter V, as part of the history and assessment conducted pursuant to paragraph (a) of this 5.6, the interdisciplinary team shall evaluate each resident regarding the suitability of the resident to be fed and 10 hydrated by a feeding assistant. Such evaluation shall include, but need not be limited to each resident 9s level of care, functional status concerning feeding and hydration, and, the resident 9s ability to cooperate and communicate with staff. 5.7 INTERDISCIPLINARY CARE PLANNING. Within two weeks of admission, an interdisciplinary long-term care facility staff team shall develop a personalized overall care plan for each resident based on the resident assessments and applicable physician orders. 5.7.1 The overall care plan shall contain a list of resident problems and the discipline that will address each problem in its own more detailed plan of care. 5.7.2 The overall care plan shall be evaluated according to the goals set out in the plan, following each assessment and whenever the resident's condition changes. 5.7.3 The interdisciplinary team shall consist of representatives of resident services inside and outside the facility, as appropriate, including at least nursing, social services, activities, and dietetic staff. Other persons, such as medical, pharmacy, and special therapies, shall be included as appropriate. Residents and their representatives shall be invited to participate in care planning. Refusal to participate shall be documented. Part 6 - Medical Care Services 6.1 PHYSICIAN CARE. Each facility resident shall be admitted to the facility by a physician and have the benefit of continuing health care under supervision of a physician. The facility shall have written policies developed by the medical advisor to coordinate and designate responsibility when more than one physician is treating a resident. [See Part 26 exceptions] 6.1.1 The facility shall take all necessary steps to assure that upon admission, the physician provides to the facility sufficient information to validate the admission and identify the resident and a medical plan of therapy to include diet, medications, treatments, special procedures, activities, specialized rehabilitative services, if applicable, and potential for discharge. 6.1.2 The facility shall take all necessary steps to assure that the admitting physician provides to the facility on admission the anticipated schedule of visits to meet resident needs, which shall be no less often than every 6 months. Acknowledgement of the visit schedule by the resident or authorized representative shall be documented in the health record. 6.1.3 The facility shall take all necessary steps to assure that telephone orders are received by a physician, licensed nurse or other appropriate disciplines as authorized by their professional licensure and are countersigned by the attending physician or dentist and entered in the record within 2 weeks. 6.1.4 The facility shall take all necessary steps to assure that the attending physician authenticates medical histories and physical examinations completed by other authorized personnel. 6.1.5 The facility shall take all necessary steps to assure that a licensed dentist authenticates dental examinations and dental histories completed by other authorized personnel and signs dental treatment records. 11 6.1.6 The facility shall take all necessary steps to assure that the attending physician writes a progress note following each visit, and at least once per year provides a written evaluation of the resident's current medical status compared to the previous year's status. 6.1.7 The facility shall take all necessary steps to assure that all drugs and therapies ordered by the physician are supported by diagnoses indicating the use of those drugs and therapies. 6.2 MEDICAL ADVISOR. The facility shall retain by written agreement a physician or medical practice group to serve as medical advisor to the facility. 6.2.1 The medical advisor is responsible for overall coordination of medical care in the facility and for systematic review of the quality of the health care provided by the facility and the medical services provided by the physicians in the facility. The medical advisor shall develop policies and procedures for medical care and for the physicians admitting residents to the facility. 6.2.5 The medical advisor is responsible to: (1) be a liaison between the facility and admitting physicians on matters related to attendance on residents, prompt writing of orders, and responding to requests by facility staff; (2) advise in developing and reviewing resident care policies; (3) establish rules governing conduct of physicians admitting residents to the facility; (4) develop a procedure to provide care in emergencies when a resident's physician is unavailable; (5) review accidents and hazards; and (6) participate in pharmacy advisory committee deliberations. Part 7 - Nursing Services 7.1 ORGANIZATION. The facility shall have a department of nursing services that is formally organized to provide complete, effective care to each resident. The facility shall clearly define qualifications, authority, and responsibility of nursing personnel in written job descriptions. 7.2 DIRECTOR OF NURSING. Except as provided in Section 7.6, a nursing care facility shall employ a full-time (40 hours/week) Director of Nursing, who is a registered nurse, qualified by education and experience to direct facility nursing care. 7.3 24-HOUR NURSING COVERAGE. The facility shall be staffed with qualified nursing personnel, awake and on duty, who are familiar with the residents and their needs in a number sufficient to meet resident functional dependency, medical, and nursing needs. 12 7.3.1 Staff shall be sufficient in number to provide prompt assistance to persons needing or potentially needing assistance, considering individual needs such as the risk of accidents, hazards, or other untoward events. Staff shall provide such assistance. 7.3.2 Except as provided in Section 7.6, a nursing care facility shall be staffed at all times with at least one registered nurse who is on duty on the premises. Each resident care unit shall be staffed with at least a licensed nurse. 7.3.3 Except as provided in Section 7.6, an intermediate care facility shall be staffed with at least one full-time licensed registered nurse or licensed practical nurse who is on duty on the premises on the day shift seven days per week. A facility using a licensed practical nurse as a director of nursing shall provide at least 4 hours per week of consultation by a licensed registered nurse. 7.3.4 A nursing care facility shall provide nurse staffing sufficient in number to provide at least 2.0 hours of nursing time per resident per day. In facilities of 60 residents or more, the time of the Director of Nursing, Staff Development Coordinator, and other supervisory personnel who are not providing direct resident care shall not be used in computing this ratio. 7.3.5 Nursing personnel shall be trained in nursing procedures and responsibilities and shall be familiar with any equipment necessary for care on the unit. 7.3.6 All nursing assistants and other nursing personnel shall function under the direction of a registered nurse. 7.3.7 If a long-term care facility operates out of more than one building, it shall have staff on duty 24 hours per day in each building in a number sufficient to meet resident care needs. 7.4 WRITTEN PROCEDURES. The facility shall have written nursing procedures establishing the standards of performance for safe, effective nursing care of residents and shall assure that they are followed by all nursing staff. 7.4.1 Procedures shall include the requirement that medications be administered in compliance with applicable Colorado law. 7.4.2 The nursing procedures shall be evaluated and revised as necessary, but no less often than annually. 7.5 NURSE STAFF RESPONSIBILITIES. Nursing staff shall participate in resident assessment, resident care planning, and resident nursing care, as prescribed by this Part and Part 5. 7.6 EXCEPTIONS. Nothing contained in this Part shall require any rural long-term care facility certified as a Skilled Nursing Facility or an Intermediate Care Facility under Medicaid to employ nursing staff beyond current federal certification requirements. Since federal standards require that nurse staffing be sufficient to meet the total nursing needs of all residents, resident conditions will in all events determine the specific numbers and qualifications of staff that each facility must provide. 7.6.1 A rural facility is one that is located in: 13 (1) a county of fewer than fifteen thousand population; or (2) a municipality of fewer than fifteen thousand population that is located ten miles or more from a municipality of fifteen thousand population or over; or (3) the unincorporated part of a county ten miles or more from a municipality of fifteen thousand population or more. 7.6.2 To the extent that these regulations require any facility to employ a registered nurse more than 40 hours per week, the Department may waive such requirements for such periods as it deems appropriate if, based on findings consistent with Part 4 of chapter II of these regulations it determines that: (1) The facility is located in a rural area as defined in Subsection 7.6.1; (2) The facility has at least one full-time registered nurse who is regularly on duty 40 hours per week; (3) The facility has only residents whose attending physicians have indicated in orders or admission notes that each resident does not require the services of a registered nurse for a 48-hour period or the facility has made arrangements for a professional nurse or physician to spend such time at the facility as is determined necessary by the resident's attending physician to provide needed services on days when the regular full-time registered nurse is not on duty; and (4) The facility has made and continues to make a good faith ort to comply with the more than 40-hour registered nurse requirement, but registered nurses are unavailable in the area. 7.7 SUPPLIES AND EQUIPMENT. The facility shall provide the supplies and equipment necessary to conduct the preventive, therapeutic, and rehabilitative nursing program. Equipment includes devices to assist residents to perform activities of daily living. 7.7.1 Equipment shall be maintained in clean and proper functioning condition. 7.7.2 The facility shall provide or assist residents to obtain walkers, crutches, canes, and wheelchairs (with appropriate padding), all of which shall fit residents properly. 7.7.3 Nursing staff shall be trained in rehabilitative nursing procedures, including preventive nursing care measures, and in the proper use of prosthetic devices and equipment. 7.8 CARE POLICIES. The facility shall have written resident care policies approved by the governing body, which staff shall follow. 7.9 RESIDENT SOCIALIZATION. Except where contraindicated by physician order or resident preference, residents shall be dressed, encouraged to be active, be out of bed for reasonable periods of time each day, and encouraged to eat in a dining room. 14 7.10 MEDICATION ADMINISTRATION. Medications shall be identified as provided in Subsection 16.3.2. Staff shall verify identification of the medication when the medication is prepared as well as when it is administered. 7.10.1 Medications and treatments shall be given only as ordered by a physician. 7.10.2 Medication shall be administered in a form that can be most easily tolerated by, the resident. Staff shall not mask the medication or alter its form, through crushing or dissolving or other means, if to do so would be hazardous and not without first informing the resident or responsible party. 7.10.3 Medications that are prepared but unused shall be disposed of in accordance with state law and the facility's written procedures. 7.10.4 All administered medications shall be recorded in the resident's health record, indicating the name, strength, dosage, and mode of administration of the medication, the date and time of administration, and the signature of the person administering the medication. 7.10.5 To encourage independence and prepare residents for discharge, the facility shall permit self-administration of medications in appropriate cases upon the order of the attending physician and under the guidance of a registered or a licensed practical nurse. 7.10.6 If facility policy permits medications to be kept at the bedside, the pharmaceutical advisory committee shall approve such types of medications. The facility shall assure that each such medication is ordered by the physician to be kept at the bedside, it is used properly, use is documented, and it is stored in a secure manner that protects all residents. 7.10.7 Drug reactions and significant medication errors shall be reported within thirty minutes to the resident's physician. A call to the office or answering service does not meet the facility's responsibility to provide emergency care. The resident's condition shall be monitored for 72 hours and observations documented in the health record. 7.10.8 If a resident is administered psychoactive medications, he or she shall be evaluated for symptoms of tardive dyskinesia at least every three months. 7.11 RESTRAINTS. A) A PHYSICAL RESTRAINT is a device or application of force that is designed to modify behavior detrimental to the resident, others or the facility. Physical restraints include without limitation, straight jackets, hard leather cuffs, or locking devices. B) A CHEMICAL RESTRAINT is a medication applied, ingested, or injected for the purpose of altering or controlling behavior. Any medication that can be used both to treat a medical condition and to alter or control behavior shall be evaluated to determine its use for the resident. If a medication is used solely or primarily to treat a medical condition, it is not a chemical restraint. 7.11.1 Linen shall not be used as restraints. 7.11.2 The facility shall establish written policies and procedures governing the use of physical and chemical restraints and shall assure that they are followed by all staff members. 15 7.11.3 Physical and chemical restraints shall only be used upon the order of a physician and only when necessary to prevent injury to the resident or others, based on a physical, functional, emotional and medication assessment. 7.11.4 Restraints shall not be used for disciplinary purposes, for staff convenience or to reduce the need for care of residents during periods of understaffing. 7.11.5 Whenever restraints are used, a call signal switch or similar device within reach or other appropriate method of communication shall be provided to the resident. 7.11.6 In an emergency in which there is documented danger of injury to self or others, a registered nurse or licensed practical nurse may order a physical restraint. The nature of the emergency shall be documented in the health record and a physician's order for the restraint shall be obtained as soon as practicable but in no event later than 24 hours after the restraint is first used. 7.11.7 Residents in physical restraints shall be monitored at least every 15 minutes to assure that the resident is properly positioned, blood circulation is not restricted, and other resident needs are met. 7.11.8 At least every two hours during waking hours, residents shall have the physical restraint removed and shall have the opportunity to: drink fluids, be toileted, and be exercised, moved, or repositioned, which activity shall be documented in the health record. 7.12 SAFETY DEVICES. A safety device is used to protect the resident from injury to self, maintain body alignment, or facilitate comfort. Safety devices include without limitation bed side rails, wheel or geri-chair tray tables, soft cloth vest, waist, or pelvic devices, roll bars, hand mittens, or helmets. 7.12.1 Linen shall not be used as safety devices. 7.12.2 Safety devices shall not be used for disciplinary purposes, for the convenience of staff, or to reduce the need for care of residents during periods of understaffing. 7.12.3 The facility shall establish written policies and procedures governing the use of safety devices and shall assure that they are followed by all staff members. 7.12.4 A registered nurse may order a safety device after assessing the need therefor. If the nurse applies a device (other than bedrails or helmets) for more than a 24 hour period, the nurse shall perform a comprehensive, documented physical and functional assessment of the resident's need for the device no less often than after the first 24 hours, at the end of the week, and monthly thereafter. 7.12.5 At least every two hours during waking hours, residents with safety devices shall be given the opportunity to: drink fluids, be toileted, and be exercised, moved or repositioned, which activity shall be documented in the health record. 7.12.6 Residents with safety devices shall have either a call signal switch or similar device within reach or some other appropriate means of communication provided. 7.13 PHYSICIAN NOTIFICATION. Facility staff shall notify the attending physician promptly in cases of significant change in resident status and any incident or accident involving the resident. 16 Part 8 - Social Services 8.1 SOCIAL SERVICES. The facility shall identify, plan care for, and meet the identified emotional and social needs of each resident to enhance resident psycho-social health and well-being. 8.1.1 Social services staff shall be involved in the pre-admission process, providing input as to appropriateness of placement from a psycho-social perspective, except in emergency admissions. Such involvement may include contact with the prospective resident or family member, or interdisciplinary conferences that consider psycho-social issues as well as medical/nursing criteria. 8.1.2 Social services staff shall provide for addressing needs of individuals or groups, either directly by staff or by referral to community agencies. 8.1.3 Social services staff shall assist residents and families in coping with the medical and psycho-social aspects of the resident's illness and disability and the stay in the facility. 8.1.4 Social services staff shall assist residents in planning, for discharge by coordinating service delivery with the nursing staff and by assessing availability and facilitating use of financial and social support services in the community. 8.1.5 When services, such as community mental health services, are available in the community to meet special residents' social and emotional needs, social services staff shall provide appropriate referrals to community services. 8.1.6 Social services staff shall coordinate transfers (other than medical transfers) within and out of the facility and assist residents in adjusting to intra-facility. transfers. 8.1.7 Social services staff shall participate in resident assessment and care planning as prescribed by 5.2, 5.4, and 5.7, and shall provide social services to residents. Staff shall review and update the assessment and care plan at least every six months. 8.1.8 Social services staff shall record information on social history in the health record and review it at least annually. 8.1.9 Social services staff shall record progress notes in the resident's health record at least quarterly for the first six months that a resident is in a long-term care facility and at least semi-annually thereafter. 8.1.10 Social services staff shall participate in developing policies and procedures pertaining to social services in the facility. 8.1.11 Social services staff shall provide orientation to new residents and their families (including explanation of residents' rights) and assistance to residents and families in raising concerns about resident care. 8.2 STAFFING. The facility shall employ social services staff qualified as provided in Subsections 8.2.1 and 8.2.2 and sufficient in number to meet the social and emotional needs of the residents. 8.2.1 A qualified social work staff member of a public or private non-profit facility* is a person who is either: 17 (1) A social worker licensed or authorized expressly by state law to practice under supervision of a licensed social worker; or (2) a person with a Master's or Bachelor's Degree in social work; or (3) a person with a Master's or Bachelor's Degree in a related human services field who has monthly consultation from a person meeting the qualifications in subsections 1, or 2. The consultation shall be sufficient in amount to assist the social work staff to meet resident needs. 8.2.2 A qualified social work staff member of a for-profit facility* is a person who is either a social worker licensed or authorized expressly by state law to practice under supervision of a licensed social worker or a person with a Master's or Bachelor's Degree in social work or other human services field who has monthly consultation from a person so licensed or authorized; the consultation shall be sufficient in amount to assist the social work staff to meet resident needs. 8.2.3 Any facility that on the effective date of these regulations employed a person with a high school degree or GED as social services staff may continue to employ that individual with prescribed consultation. 8.2.4 Any facility located in a rural area as defined by subsection 7.6.1 may apply for a waiver under Part 4 of chapter II of the qualifications for a social services staff member under this section if it demonstrates that it has made a good faith ort to hire staff with the required qualifications, but that qualified social services staff are unavailable in the area. 8.3 FACILITIES AND EQUIPMENT. The facility shall provide for social services staff suitable space, equipped with a telephone, for confidential interviews with residents and families. The space shall provide visual and auditory privacy and locked storage for confidential records and be accessible to non-ambulatory persons. Part 9 - Resident Activities 9.1 ACTIVITIES PROGRAM. The facility shall offer a program of organized activities that promotes residents' physical, social, mental, and intellectual well-being, encourages resident independence and pursuit of interests, maintains an optimal level of psycho-social functioning, and retains in residents a sense of continuing usefulness to themselves and the community. 9.1.1 Activities shall be broad enough in scope to stimulate participation of all residents, including residents with mental and emotional impairments, but no resident shall be compelled to participate in any activity. Each month, activities shall include at least one from each of the following categories: social/recreational, intellectual, physical, spiritual, and creative. 9.1.2 The facility shall provide individual and group activities designed to meet each resident's individual needs. 9.1.3 Activities staff shall participate in resident assessment and care planning as prescribed by 5.2, 5.5, and 5.7, and shall implement activity programs. 9.1.4 The facility shall develop programs to encourage community contact, including use of community volunteers inside the facility and activities for residents outside the facility. 18 The facility shall make reasonable arrangements for transportation for residents to such activities. 9.1.5 The facility shall provide activities daily, including at least one evening per week. Activities in addition to religious services shall be provided on weekends each week. 9.1.6 The facility shall post a monthly activities schedule where it is visible to all residents and families indicating date and time of each activity that is open to all residents. 9.1.7 The facility shall retain activity attendance records, maintained in a location other than the health record. 9.2 STAFFING. The facility shall employ activities staff sufficient in number to meet resident needs and qualified as either: (1) an activity professional certified by the National Certification Council for Activity Professionals as an Activity Director Certified or Activity Consultant Certified; (2) an occupational therapist or occupational therapy assistant meeting the requirements for certification by the American Occupational Therapy Association and having at least one year of experience in providing activity programming in a long term care facility; (3) a therapeutic recreation specialist (registered by the National Therapeutic Recreation Society) having at least one year of experience in providing activity programming in a long term care facility; (4) a person with a Master's or Bachelor's degree in the social or behavioral sciences who has at least one year of experience in providing activity programming in a long term care facility; (5) a person who has completed, within a year of employment, a training course for activity professionals in an accredited state facility [if available] and who has at least two years experience in social or recreational program work, at least one year of which was full-time in an activities program in a health care setting; or (6) a person with monthly consultation from a person meeting the qualifications set forth in subsections (1) through (5). The consultation shall be sufficient in amount to assist the activity staff members to meet resident needs. 9.3 RELIGIOUS SERVICES. The facility shall assist residents who are able and wish to do so to attend religious services of their choice. The facility shall honor resident requests to see their clergy and provide private space for such visits. 9.4 SPACE AND EQUIPMENT. The facility shall make available the supplies, space, and equipment to provide an activities program that meets each resident's individual needs. The facility shall provide an activities and recreation area and provide at least: books, current newspapers, games, stationery, radio, and television. 19 Part 10 - Dental Services 10.1 DENTAL EXAMINATION. Upon admission, each resident of a facility upon his/her consent or upon the consent of a responsible person, shall have an oral examination by a licensed dentist or an initial oral inspection by a licensed dental hygienist designated by a dentist. 10.1.1 The facility shall take all necessary steps to assure that the dental examination is conducted according to current dental practice. 10.1.2 The facility is not responsible to pay for such services. 10.1.3 If the local dental society provides a list of dentists who are willing to participate, the facility shall make the list available to the residents. 10.1.4 In lieu of the admission examination, the resident may present written results, for entry into his/her medical record, of an oral examination administered during a period not to exceed six months prior to admission. 10.2 DENTAL RECORDS. The dentist or the designated dental hygienist is responsible for the dental record. For residents agreeing to participate in the program, the facility shall take all necessary steps to assure that there are complete, accurate dental records that include the following: 10.2.1 Results of all current dental examinations and plans for treatment. 10.2.2 One of the following to document provision of planned treatment: (1) Record of treatment provided pursuant to a plan for treatment. (2) A document signed by each resident of a nursing care facility or responsible party that states that the resident or responsible party is aware of any and all specific oral pathology identified during an oral examination of the resident, but elects not to obtain treatment because of cost or other reasons. (3) In the event that the resident or responsible party elects not to obtain the initial oral examination, a signed statement to that effect in the resident's permanent medical record, which substitutes for the dental record requirement. 10.3 ORAL APPLIANCES. Upon consent, all residents' removable oral appliance and personal hygiene appliances (including without limitation, full dentures, partial dentures, and toothbrushes) shall be clearly identified and marked in a permanent manner with the user's name, as recommended by the dentist designated as advisory dentist to the facility. 10.4 DENTAL HYGIENE. Each facility shall implement policies for an oral hygiene for its residents, in consultation with the advisory dentist or the designated dental hygienist. 20 10.4.1 Direct care staff from each facility shall have at least annual inservice training course in preventive dentistry and oral hygiene, conducted by a dentist, dental hygienist, or preventive dental aide. Part 11 - Dietary Services 11.1 DIETARY SERVICES. The facility shall provide meals that are nutritious, attractive, well balanced, in conformity with physician orders, and served at the appropriate temperature in order to enhance residents' health and well being. It shall also offer nourishing snacks. 11.2 ORGANIZATION. The facility shall have an organized food service, appropriately planned, equipped, and staffed to prepare and serve the number of meals created in the kitchen. The facility shall offer at least three meals or their equivalent per day, at regular times, with not more than 14 hour between the beginning of the evening meal and breakfast. Routine seatings shall be no later than 8 A.M. for breakfast and no earlier than 5 P.M. for the evening meal. Timing of meals shall generally comport with cultural practices in the community, unless inconsistent with these regulations. 11.3 PERSONNEL. The administrator shall designate a dietician or person qualified by training and experience to be responsible for the dietary services. 11.3.1 If not a professional dietician, the designee shall obtain frequent regularly scheduled consultation from a registered dietician or a person eligible for registration who meets the American Dietetic Association's qualifications standards or a graduate from a baccalaureate degree program with major studies in food and nutrition. 11.3.2 The number of trained food service personnel shall be sufficient to provide food service to the residents in the facility over a period of 12 hours or more per day. 11.4 POLICIES. The facility shall have written policies and procedures approved by the governing body for dietary practices and shall assure that they are followed by staff members. 11.5 ORDERS. All diets and nourishments shall be provided and served as by the attending physician. 11.6 NUTRITIONAL ASSESSMENT AND PROGRESS NOTES. The dietary supervisor consultant shall participate, in resident, assessment and care planning as prescribed by 5.2, 5.6, and 5.7. 11.6.1 The supervisor or consultant shall write progress notes on each resident at least at six month intervals. 11.6.2 The facility shall reasonably accommodate individual resident references in meals by offering appropriate and nutritionally adequate substitutes. (See Section 5.1.13(4).) 11.7 DIET MANUAL. 21 The facility shall maintain a current diet manual conveniently available to the dietary and nursing staffs. For purposes of this section, current means initially published or revised within five years. 11.8 MENUS. Menus shall be written as approved by a dietician and planned at least one week in advance, considering residents' personal tastes, desires, and cultural patterns. Menus shall be posted in the kitchen area and maintained in the facility at least four weeks. If menus are changed, all changes shall be posted as served. Menus shall meet the requirements of the cRecommended Dietary Allowances for Food and Nutrition Board, d National Research Council, 1980. Recipes appropriate to the menus and needs of the facility shall be available to the cooks. 11.9 SPACE. The facility shall provide adequate space to accommodate fixed and movable equipment and employee functions; receive, store, refrigerate, and prepare food; assemble trays; store carts; and clean dishes, pots, and pans. 11.10 REGULATIONS. cRules and Regulations Governing the Sanitation of Food Service Establishments in the State of Colorado, d Colorado Department of Health, July 1, 1978 is hereby adopted by reference and made applicable to long-term care facilities under these regulations except as follows: Section 2-502 is not adopted; Section 4-208 applies as of the effective date of these regulations; the first sentence of Section 5-103(a) applies to new construction only; provisions of Section 6-401 pertaining to toilets for patrons are not adopted; Section 7-806 is adopted as applying to prohibit animals from only kitchen areas of facilities and from dining areas when food is being served; Chapters 8 and 9 are not adopted; Sections 10-101 through 10-205 and 10-501 are not adopted. This adoption of the Restaurant regulations does not include later amendments or editions. 11.11 REFRIGERATOR SAFETY. Walk-in refrigerators and freezers shall have inside lighting and inside lock releases. In facilities constructed after the effective date of these regulations, there shall be an alarm system that is clearly audible throughout the food preparation and storage areas of the facility and that may be readily activated by staff members from within walk-in refrigerators or freezers. 11.12 EQUIPMENT. The facility shall provide equipment sufficient in amount, adequate in type for efficient and timely preparation of meals. 11.13 STORAGE OF DISHES AND GLASSES. Clean glasses, cups, and other dishes shall not be stored in such a manner as to entrap moisture. 11.14 ISOLATION. Dishes and utensils with which food is served to residents in isolation because of infectious diseases shall be sanitized if they are contaminated with infectious material such as blood drainage or secretions or shall be disposable. 11.15 MILK. 22 Milk for drinking shall be provided to consumers in an unopened, commercially filled container not exceeding a one pint capacity, or drawn from a commercially filled container stored in a mechanically refrigerated bulk milk dispenser, or poured directly into the drinking vessel from a commercially filled half- gallon or gallon container that has been refrigerated until served to maintain a temperature of 45 degrees F or less. 11.16 NAIL POLISH AND FALSE NAILS. Staff involved in preparing and serving food shall not wear nail polish or false nails. 11.17 DINING AND RECREATIONAL FACILITIES. Dining and recreation areas shall be readily accessible to all residents, and shall not be in a hallway or lane of traffic in or out of the facility. Such space shall be sufficient to accommodate activities conducted there, consistent with resident comfort and safety. The dining and recreation areas may be separate or combined. Part 11.001 3 Feeding Assistants 11.001.1 Definitions. Unless otherwise indicated, as used in Part 11.001: (1) (a) cFeeding assistant d means an individual who assists residents by performing feeding assistant tasks, meets the requirements of Section 11.001.2 and 11.001.3; and, is paid as an employee of a facility; used by a facility under arrangement with another agency or organization; or, who is an unpaid volunteer. (b) The following individuals may provide feeding assistance to residents without meeting the requirements of section 11.001.2 and 11.001.3: (i) Registered or licensed nurses; (ii) Certified nurse aides; (iii) Registered dietitians; (iv) Licensed health care practitioners with appropriate experience in feeding and hydrating residents; (v) Private duty aides and students in nursing education programs and other allied health programs who utilize facilities as clinical practice sites; or, (vi) Resident family members. (2) cEmploying facility d means a facility that employs paid feeding assistants or utilizes the services of volunteer feeding assistants. (3) cFeeding assistant tasks d include and are limited to the provision of feeding and hydration services provided in accordance with this Section 11.001. A feeding assistant may not perform or be assigned to perform any task that constitutes: the practice of professional nursing as defined in §12-38-103 (10), C.R.S.; the practice of practical nursing as defined in §12-38-103 (9), C.R.S.; or the practice of a nurse aide as defined in §12-38.1-102 (5), C.R.S. 23 (4) cTraining program provider d means, an employing facility or other training entity approved by the department pursuant to 11.001.6 to administer a feeding assistant training program. 11.001.2 Authorization; Qualifications (1) A facility may employ or use an individual as a volunteer feeding assistant if: the individual meets all applicable requirements of this Chapter V; and, the facility first verifies that the individual: (a) Has successfully completed a feeding assistant training program in accordance with 11.001.5; and, (b) Is at least sixteen 16 years of age. (2) (a) An employing facility must screen prospective feeding assistants to ensure individuals have no history that would preclude their interaction with residents. (b) In addition to applicable facility pre-employment screening procedures, an employing facility shall obtain from each prospective paid and volunteer feeding assistant a copy of the recognition of completion document evidencing successful completion of the feeding assistant training program issued in accordance with 11.001.5 (1)(b)(II). Additionally, an employing facility shall verify the following: (I) In the case of an individual who has not previously been employed or volunteered as a feeding assistant and who has received feeding assistant training administered by an entity other than the employing facility, successful completion of the feeding assistant training program with the training entity that provided such training; (II) In the case of an individual who has been previously employed as a feeding assistant, feeding assistant employment history with the prospective employee 9s previous long-term care facility employer; (III) In the case of an individual who has previously volunteered as a feeding assistant, feeding assistant volunteer history with the long-term care facility that previously utilized the services of that individual. (3) Feeding assistants may not be counted toward meeting or complying with any requirement for nursing care staff and fun

less