.13 Resident Care Policies.

A. A nursing home shall develop written policies consistent with Regulation .11 of this chapter pertaining to:

(1) Physician services;

(2) Residentsí rights;

(3) Nursing services;

(4) Dietetic services;

(5) Specialized rehabilitative services including occupational therapy, physical therapy, speech pathology and audiology services;

(6) Pharmaceutical services;

(7) Laboratory and radiologic services;

(8) Dental services;

(9) Social services;

(10) Resident activities;

(11) Clinical records;

(12) Reports and action required in unusual circumstances;

(13) Utilization review;

(14) Infection control;

(15) Tuberculosis surveillance;

(16) Disaster plan;

(17) Housekeeping services, pest control, and laundry; and

(18) Resident care management.

B. Resident Care Policy.

(1) A nursing home shall develop resident care policies with the advice of:

(a) The principal physician or medical staff or medical director, if applicable; and

(b) At least one registered nurse.

(2) A group of professional personnel including one or more physicians and one or more registered nurses shall review the policies at least annually.

(3) Written policies shall be kept current with the policies used to administer the nursing home.

(4) For reference purposes, copies of the resident care policies shall be readily available to all personnel responsible for resident care.

(5) The nursing home shall make its resident care policies available for review by residents, the residentís representative, and the ombudsman.

C. Policies and Procedures.

(1) Upon the request of the Secretary or the Secretary's designee, the facility's policies and procedures shall be made available to the Secretary for onsite review.

(2) The licensee shall submit to the Department any significant substantive changes to the policies and procedures which have occurred since review of the policies and procedures within 2 weeks of implementation of the changes.

D. Use of Protective Device or Devices.

(1) A written physician's order is required for the use of a protective device or devices. This order shall be in effect for a maximum of 60 days. If continuation of the use of a protective device or devices beyond 60 days is necessary, a new order shall be written by the physician and rewritten every 60 days.

(2) The physician's order shall contain the specific type of protective device or devices to be used.

(3) The physician's order shall reflect his or her reason for ordering a protective device or devices.

(4) A resident in a protective device or devices shall be observed periodically by personnel, to ensure that the residentís health and personal care needs are met.

(5) A resident who is in a protective device or devices may not be left in the same postural position for more than 2 consecutive hours.