SECTION 506.32. Resident Care and Services

(a) Physician services.

(1) Each resident shall have an attending physician who is charge of the resident's medical care.

(2) The facility shall make a reasonable effort to contact the resident's physician within 72 hours after admission to obtain any information relating to the care of the resident. Any relevant information obtained from the physician will be recorded in the resident's care document.

(3) In the event of an acute illness, condition, or accident requiring medical and/or nursing care beyond the capabilities of the facility, the resident shall be transferred, in a medically appropriate manner, to a hospital or other health care facility as appropriate where needed services and facilities are available.

(b) Nursing services.

(1) Licensed nurses shall function consistent with the nursing practices recognized and authorized by Texas Board of Nurse Examiners.

(2) When nursing services are provided, nursing personnel are responsible for ensuring that residents receive treatments, medications, and diets as prescribed; receive preventive care to prevent and minimize the incidence of skin breakdown; are kept comfortable with personal hygiene needs met; are protected from accident and injury through the initiation of appropriate safety measures; and are treated with kindness and respect.

(3) Nursing or attendant personnel on duty shall be responsible for obtaining emergency medical care when a resident's condition so requires and shall be responsible for notifying the attending physician.

(c) Medications.

(1) Medications shall be provided as required for those residents on a physician or practitioner-ordered medication therapy regimen.

(2) Upon admission, and as part of the plan of care, the admitting physician shall determine whether a resident can self-administer his or her medications or will require administration by qualified personnel in accordance with paragraph (7) of this subsection.

(3) Each resident's health status shall be reviewed at least quarterly, or more often if indicated, to determine if any changes are necessary in the medication administration procedures.

(A) The appropriateness for a resident to self-administer medications shall be reviewed by facility staff and the attending physician or an advanced practice nurse working in collaboration with the attending physician.

(B) A resident's drug regimen review shall be incorporated into the individual's plan of care.

(4) Medications must be kept secured at all times. Only the resident and authorized facility staff shall have access to the secured medications. Residents self-administering their medications may:

(A) keep medications in their possession at all times;

(B) secure their medications within their locked room if the room is not shared with others, or in a locked cabinet in their room; or

(C) allow the facility to keep residents' medications in a central medication storage area under control of facility staff.

(5) The central medication storage shall be kept locked when facility staff is not actually in or at the storage area.

(6) Residents may be permitted entrance or access to the storage area for the purpose of self-administering their medications or treatments or receiving assistance with their medication or treatment regimen. A facility staff member shall remain in or at the storage area the entire time any resident is in the storage area.

(7) Medications that are administered to a resident shall be administered only by a registered professional nurse, licensed vocational nurse, or an individual under direct delegation orders by a physician and in conformance with all laws, rules, and recognized professional standards of practice. A home health agency who is providing services within a special care facility may use a home health medication aide in accordance with 40 Texas Administrative Code, §95.128 (relating to Home Health Medication Aides).

(A) The person administering medications shall properly record the medications administered. This record will be retained in the resident file.

(B) Medications classified as dangerous drugs or controlled substances may not be taken by or administered to residents unless the medication was obtained directly from or under a valid prescription or order of a physician or practitioner. If facility staff administer the medications, they shall only be administered under written orders, or verbal orders which are subsequently verified in writing by the treating physician or practitioner.

(C) All injectable medication, intravenous solutions, or medications administered by way of a tube inserted in a cavity of the body shall be administered under physician's or practitioner's orders by a physician, registered professional nurse, licensed vocational nurse, or other individual qualified under state law.

(D) If administration of medications to residents is performed by a registered professional nurse or licensed vocational nurse the following shall apply.

(i) There shall be a specific area designated for medication that is:

(I) sufficient in size and/or space for the storage of all medications that are being administered to residents and for the preparation of medications for administration to residents;

(II) lockable and shall be maintained locked at all times when not occupied;

(III) accessible only to persons authorized to administer medications to residents;

(IV) equipped with a sink having hot and cold water available at all times; and

(V) adequately ventilated and temperature controlled.

(ii) A medication storage cart may be used in addition to the medication room for the storage of residents' medications. When not in use, the medication storage cart must be kept locked in the locked medication room or in the designated locked storage room that shall be used only for the storage of the cart.

(8) When a resident needs assistance with taking oral medication, only those individuals approved in writing by the director of the facility may provide that assistance.

(A) A mechanism will be developed, implemented and monitored by the facility director to insure that the resident is given only those medications that have been prescribed by the resident's physician or practitioner at the intervals detailed on the resident's medication container.

(B) When assistance with taking oral medication is provided, the facility will maintain a medication record which documents the medication, date, and time taken. The name of the individual who assisted the resident taking the oral medication shall also be documented.

(C) The facility director or designee will monitor the medication records daily to insure accuracy.

(9) Medication requiring refrigeration shall be stored in a separate refrigerator designated for medications which is kept in the secured medication storage area. Medications may be stored in an area within the common refrigerator if they are stored in a manner that prevents contamination of the medications, and allows for the security of the medication to be maintained.

(10) Medication under storage control of the facility shall be returned to the resident upon dismissal from the facility, or as directed by the physician.

(11) Medications of a resident shall not be used for another resident. When a resident is dismissed from or otherwise leaves the facility for a period of time greater than 48 hours, medications which had been under the control of the resident and left in the facility shall be secured under locked storage control of the facility until reclaimed by the resident and no longer than 90 days. Medications of deceased residents shall not remain in the facility for more than 7 days after the resident's death. Medications of deceased residents and medications which have been left unclaimed in the facility for more than 90 days shall be handled in one of the following manners.

(A) Medications may be returned to any licensed pharmacy for destruction in accordance with regulations of the Texas Board of Pharmacy governing the destruction of dangerous drugs or controlled substances. A record shall be maintained by the facility which itemizes the quantity and strength of each medication returned to a pharmacy for destruction. Such record shall be signed by the director of the facility and the pharmacist accepting the drugs for destruction and shall be retained in the resident's file.

(B) Medications may be destroyed beyond reclamation on site by the facility director. Drugs should be destroyed by incineration, if possible. Small amounts of drugs may be flushed into the sewer system unless prohibited by local ordinance. Large quantities of drugs may be destroyed by removing the drugs from the prescription containers, placing them in a strong plastic container, and adulterating the drugs with water or bleach.

(i) A record of the destruction shall be maintained by the facility and include:

(I) the name, strength, and quantity of the drug;

(II) the method of destruction; and

(III) the signature of the facility director who destroyed the drugs and signatures of two other individuals who witnessed the destruction.

(ii) This record shall be retained in the resident's file.

(12) Controlled substances and drugs under storage control of the facility shall be kept separately locked in a permanently affixed compartment within the medicine room or medication storage cart.

(A) A separate record must be maintained for each controlled substance and drug.

(B) The record shall include, but not be limited to, prescription number, name and strength of drug, date received by the facility, date and time each dose is provided, signature of person providing the dose, name of resident, and the original amount received with the balance verifiable by drug inventory at least daily.

(13) All residents' medications shall be properly labeled in accordance with applicable laws and regulations.

(d) Dietary services.

(1) A dining room, rooms, or space with appropriate furnishings shall be provided. The dining space and furnishings should allow the residents who can come to the dining room to dine at one sitting. Where alternate or second meal services are employed, quantity and quality shall be maintained.

(2) The facility shall have a kitchen or dietary area to meet the food service needs of the residents. It shall include provisions for the storage, refrigeration, preparation, and serving of food; for dish and utensil cleaning; and for refuse storage and removal.

(3) Meal service at intervals of at least three meals per day, seven days per week, shall be provided or arranged to be commensurate with the needs of the residents. Meals shall be palatable and meet the nutritional needs of the residents.

(4) Procedures to prevent cross contamination shall be observed in the storage, preparation, and distribution of food; in the cleaning of dishes, equipment, and work area; and in the storage and disposal of waste. The facility shall provide storage of food for emergency use for a minimum of four calendar days.

(5) All dishes and utensils shall be washed in an automatic dishwasher or by the use of manual dishwashing procedures.

(A) A three-compartment sink shall be used if washing, rinsing and sanitizing of utensils and equipment is done manually; or a two-compartment sink may be utilized if single service tableware is provided, or when an approved detergent sanitizer is used.

(B) Cleaning and sanitizing may be done by spray-type or immersion dishwashing machines or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils either by chemical or mechanical sanitization.

(6) Sanitary hand washing and drying provisions shall be provided in the kitchen area and shall include soap, water and individual disposable towels.

(e) Social services/pastoral care. Services to meet identified social, spiritual, and emotional needs shall be offered to the resident. Services may also be available to the resident's family, responsible party, and significant other persons. Acceptance of these services will be at the option of the resident.

(f) Personal care services.

(1) The facility shall provide personal care services in accordance with the individualized needs of each resident.

(2) Personal care services shall include normal activities of daily, and may include:

(A) assistance with their medications;

(B) assistance with hygiene;

(C) assistance with dressing;

(D) assistance with ambulation; and

(E) emotional support.

(g) Laboratory services.

(1) A facility that provides laboratory services shall comply with the Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988), in accordance with the requirements specified in 42 Code of Federal Regulations (CFR), Chapter IV, Part 493, §§493.1-493.1780. CLIA 1988 applies to all facilities with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.

(2) The facility shall ensure that all laboratory services provided to its residents through a contractual agreement are performed in a facility certified in the appropriate specialties and subspecialties of service in accordance with the requirements specified in 42 CFR, Chapter IV, Part 493 to comply with CLIA 1988.

Source Note: The provisions of this §506.32 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467