| (E) The nursing facility that is granted a waiver by
the state notifies residents of the facility and the resident representatives
of the waiver.
(6) Waiver of the requirement to provide services of
a registered nurse for more than 40 hours a week in a Medicare skilled
nursing facility (SNF).
(A) The secretary of the U.S. Department of Health
and Human Services (secretary) may waive the requirement that a Medicare
SNF provide the services of a registered nurse for more than 40 hours
a week, including a director of nursing specified in paragraph (2)
of this subsection, if the secretary finds that:
(i) the facility is located in a rural area and the
supply of Medicare SNF services in the area is not sufficient to meet
the needs of individuals residing in the area;
(ii) the facility has one full-time registered nurse
who is regularly on duty at the facility 40 hours a week; and
(iii) the facility either has:
(I) only residents whose physicians have indicated
(through physician's orders or admission notes) that they do not require
the services of a registered nurse or a physician for a 48-hour period;
or
(II) made arrangements for a registered nurse or a
physician to spend time at the facility, as determined necessary by
the physician, to provide necessary skilled nursing services on days
when the regular full-time registered nurse is not on duty.
(B) The secretary provides notice of the waiver to
the State Ombudsman and the protection and advocacy systems in the
state for individuals with mental illness established under the Protection
and Advocacy for Mentally Ill Individuals Act (42 USC Chapter 114,
Subchapter I) and individuals with intellectual or developmental disabilities
established under the Developmental Disabilities Assistance and Bill
of Rights Act (42 USC Chapter 144, Subchapter I, Part C).
(C) The SNF that is granted a waiver notifies residents
of the facility and the resident representatives of the waiver.
(D) A waiver of the registered nurse requirement under
subparagraph (A) of this paragraph is subject to annual renewal by
the secretary.
(7) Request for waiver concerning staffing levels.
The facility must request a waiver through the local HHSC Regulatory
Services Division, in writing, at any time the administrator determines
that staffing will fall, or has fallen, below that required in paragraphs
(1) and (2) of this subsection for a period of 30 days or more out
of any 45 days.
(A) The following information must be included in the
request:
(i) beginning date when facility was or is unable to
meet staffing requirements;
(ii) type waiver requested (24-hour licensed nurse
or seven-day-per-week R.N.);
(iii) projected number of hours per month staffing
reduced for 24-hour licensed nurse waiver or seven-day-per-week R.N.
waiver; and
(iv) staffing adjustments made due to inability to
meet staffing requirements.
(B) Waivers for licensed-only or certified facilities
will be granted by HHSC Regulatory Services Division staff. Waivers
for a Medicare SNF receive final approval from the CMS.
(C) If a facility, after requesting a waiver, is later
able to meet the staffing requirements of paragraphs (1) and (2) of
this subsection, HHSC Regulatory Services Division staff must be notified,
in writing, of the effective date that staffing meets requirements.
(D) Verification that the facility appropriately made
a request and notification will be done at the time of survey.
(E) Amounts paid to Medicaid-certified facilities in
the per diem payment to meet the staffing requirements of paragraphs
(1) and (2) of this subsection may be adjusted if staffing requirements
are not met.
(8) Duration of waiver. Approved waivers are valid
throughout the facility licensure or certification period, unless
approval is withdrawn. During the relicensure or recertification survey,
the determination is made for approval or denial for the next facility
licensure or certification period if a waiver continues to be necessary.
The facility requests a redetermination for a waiver from HHSC Regulatory
Services Division staff at the time the survey is scheduled. At other
times if a request is made, HHSC staff may schedule a visit for waiver
determination.
(9) Requirements for waiver approval. To be approved
for a waiver, the nursing facility must meet all of the requirements
stated in this subchapter and the requirements specified throughout
this chapter. In some instances, the survey agency may require additional
conditions or arrangements such as:
(A) an additional licensed vocational nurse on day-shift
duty when the registered nurse is absent;
(B) modification of nursing services operations; and
(C) modification of the physical environment relating
to nursing services.
(10) Denial or withdrawal of a waiver. Denial or withdrawal
of a waiver may be made at any time if any of the following conditions
exist:
(A) requirements for a waiver are not met on a continuing
basis;
(B) the quality of resident care is not acceptable;
or
(C) justified complaints are found in areas affecting
resident care.
(11) Requirement that SNFs be in a rural area. A SNF
(Medicare) must be in a rural area for waiver consideration, as specified
in paragraph (6) of this subsection. A rural area is any area outside
the boundaries of a standard metropolitan statistical area. Rural
areas are defined and designated by the federal Office of Management
and Budget; are determined by population, economic, and social requirements;
and are subject to revisions.
(b) Nurse staffing information.
(1) Data requirements. The facility must post the following
information:
(A) on a daily basis:
(i) the facility name;
(ii) the current date;
(iii) the resident census; and
(iv) the specific shifts for the day; and
(B) at the beginning of each shift, the total number
of hours and actual time of day to be worked by the following licensed
and unlicensed nursing staff, including relief personnel directly
responsible for resident care:
(i) RNs;
(ii) LVNs; and
(iii) CNAs.
(2) Posting requirements. The nursing facility must
post the data described in paragraph (1) of this subsection:
(A) in a clear and readable format; and
(B) in a prominent place readily accessible to residents
and visitors.
(3) Public access to posted nurse staffing data. The
facility must, upon oral or written request, make copies of nurse
staffing data available to the public for review at a cost not to
exceed the community standard rate.
(4) Facility data retention requirements. The facility
must maintain the posted daily nurse staffing data for the period
of time specified by written facility policy or for at least two years
following the last day in the schedule, whichever is longer.
|
| Source Note: The provisions of this §554.1001 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 30, 2011, 36 TexReg 7174; amended to be effective April 5, 2018, 43 TexReg 2017; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037 |
