| (a) Administration and staffing.
(1) Legal responsibility. There shall be an individual
or individuals that assume(s) full legal responsibility for the overall
conduct of the facility and are responsible for compliance with all
applicable laws and rules of the department.
(2) Facility director.
(A) The facility director, who is to be accountable
for the overall management of the facility, shall be named in writing.
(B) The director's responsibilities shall be defined
in writing.
(C) If the facility can be successfully managed with
less than the director's full-time management, the director may be
less than full-time. In such instances, the director shall assign
another responsible individual who can perform management tasks so
that there is administrative management essentially for the usual
and customary 40-hours-per-week business operations.
(D) There shall be a competent individual authorized
to be in charge of the facility when the director is absent.
(E) The director shall be at least 18 years of age
and shall be qualified by education or training to perform the duties
required to manage the facility.
(F) The director shall be responsible for coordinating
the provision of all services.
(3) Personnel requirements.
(A) The facility shall have written personnel policies
and procedures for paid staff and volunteer staff which include at
a minimum:
(i) written position descriptions that include responsibilities
for all positions in the facility;
(ii) qualifications for employment for all positions
in the facility; and
(iii) the process for filling a position, evaluating
performance and termination.
(B) The facility shall maintain personnel records which
contain sufficient information to support appropriate placement of
an individual in a position. The file shall include a copy of the
individual's current license or certification, if applicable, or other
evidence that license or certification status was verified.
(C) The facility shall be staffed at all times with
sufficient qualified personnel to meet the needs of residents and
maintain a clean and safe environment. A minimum of one staff person
shall be on duty at all times. A qualified staff person will be designated
as in charge on each shift.
(4) Contracted services. If a facility does not employ
a person qualified to provide a required or needed service, it shall
have a contract with an outside resource to provide the service directly
to residents or to act as a consultant to the facility. The facility
maintains responsibility for ensuring that contract staff is qualified
to perform the services to be provided and that they are appropriately
supervised.
(5) Volunteer services. Volunteer staff may be placed
in any position for which they are qualified. Requirements in paragraph
(6) of this subsection shall apply to all volunteer staff.
(6) Staff development and training.
(A) All staff shall receive orientation training prior
to being allowed to work with residents. Orientation shall include
information pertaining to the facility's mission and philosophy, position
specific responsibilities and all operational policies and procedures.
(B) All staff must participate in periodic staff development
training designed to update their knowledge and skills in providing
care to residents. Training will also include a review of operational
policies and procedures.
(C) The facility shall maintain documentation which
verifies each staff person's participation in the orientation training
program and staff development training.
(b) Policies and procedures. The facility shall adopt,
implement and enforce written policies and procedures detailing the
operations of the facility. The policies shall be reviewed and updated
annually. In addition to describing the operations of the facility
and the manner in which care and services will be provided, the policies
and procedures shall include:
(1) Resident admission.
(A) Admission policies shall include qualifications
and criteria for admission based on the mission and philosophy of
the facility.
(B) Policies may include restriction of admission and
retention of individuals with regard to illegal drug use, alcohol
abuse, or actions that pose a threat to the health and safety of other
residents or staff.
(C) Policies shall require a written admission agreement
between the resident and the facility that addresses the care and
services to be provided and the method of payment for services.
(D) The facility policy shall require that a chronological
register of all residents admitted to and discharged from the facility
be maintained. The register shall contain at least the name of the
resident, date of birth, date of admission, date of discharge or death,
and disposition.
(2) Infection control and universal precautions. There
shall be written policies and procedures providing for a safe and
sanitary environment, and the control of communicable diseases and
infections in staff, residents, and visitors. The policy shall also
provide for monitoring compliance of the facility and its staff with
universal precautions in accordance with the Health and Safety Code
(HSC), Chapter 85, Subchapter I, (relating to the Prevention of Transmission
of Human Immunodeficiency Virus and Hepatitis B Virus by Infected
Health Care Workers).
(3) Determination of death. If applicable, there shall
be a written policy with protocols to be used in determining death
that complies with HSC, Title 8, Subtitle A, Chapter 671, Subchapter
A (relating to Determination of Death).
(4) Special waste. The facility shall comply with the
requirements set forth by the department in §1.131-1.137 of
this title (relating to Definition, Treatment, and Disposition of
Special Waste from Health Care Related Facilities), and the Texas
Commission on Environmental Quality requirements in Title 30, Texas
Administrative Code, Subchapter Y, §330.1004 (relating to Generators
of Medical Waste).
(5) Confidentiality of records. There shall be a written
policy that addresses the confidentiality of resident information.
(6) Advance directives. There shall be policies and
procedures regarding the use of advance directives in the facility.
These policies and procedures shall be in accordance with the Advance
Directives Act, HSC, Chapter 166. Violations of §166.004 may
result in the assessment of administrative penalties, in accordance
with HSC, §248.0545 (relating to Violation of Law Relating to
Advance Directives).
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