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RULE §553.261Coordination of Care

(a) Medications.

  (1) Administration. Medications must be administered according to physician's orders.

    (A) Residents who choose not to or cannot self-administer their medications must have their medications administered by a person who:

      (i) holds a current license under state law that authorizes the licensee to administer medication;

      (ii) holds a current medication aide permit and who:

        (I) acts under the authority of a person who holds a current nursing license under state law that authorizes the licensee to administer medication; and

        (II) functions under the direct supervision of a licensed nurse on duty or on call by the facility; or

      (iii) is an employee of the facility to whom medication administration has been delegated by a registered nurse, who has trained the employee to administer medications or verified their training. The delegation of the medication administration is governed by 22 TAC Chapter 225 (concerning RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions), which implements the Nursing Practice Act.

    (B) Each resident's prescribed medication must be dispensed through a pharmacy or by the resident's treating physician or dentist.

    (C) Physician sample medications may be given to a resident by the facility provided the medication has specific dosage instructions for the individual resident.

    (D) Each resident's medications must be listed on the individual resident's medication profile record. The recorded information obtained from the prescription label must include the medication:

      (i) name;

      (ii) strength;

      (iii) dosage;

      (iv) amount received;

      (v) directions for use;

      (vi) route of administration;

      (vii) prescription number;

      (viii) pharmacy name; and

      (ix) the date each medication was issued by the pharmacy.

  (2) Supervision. Supervision of a resident's medication regimen by facility staff may be provided to residents who are incapable of self-administering without assistance to include and be limited to:

    (A) reminders to take their medications at the prescribed time;

    (B) opening containers or packages and replacing lids;

    (C) pouring prescribed dosage according to medication profile record;

    (D) returning medications to the proper locked areas;

    (E) obtaining medications from a pharmacy; and

    (F) listing on an individual resident's medication profile record the medication:

      (i) name;

      (ii) strength;

      (iii) dosage;

      (iv) amount received;

      (v) directions for use;

      (vi) route of administration;

      (vii) prescription number;

      (viii) pharmacy name; and

      (ix) the date each medication was issued by the pharmacy.

  (3) Self-administration.

    (A) Residents who self-administer their own medications and keep them locked in their room must be counseled at least once a month by facility staff to ascertain if the residents continue to be capable of self-administering their medications or treatments and if security of medications can continue to be maintained. The facility must keep a written record of counseling.

    (B) Residents who choose to keep their medications locked in the central medication storage area may be permitted entrance or access to the area for the purpose of self-administering their own medication or treatment regimen. A facility staff member must remain in or at the storage area the entire time any resident is present.

  (4) General.

    (A) Facility staff will immediately report to the resident's physician and responsible party any unusual reactions to medications or treatments.

    (B) When the facility supervises or administers the medications, a written record must be kept when the resident does not receive or take his or her medications or treatments as prescribed. The documentation must include the date and time the dose should have been taken, and the name and strength of medication missed; however, the recording of missed doses of medication does not apply when the resident is away from the facility.

  (5) Storage.

    (A) The facility must provide a locked area for all medications. Examples of areas include:

      (i) central storage area;

      (ii) medication cart; and

      (iii) resident room.

    (B) Each resident's medication must be stored separately from other resident's medications within the storage area.

    (C) A refrigerator must have a designated and locked storage area for medications that require refrigeration, unless it is inside a locked medication room.

    (D) Poisonous substances and medications labeled for "external use only" must be stored separately within the locked medication area.

    (E) If facilities store controlled drugs, facility policies and procedures must address the prevention of the diversion of the controlled drugs.

  (6) Disposal.

    (A) Medications no longer being used by the resident for the following reasons are to be kept separate from current medications and are to be disposed of by a registered pharmacist licensed in the State of Texas:

      (i) medications discontinued by order of the physician;

      (ii) medications that remain after a resident is deceased; or

      (iii) medications that have passed the expiration date.

    (B) Needles and hypodermic syringes with needles attached must be disposed as required by 25 TAC §§1.131 - 1.137.

    (C) Medications kept in a central storage area are released to discharged residents when a receipt has been signed by the resident or responsible party.

(b) Accident, injury, or acute illness.

  (1) In the event of accident or injury that requires emergency medical, dental or nursing care, or in the event of apparent death, the facility will

    (A) make arrangements for emergency care or transfer to an appropriate place for treatment, such as a physician's office, clinic, or hospital;

    (B) immediately notify the resident's physician and next of kin, responsible party, or agency who placed the resident in the facility; and

    (C) describe and document the injury, accident, or illness on a separate report. The report must contain a statement of final disposition and be maintained on file.

  (2) The facility must stock and maintain in a single location first aid supplies to treat burns, cuts, and poisoning.

  (3) Residents who need the services of professional nursing or medical personnel due to a temporary illness or injury may have those services delivered by persons qualified to deliver the necessary service.

(c) Health Care Professional.

  (1) A health care professional may coordinate the provision of services to a resident within the professional's scope of practice and as authorized under Texas Health and Safety Code, Chapter 247, however, a facility must not provide ongoing services to a resident that are comparable to the services available in a nursing facility licensed under Texas Health and Safety Code, Chapter 242.

  (2) A resident may contract with a home and community support services agency licensed under Chapter 558 of this title, or with an independent health professional, to have health care services delivered to the resident at the facility.

(d) Activities program. The facility must provide an activity or social program at least weekly for the residents.

(e) Dietary services.

  (1) A person designated by the facility is responsible for the total food service of the facility.

  (2) At least three meals or their equivalent must be served daily, at regular times, with no more than a 16-hour span between a substantial evening meal and breakfast the following morning. All exceptions must be specifically approved by HHSC.

  (3) Menus must be planned one week in advance and must be followed. Variations from the posted menus must be documented. Menus must be prepared to provide a balanced and nutritious diet, such as that recommended by the National Food and Nutrition Board. Food must be palatable and varied. Records of menus as served must be filed and maintained for 30 days after the date of serving.

  (4) Therapeutic diets as ordered by the resident's physician must be provided according to the service plan. Therapeutic diets that cannot customarily be prepared by a layperson must be calculated by a qualified dietician. Therapeutic diets that can customarily be prepared by a person in a family setting may be served by the facility.

  (5) Supplies of staple foods for a minimum of a four-day period and perishable foods for a minimum of a one-day period must be maintained on the premises.

  (6) Food must be obtained from sources that comply with all laws relating to food and food labeling. If food subject to spoilage is removed from its original container, it must be kept sealed and labeled. Food subject to spoilage must also be dated.

  (7) Plastic containers with tight fitting lids are acceptable for storage of staple foods in the pantry.

  (8) Potentially hazardous food, such as meat and milk products, must be stored at 45 degrees Fahrenheit or below. Hot food must be kept at 140 degrees Fahrenheit or above during preparation and serving. Food that is reheated must be heated to a minimum of 165 degrees Fahrenheit.

  (9) Freezers must be kept at a temperature of 0 degrees Fahrenheit or below and refrigerators must be 41 degrees Fahrenheit or below. Thermometers must be placed in the warmest area of the refrigerator and freezer to assure proper temperature.

  (10) Food must be prepared and served with the least possible manual contact, with suitable utensils, and on surfaces that have been cleaned, rinsed, and sanitized before use to prevent cross-contamination.

  (11) Facilities must prepare food in accordance with established food preparation practices and safety techniques.

  (12) A food service employee, while infected with a communicable disease that can be transmitted by foods, or who is a carrier of organisms that cause such a disease or while afflicted with a boil, an infected wound, or an acute respiratory infection, must not work in the food service area in any capacity in which there is a likelihood of such person contaminating food or food-contact surfaces with pathogenic organisms or transmitting disease to other persons.

  (13) Effective hair restraints must be worn to prevent the contamination of food.

  (14) Tobacco products must not be used in the food preparation and service areas.

  (15) Kitchen employees must wash their hands before returning to work after using the lavatory.

  (16) Dishwashing chemicals used in the kitchen may be stored in plastic containers if they are the original containers in which the manufacturer packaged the chemicals.

  (17) Sanitary dishwashing procedures and techniques must be followed.

  (18) Facilities that house 17 or more residents must comply with 25 TAC Chapter 228 (relating to Retail Food) and local health ordinances or requirements must 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.

(f) Infection prevention and control.

  (1) Each facility must establish, implement, enforce, and maintain an infection prevention and control policy and procedure designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.

  (2) The facility must comply with rules regarding special waste in 25 TAC Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).

  (3) The facility must immediately report the name of any resident of a facility with a reportable disease as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases) to the city health officer, county health officer, or health unit director having jurisdiction, and implement appropriate infection control procedures as directed by the local health authority.

  (4) The facility must have, implement, enforce, and maintain written policies for the control of communicable disease among employees and residents, which must address tuberculosis (TB) screening and provision of a safe and sanitary environment for residents and employees.

    (A) If an employee contracts a communicable disease that is transmissible to residents through food handling or direct resident care, the facility must exclude the employee from providing these services for the applicable period of communicability.


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