APPENDIX

ADDITIONAL MATERIAL FROM WITNESSES

ITEM 1: SUBMITTED BY PAUL DE PREAUX,1 PRESIDENT, CONNECTICUT ASSOCIATION OF NONPROFIT HOMES AND HOSPITALS FOR THE

AGED

EXHIBIT A. PUBLIC HEALTH CODE OF CONNECTICUT: REGULATIONS GOVERNING THE OPERATION AND MAINTENANCE OF CHRONIC AND CONVALESCENT NURSING HOMES

All institutions licensed under Section 19-32 to 19-42 of the General Statutes, as amended, must comply with the requirements set forth in these regulations before a license is issued.

Section 19-13-D 8-Chronic and Convalescent Nursing Homes-is repealed and the following substituted in lieu thereof:

(a) Physical Plant

(1) The building shall be of sound construction and shall be designed so as to provide a pleasant atmosphere and comfort for all patients. Minimum services required shall include business and administration offices, patient rooms, nurses' station, service areas, dietary facilities, sitting and dining areas, recreation areas, adequate storage, laundry, employees' facilities, physical therapy unit and examining room. Each patient room shall be numbered; the number, together with the licensed capacity of each room shall be posted at each door. The census shall not exceed the number for which the license is issued, nor shall the number of patients in any room exceed the licensed capacity of that room.

Each nursing unit of thirty beds shall have a nurses' station of at least one hundred square feet of floor space. A central nursing station may serve two thirty bed units, but shall have one hundred fifty square feet of floor space and a separate clean utility room. A central nursing station shall not serve more than sixty beds.

(2) The site shall be away from nuisances detrimental to the facility, such as industrial development, or other types of business that produce noise, polluted air or foreign odors. Roads and walks shall be provided within the lot lines to the main entrance and for service, including loading and unloading space for delivery trucks. Adequate off-street parking shall be provided. There should be one visitor parking space for every three patients and three employee parking spaces for every four employees on the 7:00 a.m. to 3:00 p.m. shift.

(3) The building, equipment and precautions taken to provide for the safety of patients and employees shall be approved by the state department of health. Exit facilities shall comply with the requirements for exit facilities in the state fire safety code. Minimum width of doors to all rooms needing access for beds or stretchers shall be three feet eight inches. Doors to patient toilet rooms and other rooms needing access for wheelchairs shall have a minimum width of three feet. An annual certificate from the local fire marshal that precautionary measures meet his approval shall be submitted with the annual application for license. (4) The heating system shall be adequate to provide a minimum temperature of seventy-five Fahrenheit degrees at all times.

1 See statement, p. 31.

(115)

(5) Emergency electrical service shall be provided to circuits as follows: (a) Lighting:

1. Exitways and all necessary ways of approach thereto including exit signs and exit direction signs, exterior of exits, exit doorways, stairways, and corridors.

2. Dining and recreation rooms.

3. Nursing station and medication preparation area.

4. Generator set location, switch-gear location and boiler room.

5. Elevator (if required for emergency).

(b) Facilities essential to life safety and for protection of important equipment or vital materials:

1. Nurses' calling system.

2. Alarm system including fire alarm actuated at manual stations, water flow alarm devices of sprinkler systems if electrically operated, fire detecting and smoke detecting systems, paging or speaker systems if intended for issuing instructions during emergency conditions, and alarms required for nonflammable medical gas systems, if installed.

3. Fire pump, if installed.

4. Sewerage or sump lift pump, if installed.

5. All required duplex receptacles in patient corridors.

6. One elevator, where elevators are used for vertical transportation of patients.

7. Equipment such as burners and pumps necessary for operation of one or more boilers and their necessary auxiliaries and controls, required for heating and sterilization.

8. Equipment necessary for maintaining telephone service.

(c) Where electricity is the only source of power normally used for space heating, the emergency service shall provide for heating of patient rooms. Emergency heating of patient rooms shall not be required in areas where:

1. The design temperature is higher than twenty degrees Fahrenheit, based on the Median of Extremes as shown in the current edition of the ASHRAE Handbook of Fundamentals, or

2. The nursing home is supplied by at least two utility service feeders, each supplied by separate generating sources, or a network distribution system fed by two or more generators, with the hospital feeders so routed, connected and protected that a fault any place between the generators and the hospital is not likely to cause an interruption of more than one of the hospital service feeders.

(6) A complete electrical system shall be installed to provide an adequate electrical service to the facility. All materials and equipment shall comply with applicable standards of Underwriters Laboratories, Inc., or other similarly established standards.

(7) All chronic and convalescent nursing homes where either patient beds or inpatient facilities, such as diagnostic, recreation, patient dining or therapy rooms, are located on other than the first floor, shall have electric or electri-hydraulic elevators. Elevators shall have automatic leveling of the two-way automatic type with accuracy within plus or minus one-half inch.

(8) Temperature of hot water at plumbing fixtures used by patients and employees shall not exceed 110 degrees F.

(9) The building, equipment and site shall be maintained in a good state of repair and shall be kept clean at all times.

(b) Administration

(1) The proprietor or administrator of the institution shall be responsible for operation of the institution in compliance with these regulations.

(2) The proprietor or administrator of the institution shall be responsible for submitting to the state department of health the annual application for license and such reports as may be required.

(3) The proprietor or administrator of the institution shall be responsible for the appointment of a qualified medical director, and a competent director of nursing as provided in these regulations.

(4) The proprietor, corporation or administrator shall furnish with his initial application, three references to assist the state department of health in evaluating his suitability to operate a chronic and convalescent institution, as follows: One from a physician licensed to practice medicine or surgery or from a registered nurse indicating his professional qualifications or degree of experience in

the care of chronic and convalescent patients, one from a bank or fiinancial institution and a character reference from a suitable and unrelated person. The sponsor shall submit to the state department of health an audited statement of assets and liabilities and evidence of operating capital sufficient for the size of the proposed institution based on criteria approved by an independent, reputable lending insurance and/or auditing firm.

(5) Sufficient capable personnel of good character and suitable temperament shall be employed in sufficient numbers to provide satisfactory care for the patients. They shall be competent in their respective work areas and shall be instructed regarding their share of the responsibility for caring for patients and in evacuation procedures in cases of emergencies including those required in section 29-40-199 of the state fire safety code.

(6) The proprietor or administrator shall furnish, with his initial and each subsequent annual application, a certificate of physical and mental health signed by a physician.

(7) The management, personnel, equipment, facilities, sanitation and maintenance of the home shall be such as reasonably to ensure the health, comfort and safety of residents at all times.

(8) In institutions of sixty beds or more the administrator shall be fulltime and for only one institution, and shall not serve as director of nurses.

(9) On or after January 1, 1970, all administrators shall satisfactorily complete at least a one-week course of instruction approved by the commissioner of health of at least thirty hours of classroom time or its equivalent in nursing home administration.

(10) Effective January 1, 1970, nursing home administrators shall show evidence of at least two years' experience in a responsible administrative position in a health care institution or equivalent administrative experience acceptable to the state department of health.

(11) Authority and responsibility of the administrator for the internal operation of the nursing home shall be stated in writing by the governing body. (c) Medical Supervision

(1) There shall be a medical director licensed to practice medicine and surgery in Connecticut, who will be available, if emergency should require, for service in the institution and who shall be responsible for the adequacy of medical and nursing care rendered and special diets served patients in the institution. The medical director shall be a member of the medical staff of a general hospital licensed in Connecticut.

(2) All patients admitted, who are not accompanied by a record of physical findings and diagnosis and signed doctor's orders for treatment, diet and activity shall be seen by their personal physician, or by the medical director within twenty-four hours of admission and medical history, physical findings, laboratory findings and signed medical orders shall be recorded and each twelve months thereafter a thorough medical examination shall be made and recorded.

(3) No medications or treatments shall be given without doctor's orders. If orders are given by telephone, they shall be recorded by the licensed nurse on duty with the doctor's name and shall be signed by the doctor on his next visit.

(4) If a nursing home is engaged solely in administering treatment in accordance with any one of the healing arts only, there shall be a duly licensed resident practitioner or consulting practitioner of that healing art available as above.

(5) The medical director shall visit the nursing home at least once each month and shall indicate, in a statement over his signature, conditions existing in the institution relative to the adequacy of nursing care and diets furnished to the patients.

(6) The medical director shall receive reports from the director of nurses on significant clinical developments that might require medical attention.

(7) If the patient has a personal physician, that physician shall be summoned in instances where a clinical development might require medical attention. If the personal physician does not respond promptly, the director of nurses shall notify the medical director who shall examine the patient in a manner adequate to the clinical problems present and order necessary care. An adequate progress note shall be entered into the patient's chart at that time.

(8) Each patient shall be seen by a physician at least once each month. (9) A record shall be kept by the nursing home of the medical director's visits and statements for review by the state department of health.

(d) Medical Records

(1) A medical record including a patient care plan shall be started for each patient immediately upon admission with complete identification data and the licensed nurse's note of the patient's condition on admission. To this shall be added any records, reports or orders which accompanied the patient. A nurse's progress note shall be recorded at least once a month.

(2) Within twenty-four hours of admission a physician shall examine the patient and initiate a record of the patient's medical history, physical and laboratory findings, diagnosis and orders and sign his name, provided this shall not be required if current reports and orders, signed by a physician, accompanied the patient.

(3) The medical record shall note all medications and treatments each time they are given and signed by the licensed nurse who gives them. Nurses' notes shall also report any accidents, changes in patient's condition or other unusual

Occurrences.

(4) A careful and accurate record shall be kept of all narcotics and sedative drugs in accordance with the requirements of the state department of health, which shall include as a minimum an audit every eight hours at change of shifts. (5) A roster shall be maintained of all patients admitted and discharged on forms prescribed by the state department of health. A copy of the roster, together with the annual census report, shall be submitted to the state department of health not later than January thirty-first each year.

(6) All medical records shall be prepared, maintained and filed in a manner approved by the state department of health. They shall be kept for a minimum of ten years after discharge of patients.

(7) Physicians' progress notes shall be written at the time of each visit describing significant observations and changes in the patient's condition so that, if another physician is called to see the patient in an emergency, he will have an adequate understanding of the patient's underlying medical condition.

(8) Narcotic records shall be kept at least three years by the nursing home. (9) The type of medical records used by the nursing home shall be subject to the approval of the commissioner of health.

(e) Nursing Service

(1) There shall be a competent director of nurses who shall be responsible for the nursing care of patients, for adequate staffing of the nursing service of the institution, proper care of drugs, proper maintenance of medical records, and proper dietary procedures. If the director of nurses is responsible for administrative duties outside the nursing service, an assistant shall be provided.

(2) For an institution of thirty beds or over, the director of nurses shall be a nurse registered in Connecticut. For an institution of under thirty beds, the director of nurses may be a practical nurse licensed in Connecticut. A nurse-incharge appropriately registered or licensed, shall be provided seven days a week. (3) There shall be at least one nurse registered in Connecticut or one practical nurse licensed in Connecticut on duty, in uniform, at all times. Additional registered nurses or licensed practical nurses shall be provided as necessary; at no time shall there be less than one registered nurse or licensed practical nurse for every thirty patients or fraction thereof from 7 a.m. to 3 p.m.; and one registered nurse or licensed practical nurse for every forty-five patients or fraction thereof from 3 p.m. to 11 p.m. and one registered nurse or licensed practical nurse for every sixty patients or fraction thereof from 11 p.m. to 7 a.m.

(4) The director of nurses shall be on duty in uniform and cover the day shift.

(5) The charge nurse shall approve all menus for regular meals and for special diets.

(6) Nursing care plans shall be prepared on all patients in a manner approved by the commissioner of health.

(7) There shall be additional nursing attendants or aides on duty sufficient to provide not less than one nurse or attendant for each ten patients or fraction thereof on the day shift and one nurse or attendant for each fifteen patients or fraction thereof on the evening shift, and one nurse or attendant for each twenty patients or fraction thereof on the night shift. The calculation of this ratio shall not include the director of nurses on the 7 a.m. to 3 p.m. shift in a nursing home of 61 beds or more and charge nurse or supervisor on the 3 p.m. to 11 p.m. shift in a nursing home of 121 beds or more.

(8) In multiple story buildings, nurse and attendants shall be on duty on each patient-occupied floor at all times.

(9) All medications shall be given by a nurse registered in Connecticut or by a practical nurse licensed in Connecticut.*

(f) Dietary Service

(1) Adequate space, equipment and qualified personnel shall be provided to ensure proper selection, storage, preparation and serving of regular and special diets to patients at regularly scheduled hours.

(2) Menus shall be prepared and posted and filed and shall meet state department of health requirements for basic nutritional needs.

(3) The time scheduling of regular meals and snacks shall be approved by the commissioner of health with not more than fourteen hours between supper and breakfast.

(4) Methods of dishwashing and dish sanitizing, food handling and garbage disposal shall comply with section 19-13 B 42 of the Public Health Code.

(g) General Conditions

(1) Patients shall be admitted only on referral from a responsible source. No patients may be admitted on an emergency basis except in the event of a major disaster, in which case the state department of health shall be notified at the earliest possible time.

(2) Provisions for visiting hours shall be as liberal as may be consistent with good patient care. Personnel shall be instructed to treat both patients and their visitors with courtesy and consideration at all times.

(3) Any accident, disaster or other unusual occurrence in the institution shall be reported within seventy-two hours to the state department of health.

(4) Proper heat, hot water, lighting and ventilation shall be maintained at

all times.

(5) There shall be a system of communication sufficient to meet the needs of the institution and the requirements of the state department of health.

(6) Adequate housekeeping, laundry and maintenance services shall be provided.

(7) Licenses are not transferable and are in effect only for the operation of the institution as it is organized at the time the license is issued. The state department of health shall be immediately notified if the licensee plans any structural changes, plans to sell the institution or plans to discontinue operation. (8) When an institution changes ownership, the new licensee shall not only comply with all requirements of these regulations but shall, in addition, comply with the requirements of new structures insofar as existing structural and mechanical systems will permit.

(9) Institutions caring for more than four persons shall comply with the state fire safety code (see reg. 29-40-1 et seq.).

(10) The site of new institutions shall be approved by the state department of health.

(11) Private water supplies and/or sewerage shall be installed in accordance with the public health code and with written approval by the local director of health.

(12) All plans and specifications for new construction or alterations shall be submitted to the state department of health, the local fire marshal, the local building inspector, if any, and the local zoning authorities for approval before construction is undertaken.

(13) No person shall be admitted to or housed in the institution if such person is not under the direct supervision of the licensee.

(14) There shall be a day space or recreation area on each floor of the institution adequately equipped for the purposes intended.

(15) Effective July 1, 1969, no chronic and convalescent nursing home shall be constructed without a certificate of need issued by the state department of health to the sponsor which certificate shall be issued in accord with the Connecticut construction plan for hospitals and medical facilities as prepared by the state's Hill-Burton authority.

(16) All licensed nursing homes shall carry an adequate amount of malpractice and public liability insurance.

(h) Special Conditions

(1) Children under fourteen years of age shall not be admitted unless a separate unit with special staff and children's facilities is maintained for the care

* Reference to eight hour periods of nursing service as beginning at 7 a.m., 3 p.m., and 11 p.m. is not mandatory; the eight hour periods may begin, for example, at 8 a.m., 4 p.m., and 12 midnight at the discretion of the proprietor or administrator with the approval of the state department of health.