Nursing Services Requirements for the State of Illinois

Section 300.1210 General Requirements for Nursing and Personal Care

a) The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident, in accordance with each resident's comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.

Restorative measures shall include at a minimum the following procedures:

1) The licensed nurse in charge of the restorative/rehabilitative nursing program shall have successfully completed a course or other training program that includes at least 60 hours of classroom/lab training in restorative/rehabilitative nursing as evidenced by a transcript, certificate, diploma, or other written documentation from an accredited school or recognized accrediting agency such as a State or National organization of nurses or a State licensing authority. Such training shall address each of the measures outlined in subsections (a)(2)-(5) of this Section. This person may be the Director of Nursing, Assistant Director of Nursing or another nurse designated by the Director of Nursing to be in charge of the restorative/rehabilitative nursing program.

2) All nursing personnel shall assist and encourage residents so that a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable. All nursing personnel shall assist and encourage residents so that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

3) All nursing personnel shall assist and encourage residents so that a resident who is incontinent of bowel and/or bladder receives the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. All nursing personnel shall assist residents so that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary.

4) All nursing personnel shall assist and encourage residents so that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's abilities to bathe, dress, and groom; transfer and ambulate; toilet; eat; and use speech, language, or other functional communication systems. A resident who is unable to carry out activities of daily living shall receive the services necessary to maintain good nutrition, grooming, and personal hygiene.

5) All nursing personnel shall assist and encourage residents with ambulation and safe transfer activities as often as necessary in an effort to help them retain or maintain their highest practicable level of functioning.

b) General nursing care shall include at a minimum the following and shall be practiced on a 24-hour, seven day a week basis:

1) Medications including oral, rectal, hypodermic, intravenous and intramuscular shall be properly administered.

2) All treatments and procedures shall be administered as ordered by the physician.

3) Objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the resident's medical record.

4) Personal care shall be provided on a 24-hour, seven day a week basis. This shall include, but not be limited to, the following:

A) Each resident shall have proper daily personal attention, including skin, nails, hair, and oral hygiene, in addition to treatment ordered by the physician.

B) Each resident shall have at least one complete bath and hair wash weekly and as many additional baths and hair washes as necessary for satisfactory personal hygiene.

C) Each resident shall have clean suitable clothing in order to be comfortable, sanitary, free of odors, and decent in appearance. Unless otherwise indicated by his/her physician, this should be street clothes and shoes.

D) Each resident shall have clean bed linens at least once weekly and more often if necessary.

5) A regular program to prevent and treat pressure sores, heat rashes or other skin breakdown shall be practiced on a 24 hour, seven day a week basis so that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that the pressure sores were unavoidable. A resident having pressure sores shall receive treatment and services to promote healing, prevent infection, and prevent new pressure sores from developing.

6) All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.

(Source: Amended at 23 Ill. Reg. 8106, effective July 15, 1999)

Section 300.1220 Supervision of Nursing Services

a) Each facility shall have a director of nursing services (DON) who shall be a registered nurse.

1) This person shall have knowledge and training in nursing service administration and restorative/rehabilitative nursing. This person shall also have some knowledge and training in the care of the type of residents the facility cares for (e.g., geriatric or psychiatric residents). This does not mean that the director of nursing must have completed a specific course or a specific number of hours of training in restorative/rehabilitative nursing unless this person is in charge of the restorative/rehabilitative nursing program. (See Section 300.1210(a).)

2) This person shall be a full-time employee who is on duty a minimum of 36 hours, four days per week. At least 50 percent of this person's hours shall be regularly scheduled between 7 A.M. and 7 P.M.

A) A facility may, with written approval from the Department, have two registered nurses share the duties of this position if the facility is unable to obtain a full-time person. Such an arrangement will be approved only through written documentation that the facility was unable to obtain the full-time services of a qualified individual to fill this position. Such documentation shall include, but not be limited to: an advertisement that has appeared in a newspaper of general circulation in the area for at least three weeks; the names, addresses and phone numbers of all persons who applied for the position and the reasons why they were not acceptable or would not work full time; and information about the numbers and availability of licensed nurses in the area. The Department will grant approval only when such documentation indicates that there were no qualified applicants who were willing to accept the job on a full-time basis, and the pool of nurses available in the area cannot be expected to produce, in the near future, a qualified person who is willing to work full time.

B) In facilities with a capacity of fewer than 50 beds, this person may also provide direct patient care, and this person's time may be included in meeting the staff-to-resident ratio requirements.

3) In skilled nursing facilities of l00 or more occupied beds, there shall be an assistant director of nursing (ADON) who is a registered nurse. This person shall also meet the qualifications specified in subsection (a)(1) of this Section for the director of nursing service.

4) In intermediate care facilities of 150 or more occupied beds, a licensed nurse shall be designated as the ADON. The assistant may provide direct patient care and be included in staff-to-resident ratio calculations.

5) The assistant shall be a full-time employee who is on duty a minimum of 36 hours, four days per week. The assistant may be assigned to work hours any time of the day or night.

6) The assistant shall assist the DON in carrying out his/her responsibilities.

7) If other duties interfere with the proper performance of the DON's or ADON's duties, another nurse shall be assigned to perform the duties of the DON or assistant for that period of time.

b) The DON shall supervise and oversee the nursing services of the facility, including:

1) Assigning and directing the activities of nursing service personnel.

2) Overseeing the comprehensive assessment of the residents' needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.

3) Developing an up-to-date resident care plan for each resident based on the resident's comprehensive assessment, individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. Personnel, representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician, shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident's condition. The plan shall be reviewed at least every three months.

4) Recommending to the administrator the number and levels of nursing personnel to be employed, participating in their recruitment and selection and recommending termination of employment when necessary.

5) Participating in planning and budgeting for nursing services, including purchasing necessary equipment and supplies.

6) Developing and maintaining nursing service objectives, standards of nursing practice, written policies and procedures, and written job descriptions for each level of nursing personnel.

7) Coordinating the care and services provided to residents in the nursing facility.

8) Supervising and overseeing in-service education, embracing orientation, skill training, and on-going education for all personnel and covering all aspects of resident care and programming. The educational program shall include training and practice in activities and restorative/rehabilitative nursing techniques through out-of-facility or in-facility training programs. This person may conduct these programs personally or see that they are carried out.

9) Participating in the development and implementation of resident care policies and bringing resident care problems, requiring changes in policy, to the attention of the facility's policy development group. (See Section 300.610(a).)

10) Participating in the screening of prospective residents and their placement in terms of services they need and nursing competencies available.

(Source: Amended at 26 Ill. Reg. 10523, effective July 1, 2002)

Section 300.1230 Staffing

a) Staffing shall be based on the needs of the residents, and shall be determined by figuring the number of hours of nursing time each resident needs on each shift of the day. This determination shall be made separately for both licensed and nonlicensed nursing personnel. (A, B)

b) In a facility whose residents participate in regularly scheduled therapeutic programs outside the facility, such as school or sheltered workshops, the minimum hours per day of nursing care are reduced proportionately. Exceptions to the shift distribution will be allowed if more than 50% of the residents are regularly scheduled to be out of the facility, but the total required hours must be provided daily. For example: an ICF resident requires 1.75 hours of care per day, but attends a workshop for six hours five days a week. The resident's required minimum hours of care is reduced by 25% in calculating staffing hours required on week days.

c) It is the responsibility of each facility to determine the staffing needed to meet the needs of its residents.

d) In determining the level of care a resident needs, the patient evaluation system in Medical Review/Utilization Review program may be used. The facility may use other methods of determining skilled and intermediate level residents, but must make the method of determination used available to the Department. Residents whose care is reimbursed by the State shall be at the level determined by the Medical Review/Utilization Review patient evaluation system.

e) The designations used for shifts in the following tables are used for illustrative purposes only, and are not meant to imply that other shift designations cannot be used by the facility.

f) The following figures apply to numbers of persons actually on duty and not to numbers of persons scheduled to be on duty.

g) The director of nursing's time shall not be included in staffing ratios.

h) Level of Care Determinations

1) The following figures are also considered to be minimum requirements, and each facility, except those of 250 or more occupied beds, shall provide at least the amount of staffing indicated. However, it is recognized that there may be occasional differences of opinion between facility staff and Department surveyors regarding the level of care an individual resident may require. When such differences occur, the surveyor shall determine whether or not the resident is receiving appropriate care. If the resident is, the surveyor shall accept the facility's level of care determination in determining the number of nursing hours to be provided by the facility.

2) Facilities of more than 250 occupied beds must meet the staff-resident ratio for the 250 residents needing the highest level of care. Additional staff shall be provided to meet resident needs as determined by the facility and verified by the Department. The Department may, based upon the Department's Patient Care Evaluation System review of resident care, require the facility to provide additional nursing hours to meet resident needs.

i)In computing the number of persons needed in the following examples, any figure less than .25 will be dropped from the computation and any figure of .75 or higher will go to

the next higher number. Figures in between .25 and .75 will require at least the amount of coverage indicated: for example, .25 will require two hours of coverage; .3 will require two hours of coverage; .5 will require four hours of coverage; .6 will require five hours of coverage; .74 will require six hours of coverage; etc. .75 or higher will require eight hours of coverage.

j)These additional hours may be provided by: a part-time person working those hours only on that shift each day; a full-time person working a shift that spans two regular shifts - for example from noon to 8 P.M.; or by an additional full-time person on the shift. However, these figures are minimal staffing requirements, and it is recommended that a full-time person be provided.

k) The facility shall schedule nursing personnel in such a manner that the needs of all residents are met. At least 40% of the minimum required hours shall be on the day shift, at least 25% of the minimum required hours shall be on the evening shift, and at least l5% of the minimum required hours shall be on the night shift.

l) Skilled Nursing Care

Residents needing skilled nursing care may only be cared for in facilities licensed as Skilled Nursing Facilities. Each resident needing skilled care shall be provided at least 2.5 hours of nursing-personal care each day, of which 20% must be licensed nurse time. (A, B)

m) Intermediate Nursing Care – General

Residents needing intermediate care may be cared for in facilities licensed as either Skilled Nursing Facility or Intermediate Care Facility. Each resident needing intermediate care shall be provided at least 1.7 hours of nursing/personal care each day, of which at least 20% must be licensed nurse time. (A, B)

n) Intermediate Nursing Care – Light

A Long-term care resident needing light intermediate care is one who needs personal care as defined in Section 1-120 of the Act; is mobile; requires some nursing services; needs a program of social services and activities directed toward independence in daily living skills; and needs daily monitoring. Each resident needing light intermediate care shall be provided with at least one hour of nursing/personal care each day, of which at least 20% must be licensed nurse time. (A, B)

o) In order to determine the numbers of nursing personnel needed to staff any facility, the following procedures shall be used:

1) The facility shall determine the number of residents needing skilled, general`fc intermediate, and light intermediate or sheltered care.

2) The number of residents in each of the three categories shall be multiplied by the overall hours of coverage needed each day for each category.

3) Adding the hours of care needed for the residents in each of the three categories will give the total hours of care needed by all residents in the facility.

4) Multiplying the total hours needed each day by the percentages assigned to each shift will give the total minimum hours of care that must be provided on that shift. (Remember that the percentages assigned to each shift must total 100% each day.)

5) Multiplying the total minimum hours of care needed on each shift by 20% will give the minimum amount of licensed nurse time that must be provided during a 24-hour period.

6) The remaining 80% of the minimum required nursing hours of care can be fulfilled by either nursing assistants or licensed nursing personnel as long as it can be documented that they provide restorative/rehabilitative nursing measures, general nursing care, and personal care as defined in Section 300.1210.

7) The amount of time determined in subsection (5) and (6) is expressed in hours. Dividing the total number of hours needed by the number of hours each person works per shift (usually seven and one half or eight hours) will give the number of persons needed to staff each shift.

p) Example of Staffing Calculations

1) Following is an example of this computation assuming a l00 bed Skilled Nursing Facility which has 25 skilled, 50 general intermediate and 25 light intermediate residents, assigning 45% to day shift; 35% to evening shift and 20% to the night shift.

2) Staffing would be computed as follows:

A) Total Minimum Hours of Care Needed

B) Minimum Total Hours Needed Per Shift

Section 300.1240 Additional Requirements

In addition to the staffing requirements, in Section 300.1230, the following staffing requirements also apply to all Skilled Nursing Facilities and Intermediate Care Facilities:

a) There shall be a licensed nurse designated as being in charge of nursing services on all shifts when neither the director of nursing or assistant director of nursing are on duty. If registered nurses and licensed practical nurses are on duty on the same shift, this person shall be a registered nurse. This person may be a charge nurse on one of the nursing units. (A, B)

b) There shall be at least one person awake, dressed and on duty at all times in each separate nursing unit. (A, B)

c) There shall be at least one registered nurse on duty seven days per week, 8 consecutive hours, in a skilled nursing facility. (A, B)

d) There shall be at least one registered nurse or licensed practical nurse on duty at all times in an intermediate care facility or a skilled nursing facility. (A, B)

e) There shall be at least one registered nurse or licensed practical nurse on duty on each floor housing residents in a skilled nursing facility. (A, B)

f) The need for licensed nurses on each nursing unit in a skilled nursing facility and each floor or nursing unit in an intermediate care facility will be determined on an individual case basis, dependent upon the individual situation. If such additional staffing is required, the Department will inform the facility in writing of the kind and amount of additional staff time required, and the reason why it is needed.

g) The need for an additional licensed nurse to serve as a "house supervisor" will be determined on an individual case basis. If the Department determines that there is a need for a registered nurse in a skilled nursing facility or a licensed practical nurse in an intermediate care facility on certain shifts whose sole duties will consist of supervising the nursing services of the facility, the Department shall notify the facility in writing when and why such a person is needed. This person shall not perform the duties of a charge nurse while serving as the "house supervisor".

(Source: Amended at 16 Ill. Reg. 17089, effective November 3, 1992)