Nursing Services Requirements for the State of Massachusetts

150.007 Nursing Services

(A) All facilities shall provide appropriate, adequate and sufficient nursing services to meet the needs of patients or residents and to assure that preventive measures, treatments, medications, diets, restorative services, activities and related services are carried out, recorded and reviewed

(1) Facilities that provide Level I, II or II care shall provide a 24-hour nursing service with an adequate number of trained and experienced nursing personnel on duty 24 hours per day, seven days a week, including vacation and other relief periods.

(2) Nursing services in facilities that provide Level I, II or III care shall be in accordance with written policies and procedures.

(3) Facilities that provide only Level IV care are not required to provide organized, routine nursing services. However, nursing services shall be provided as needed to residents in the case of minor illness of a temporary nature. Exception: Community Support Facilities and Resident Care Facilities with Community Support Residents shall provide organized, routine nursing services in order to monitor resident medications, potential medication side effects, and general resident physical and psychosocial well-being. Nursing services shall be provided at a minimum of at least 15 hours per 30 residents per month and more if needed, and shall be scheduled so as to assure at least one visit per week. Such services shall be equally distributed across the month.

(B) Minimum Nursing Personnel Requirements.

(1) General.

(a) Nursing personnel shall not service on active duty more than 12 hours per day, or more than 48 hours per week, on a regular basis.

(b) One director of nurses may cover multiple units of the same or different levels of care within a single facility. One supervisor of nurses may cover up to two units of the same or different levels of care within a single facility.

(c) Full-time shall mean 40 hours per week, five days per week.

(d) The amount of nursing care time per patient shall be exclusive of non-nursing duties.

(e) The minimum staffing patterns and nursing care hours as contained herein shall mean minimum, basic requirements. Additional staff will be necessary in many facilities to provide adequate services to meet patient needs.

(f) The supervisor of nurses and the charge nurse, but not the director of nurses, may be counted in the calculation of licensed nursing personnel.

(2) Facilities that provide Level I care shall provide:

(a) A full-time director of nurses during the day shift.

(b) A full-time supervisor of nurses during the day shift, five days a week for facilities with more than one unit. In facilities with a single unit, the director of nurses may function as supervisor.

(c) A charge nurse 24 hours per day, seven days a week for each unit.

(d) Sufficient ancillary nursing personnel to meet patient needs.

(e) As a basic minimum, facilities that provide Level I care shall provide a total 2.6 hours of nursing care per patient per day; at least 0.6 hours shall be provided by licensed nursing personnel and 2.0 hours by ancillary nursing personnel.

(3) Facilities that provide Level II care shall provide:

(a) A full-time director of nurses.

(b) A full-time supervisor of nurses during the day shift, five days a week for facilities with more than one unit. In facilities with only a single unit, the director of nurses may function as supervisor.

A SNCFC shall provide a full-time supervisor of nursing during the day and evening shifts seven days a week, who shall be a registered nurse and shall have had at least one year of nursing experience in pediatrics, preferably with the developmentally disabled population.

(c) A charge nurse 24 hours per day, seven days a week for each unit.

(d) Sufficient ancillary nursing personnel to meet patient needs.

(e) As a basic minimum, facilities that provide Level II care shall provide a total of 2.0 hours of nursing care per patient per day; at least 0.6 hours shall be provided by licensed nursing personnel and 1.4 hours by ancillary nursing personnel.

1. As a basic minimum, a SNCFC shall provide a total of 5.0 hours of nursing care per patient per day. In facilities housing 40 bed units, at least 1.4 to 1.8 hours shall be provided by licensed nursing personnel and the balance by ancillary nursing personnel. In facilities having less than 40 bed units at least 1.8 to 2.1 hours shall be provided by licensed nursing personnel and the balance by ancillary nursing personnel.

2. A SNCFC shall provide a staff nurse, 24 hours a day, seven days a week for each unit.

3. As a basic minimum an AIDSSNF shall provide 4.4 hours of nursing care per patient per day; at least 2.0 hours of this care must be provided by licensed personnel and 2.4 by ancillary personnel.

4. An AIDSSNF shall employ, at a minimum, one .5 FTE (20 hours per week) psychiatric nurse who shall be responsible for direct patient care as well as staff training. These hours are in addition to the 4.4 hours of direct nursing specified in 105 CMR 150.007(B)(3)(e)3.. The psychiatric nurse shall work closely with the social work and substance abuse counseling staff in developing and coordinating the mental health component of the resident's Individual Service Plan (ISP) as well as in developing programs for staff support.

(4) Facilities that provide Level III care shall provide:

(a) A full-time supervisor of nurses during the day shift, five days a week, in facilities with more than one unit.

(b) A charge nurse during the day and evening shifts, seven days a week, for each unit.

(c) A nurse's aide who is a responsible person, on duty during the night shift.

(d) Sufficient ancillary nursing personnel to meet patient needs.

(e) As a basic minimum, facilities that provide Level III care shall provide a total of 1.4 hours of nursing care per patient per day; at least 0.4 shall be provided by licensed nursing personnel and 1.0 hours by ancillary nursing personnel.

(f) The facility shall provide additional nursing services, sufficient to meet the needs, in the event a patient has a minor illness and is not transferred to a higher level facility or unit.

(5) Facilities that provide Level IV care shall provide:

(a) A responsible person on the premises at all times.

(b) In facilities with less than 20 beds, at least one "responsible person" on active duty during the waking hours in the ratio of one per ten residents.

(c) In facilities with more than 20 beds, at least one "responsible person:" on active duty at all times during the 24 hours of the day, seven days a week, per unit.

(d) If none of the responsible persons on duty are licensed nurses, then the facility shall provide a licensed consultant nurse, four hours per month per unit. (In multiple level facilities the director or supervisor of nurses may function in this capacity.)

(e) In all facilities with more than ten Community Support Residents, at least one responsible person awake and on duty at all times on the night shift.

(C) Qualifications and Duties.

(1) Director of Nurses: The Director of Nurses shall be a registered nurse with at least two years of nursing experience, at lest one of which has been in an administrative or supervisory capacity. The director of nurses shall be responsible for: development of the objectives and standards of nursing practice and procedures, overall management of nursing personnel, coordination of nursing services, development of staff training programs, and the evaluation and review of patient care and nursing care practices. In addition to the requirements above, the Director of Nursing of a free-standing SNCFC must have at least one year of nursing experience in pediatrics, preferably with the developmentally disabled population.

(2) Supervisor of Nurses: The supervisor of nurses shall be a registered nurse with at least two years of nursing experience, one of which has been in a charge nurse capacity. The supervisor of nurses shall be responsible for: the supervision of nursing care and nursing personnel, the supervision and evaluation of staff assignments and performance, the supervision of patient care, the application and evaluation of patient care plans and the integration of nursing care with other professional services. In cases where a supervisor of nursing is responsible for a SNCFC unit or units, that individual must have a minimum of one year training or experience in pediatrics, preferably with the developmentally disabled population.

(3) Charge Nurse: The charge nurse shall be a registered nurse or a licensed practical nurse; provided that, in a Level I or II unit, a practical nurse licensed by waiver may serve in such capacity only if she/he has received a passing grade either on the Massachusetts written state licensure examination given in the years 1958, 1959, 1960 by the Board of Registration in Nursing or on the federal Public Health Service Proficiency Examination for Practical Nurses Licensed by Waiver given periodically by the Department in accordance with federal regulations. The charge nurse shall be responsible for the performance of total nursing care of the patients in his/her unit during his/her tour of duty with the assistance of ancillary nursing personnel.

(a) In a SNCFC, the charge nurse shall be a registered nurse or a licensed practical nurse, preferably with training and/or experience in pediatric nursing.

(b) In a SNCFC, the staff nurse shall be a registered nurse or licensed practical nurse, preferably with training and/or experience in pediatric nursing.

(4) The Nurse's Aide or the Responsible Person on duty in facilities that provide Level III or IV care shall be readily accessible so that patients or residents can report injuries, symptoms, or emergencies. Such person shall be responsible for assuring that appropriate action is taken promptly, and facilities shall be responsible for establishing mechanisms and procedures for the nurse's aide or responsible person to obtain assistance in the case of an emergency.

(5) Licensed practical nurses, nurses' aides and orderlies shall be assigned duties consistent with their training and experience. A SNCFC or INCFC shall provide nurses' aides who have training or experience in caring for children. Assignments shall be made so that each patient is cared for by at least one aide who is assigned to care for him on a continuing basis.

(6) At no time shall direct patient care be provided by individuals under 16 years of age, housekeeping staff or kitchen workers.

(7) Nursing personnel shall not perform housekeeping, laundry, cooking or other such tasks normally performed by maintenance or other personnel.

(D) Nursing Care.

(1) Nursing care shall be an integral part of total health care and shall emphasize the promotion of health, the prevention and treatment of disease and disability, and the teaching counseling and emotional support of patients. Assignment of nursing staff within a SNCFC shall be made so that each patient is cared for by at least some nursing personnel who are assigned to care for him on a continuing basis.

(2) Nursing Care Plan: In facilities that provide Level I, II or III care, the nursing care shall include a comprehensive, nursing care plan for each patient developed by the nursing staff in relation to the patient's total health needs.

(a) The nursing care plan shall be an organized, written daily plan of care for each patient. It shall include: diagnoses, significant conditions or impairments, medication, treatments, special orders, diet, safety measure, mental condition, bathing and grooming schedules, activities of daily living, the kind and amount of assistance needed, long-term and short-term goals, planned patient teaching programs, encouragement of patient's interests and desirable activities. It shall indicate what nursing care is needed, how it can best be accomplished, and what methods and approaches are most successful. This information shall be summarized on a cardex and be available for use by all personnel involved in patient care.

In a SNCFC, the nursing care plan shall also include consideration of the patient's physical and mental status with respect to his need for recreational and educational stimulation and growth; consideration of the patient's familial situation, and of his behavior with other patients, staff, family and visitors. The nursing care plan shall be part of the patient's ISP.

(b) The nursing care plan shall be initiated on admission and shall be based on the physician's or physician-physician assistant team's or physician-nurse practitioner team's medical care plan and the nursing assessment of patient needs.

(c) The plan shall be the responsibility of the director or supervisor of nurses and shall be developed in conjunction with the nursing staff and representatives of other health disciplines where appropriate.

(d) All personnel who provide care to a patient shall have a thorough knowledge of the patient's condition and the nursing care plan.

(e) The plan shall specify priorities of nursing need, which shall be determined through communication with the patient, the physician or physician-physician assistant team or physician-nurse practitioner team, other staff and the family.

The plan shall reflect the patient's psycho-social needs and ethnic, religious, social, cultural or other preferences.

g) Nursing care plans shall be reviewed, revised and kept current so that patient care constantly meets patient needs. Plans shall show written evidence of review and revision at lest every 30 days in facilities that provide Level I or II care, and every 90 days in facilities that provide Level III care. Reviews of nursing care plans shall be performed in conjunction with reviews of other aspects of the patient's total health care.

(h) Relevant information from the nursing care plan shall be included with other health information when a patient is transferred or discharge.

(e) Restorative Nursing Care.

(1) All facilities that provide Level I, II or III care shall provide a program of restorative nursing care as an integral part of overall nursing care. Restorative nursing care shall be designed to assist each patient to achieve or maintain the highest possible degree of function, self-care and independence.

(2) Nursing personnel shall provide restorative nursing services in their daily care of patients.

(3) Restorative nursing services shall include such procedures as:

(a) Maintaining good body alignment, keeping range of motion of weak or paralyzed limbs, proper positioning and support with appropriate equipment -- particularly of bedfast or wheel chair patients.

(b) Encouraging and assisting bedfast patients to change positions at least every two hours during waking hours (7:00 A.M. to 10:00 P.M.) in order to stimulate circulation, and prevent decubiti and contractures.

(c) Maintaining a program of preventive skin care.

(d) Assisting patients to keep active and out of bed for reasonable periods of time except when contraindicated by physician's or physician-physician assistant team's or physician-nurse practitioner team's orders or the patient's condition.

(e) Maintaining a bowel and bladder training program.

(f) Assisting patients to adjust to any disabilities and to redirect their interests if necessary.

(g) Assisting patients to carry out prescribed physical therapy, occupational therapy and speech, hearing and language therapy exercises between visits by the therapist.

(h) Assisting patients to maintain or restore function and activity through proper general exercises and activities appropriate to their condition.

(i) Assisting and teaching the activities of daily living (such as feeding, dressing, grooming and toilet activities).

(j) Coordinating restorative nursing services with restorative services, activity programs and other patient care services.

(F) Dietary Supervision.

(1) Nursing personnel shall have knowledge of the dietary needs, food and fluid intake and special dietary restrictions of patients and shall see that patients are served diets as prescribed. Patients' acceptance of food shall be observed, and any significant deviation from normal food or fluid intake or refusal of food shall be reported to the nurse in charge and the food service supervisor or dietitian.

(2) Patients requiring assistance in eating shall receive adequate assistance. Help shall be assigned promptly upon receipt of meals, and adaptive self-help devices shall be provided when necessary.

(G) Nursing and Supportive Routines and Practices.

(1) All facilities shall provide sufficient nursing care and supportive care so that each patient or resident:

(a) Receives treatments, medications, diet and other services as prescribed and planned in his medical, nursing, restorative, dietary, social and other care plans.

(b) Receives proper care to prevent decubiti, contractures and immobility.

(c) Is kept comfortable, clean and well groomed.

(d) Is protected from accident and injury through safety plans and measures.

(e) Is treated with kindness and respect.

(2) No medication, treatment or therapeutic diet shall be administered to a patient or resident except on written or oral order of a physician or physician assistant or nurse practitioner.

(3) Nursing personnel and responsible persons shall constantly be alert to the condition and health needs of patients and residents and shall promptly report to the nurse or person in charge any untoward patient conditions or symptomatology such as dehydration, fever, drug reaction or unresponsiveness.

(4) Nursing personnel and responsible persons shall assist patients or residents to dress and prepare for appointments, medical or other examinations, diagnostic tests, special activities and other events outside the facility.

(5) The following personal care routines shall be provided by all facilities as a part of the patient's or resident's general care and well-being.

(a) A tub bath, shower, or full-bed bath as desired or required, but at least weekly. In a SNCFC or INCFC, a bath or shower daily.

(b) Bed linen changed as required, but at least weekly.

(c) Procedures to keep incontinent patients clean and dry.

(d) Frequent observation of bedfast patients for skin lesions and special care for all pressure areas.

(e) Daily ambulation or such movement as condition permits (as ordered by the physician or physician assistant or nurse practitioner).

(f) A range of recreational activities.

(g) Provision of daily shaving of men.

(h) Provision for haircuts for men at least monthly.

(i) Hair shampoos at least once every two weeks. In a SNCFC or INCFC, hair shampoos twice a week.

(j) Daily oral hygiene and dentures or teeth cleaned morning and night.

(k) Foot care sufficient to keep feet clean and nails trimmed.

(l) Appropriate, clean clothing that is properly mended, appropriate to the time of day and season, whether indoors or outdoors. No clothing of highly flammable fabrics shall be permitted.

(m) An attendant for walks and other such activities, when necessary, to safeguard ambulatory patients or residents.

(H) Nursing Review and Notes. Each patient's condition shall be reviewed with special notation of any untoward events, change in condition, nursing or other services provided and the patient's response or progress.

(1) In facilities that provide Level II care each patient shall be reviewed by the nursing personnel going off duty with the nursing personnel coming on duty at each change of shift. At minimum, a weekly progress note shall be recorded in each patient's record unless the patient's condition warrants more frequent notations; the weekly progress note documentation shall be performed by a licensed nurse.

(2) In facilities that provide Level III care, each resident's general condition shall be reviewed each morning. Significant changes of findings shall be noted in the clinical record and the attending physician or physician-physician assistant team or physician-nurse practitioner team notified with a written notation or the time and date of notification. A note summarizing the resident's condition shall be written monthly in the clinical record.

(I) Educational Programs. Facilities that provide Level I, II or III care shall provide a continuing inservice educational program appropriate to the level of care provided in the facility for all nursing personnel. Such a program shall be in addition to a thorough job orientation for new personnel.