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Quality of Care

Description of Federal Requirements
Comparison of State Requirements
Table Comparing States
Complete Transcript of State Requirements on Quality of Care (PDF)

Federal Regulations & Related F-tags for 483.25 Applicable Federal Regulation
(a) Activities of daily living | F310-F312
(b) Vision and hearing | F313
(c) Pressure Sores | F314
(d) Urinary Incontinence | F389
(e)Range of Motion | F317-F318
(f) Mental and Psychosocial functioning | F319-F320
(g) Naso-gastric tubes | F321-F322
(h) Accidents | F323-F324
(i) Nutrition | F325-326
(j) Hydration | F327
(k) Special Needs | F328
(l) Unnecessary drugs | F29-F331
(m) Medication errors | F332-F333
(n) Influenza & pneumococcal vaccine | F334
  • 483.25 Quality of Care
  • 483.20 Resident Asessment
  •  

    Description of Federal Requirements    (TOP)    (NEXT)

    Under 483.25each resident must receive and the facility must provide “the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the resident’s comprehensive assessment and plan of care.”

    Among the specific components, the facility shall ensure

    (a) that the resident's ability to perform activities of daily living do not diminish, unless unavoidable, and those who cannot carry out those activities receive necessary services to maintain good nutrition, grooming, and personal oral hygiene; 

    (b) residents receive proper treatment and assistive devices to maintain vision and hearing, and assistance with necessary appointments and transportation to see specialists in these fields;

    (c) that a resident who is admitted without pressure sores does not develop them unless it is unavoidable, and a resident with pressure sores receives the necessary treatment to promote healing, prevent infections, and new sores;

    (d) that a resident admitted without a urinary catheter not receive one unless it is unavoidable, and that residents who are incontinent of bladder receive services to prevent urinary infections and restore as much bladder function as possible;

    (e) that residents who are admitted without limited range of motion do not experience reductions in range of motion unless unavoidable, and that resident with a limited range of motion receive treatment to increase those abilities and prevent further deterioration;

    (f) that residents who displays mental or psychosocial adjustment difficulties receive appropriate treatment to correct the assessed problem, and that a resident whose initial assessment did not reveal such a problem does not show decreased social interaction or increased withdrawn, angry, or depressive behaviors, unless such deterioration was deemed unavoidable because of the clinical condition;

    (g) that a resident admitted without a nasogastric feeding tube not be fed through such a tube, unless deemed necessary, and that a resident with a feeding tube receive appropriate treatment and services to prevent aspiration pneumonia, vomiting, dehydration, metabolic disorders, and nasal-pharyngeal ulcers, and that afford be mode to restore normal feeding skills;

    (h) that the environment be as free of hazards as possible, and each resident receives supervision and assistive devices so as to prevent accidents;

    (i) that the resident maintain acceptable parameters of nutrition status such as body weight and protein levels, unless his or her physical condition makes that impossible, and that the resident receives a therapeutic diet when it is indicated; and

    (j) that the resident receive sufficient fluids to maintain hydration and health.  Each of these regulations follows a similar pattern: first, stating that if the resident is admitted without a particular problem, he or she should not develop it unless the clinical condition makes it unavoidable; but that if the resident has or develops the problem, the treatment should prevent complications and attempt to restore the original function.

    (k) receive proper treatment for special needs and services, which include: injections; parenteral and enteral fluids; colostomy, ureterostomy, or ileostomy care; tracheostomy care; tracheal suctioning; respiratory care; foot care; and prostheses. 

    (l), the resident should be free of unnecessary drugs, defined as excessive doses, excessive duration, drugs not indicated, or drugs with adverse consequences.  If residents are admitted without antipsychotic drugs, they should not be started unless necessary to treat a specific condition, and residents who receive antipsychotic drugs should receive gradual reductions and behavioral therapy in an effort to discontinue those drugs. 

    (m), the facility must ensure that the resident be free of medication errors, and that the medication error rate in the facility be 5% or less.  Under (m), the facility is responsible for offering each resident an influenza vaccine during flu season and the pneumococcal vaccine, educating them as to their benefits, and documenting any refusal to be vaccinated.

    The regulation on Resident Assessment, 483.20, is related to the Quality of Care regulation in that many of the expectations in the latter are reinforced by the areas for assessment and planning contained within the Resident Assessment rule.

    Comparison of State Requirements    (TOP)    (NEXT)

    NOTE:  The examples below may not list all States with similar language; always check your state for specifics

    The Federal regulations on quality of care are extremely detailed, and cover a diverse array of topics; moreover, these topics overlap with State detail related to other Federal regulations such as Pharmacy Services (related to psychoactive drugs and unnecessary medications), Nursing Services (related to ADL care, hygiene, rehabilitative nursing, and prevention and treatment of decubitus ulcers and contractures, among other things), Dietary Services (related to nutrition, hydration, special menus, and feeding tubes), Special Rehabilitation Services (related to range of motion and maximizing function).  They even overlap somewhat with State regulations on Resident’s Rights and on Resident Behavior and Facility Practices (i.e. physical and pharmacological restraints)   

     As always, all nursing homes must meet federal requirements for quality of care, even if they do not reiterate them in State regulations.  However, many States repeat the entire federal quality of care regulation as part of their own State regulations, sometimes with minimal additions to one section or another.   

     A search of the regulations of various States yields additional content related to many   subparts of the Federal quality of care regulation.  Sometimes the additions are terse, say, a statement of frequency for bathing or for turning residents, and sometimes the additions are detailed, say, an entire protocol for preventing and treating bedsores.  Most frequently the added detail concerns the subcategories of ADL care and basic hygiene; prevention and treatment of decubitus ulcers; prevention and treatment of contractures; and bowel and bladder care. 

    General Issues    (TOP)    (NEXT)

    Most States indicate that the quality of care provisions will be implemented with reference to the comprehensive resident care plan.   Some States add other language to the Federal quality of life regulations at the beginning or in multiple sections to clarify that these rules are being applied in ways that allow residents to refuse certain services.

     For example:

    Washington rules qualify the requirements to optimize resident physical, mental, and social functioning with the language, “as consistent with residents’ rights.” 

    Indiana regulations repeat the phrase “based on a resident's comprehensive assessment and care plan, but subject to the resident's right to refuse” at various places.  They also offer a general caveat as well that “the resident has the right to refuse care and treatment to restore or maintain functional abilities after efforts by the facility to counsel and/or offer alternatives to the resident,” and that “refusal of such care and treatment should be documented in the clinical records.”  [NH Regs Plus Comment: Recognition of the residents right to refuse various treatment regimens is an important bow to resident autonomy, though best, if coupled with expectations for educating and informing residents on various treatments.]

    - In Illinois the language “all nursing staff shall assist and encourage residents” is inserted in front of most of the major clauses of its Quality of Life regulation.

    Maine adds the notion of measurement and timetables and evokes the American Nurses Association standards at various intervals.  The statement reads each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing and psychosocial needs that are identified in the comprehensive assessment and that is in conformance with the current standards of the Gerontological Nursing Practice of the American Nurses Association.

    Several States introduce the idea that residents should be free from pain as part of their quality of care regulations.

     - New Jersey regulations contain a preamble that says that “the facility shall provide and ensure that each resident receives all care and services needed to enable the resident to attain and maintain the highest practicable level of physical (including pain management), emotional and social well-being, in accordance with individual assessments and care plans.

     - Oregon includes “optimum freedom from pain” in the list of other goals that are in the federal quality of care regulation.

    Several States include an explicit stipulation that the facility be aware of changes in the acute health status of the resident.  For example: 

    - In North Carolina, acute changes in the patient's physical, mental or psychosocial status shall be evaluated and reported to the physician or other persons legally authorized to perform medical acts.

    - In Maryland, 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 symptoms such as dehydration, fever, drug reaction or unresponsiveness.

    The Federal quality of care regulation repeatedly uses language that a resident shall not develop a particular condition unless its development is “unavoidable.”  Recognizing that whether a condition is unavoidable is a judgment call. 

     - Michigan identified a process by which the State helps facilities determine what is unavoidable.  In the language of its regulations, to improve consistency and to avoid disputes over “avoidable” and “unavoidable” negative outcomes, nursing homes and survey agencies must have a common understanding of accepted process guidelines and of the circumstances under which it can reasonably be said that certain actions or inactions will lead to avoidable negative outcomes. If the “state operations manual” or “the guidance to surveyors” published by the federal centers for Medicare and Medicaid services is not specific, a nursing home's overall documentation of adherence to a clinical process guideline with a process indicator adopted pursuant to subsection (18) is relevant information in considering whether a negative outcome was “avoidable” or “unavoidable” and may be considered in the application of that term.  Further the State, in consultation with the clarification work group appointed under the previous section, shall develop and adopt clinical process guidelines that shall be used in applying the terms set forth in subsection. The areas for which the department shall establish and adopt clinical process guidelines and compliance protocols will include but not be limited to the following topics:  (a) Bed rails; (b) Adverse drug effects; (c) Falls; (d) Pressure sores; (e) Nutrition and hydration including, but not limited to, heat-related stress; (f) Pain management; (g) Depression and depression pharmacotherapy;  (h) Heart failure; (i) Urinary incontinence; (j) Dementia; (k) Osteoporosis; (l) Altered mental states; and (m) Physical and chemical restraints. 

    Bedsore and Contractures    (TOP)    (NEXT)

    Prevention and treatment of decubitus ulcers (i.e. bedsores) and of contractures are separate but related topics since some of the strategies to prompt mobility deal with both problems simultaneously.   Federal rules merely state that if residents come to the facility without the condition they should not incur it unless unavoidable, and if they are admitted with the condition or incur it, they should be treated actively for it.  Some State regulations provide more detail.   A common form of detail is to specify frequency for turning residents and/or getting them out of bed.  For example: 

    - Idaho holds that to prevent decubitus ulcers or deformities or to treat them, the resident’s position should be changed every 2 hours when confined to bed or wheelchairs and they should have opportunity to exercise to promote circulations.  

    Kansas calls for frequent changes of position, at least one time every two hours.  Maryland also requires position changes every two hours.

    Massachusetts stipulates 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.

    -Oklahoma calls for turning bed residents [sic] every two hours or as needed, to prevent pressure areas, contractures, and decubitus, and ensuring that residents positions are changed every two hours or as needed when in a chair and are toileted as needed.

    -  Arkansas and Wyoming also specifies round-the-clock turning every two hours.  In Arkansas, in addition to running every two hours day or night, each mattress and pillow shall be moisture proof or must have a moisture proof cover. Rubber or plastic sheets shall be cleaned often to prevent accumulation of odors. Clean cloth draw sheets shall be used over the rubber or plastic sheet.  Arkansas also requires that each patient shall be up and out of bed for at least a brief period everyday unless the physician has written an order for him/her to remain in bed.

    -  Wyoming requires encouraging and assisting dependent residents, as appropriate, to change position at least every two hours, day and night, to stimulate circulation and prevent decubitus and deformities.  Wyoming also requires making every effort to keep residents active and out of bed for reasonable periods of time, except when contraindicated by physician’s orders, and encouraging residents to achieve independence in activities of daily living by teaching self care, transfer, and ambulation activities; and assisting residents to carry out the prescribed therapy regimen between visits of the physical, occupational, and speech therapists.  [NH Regs Plus Comment: This specification that PT, OT, and ST regimens should be reinforced is an important caveat.]

    - In the District of Columbia, requirements are for encouraging and assisting bedridden residents or those residents that are confined to a chair to change position at least every two hours or more often as the resident’s condition warrants, “day and night,” to stimulate circulation; prevent bed sores, pressure ulcers and deformities; and to promote the healing of pressure ulcers.  Other stipulations are encouraging residents to be active and out of bed for reasonable periods of time, except when contraindicated by physician’s orders; and encouraging residents to be independent in activities of daily living by teaching and explaining the importance of self-care, ensuring and assisting with transfer and ambulating activities, by allowing sufficient time for task completion by the residents, and by encouraging and honoring resident’s choices.   [NH Regs Plus Comment: the reference to teaching residents the importance of self-care, and assuring enough time to assist with ADL is a welcome addition to promote resident-centered care.]

    - In West Virginia, nursing personnel shall employ appropriate nursing management techniques to promote the maintenance of skin integrity and to prevent development of decubiti.  Specified techniques may include periodic position change, massage therapy and regular monitoring of skin integrity.

    - In Maryland, the tasks of the required Restorative Nursing Care Program are laid out and include encouraging and assisting patients to keep active and out of bed for reasonable periods of time, within the limitations permitted by physicians' orders, and encouraging patients to achieve independence in activities; and (5) assisting patients to adjust to their disabilities, to use their prosthetic and assistive devices, and to redirect their interests, if necessary. [NH Regs Plus Comment: This reference to helping residents adjust to their prosthetic devices and redirect interests seems unique to Maryland.]

    Detailed protocols are built into regulations in ColoradoCalifornia, and New Jersey.  For example:

    - In Colorado, the detailed quality instructions cross-references the section on assessment and care planning and for decubitus ulcers says:

    (1) For residents whose decubitus ulcers developed while resident was in the facility, the facility shall have: (a) assessed the potential for skin breakdown; and (b) provided preventative measures before the ulcer developed to residents identified in the assessment section.  Colorado describes residents at risk of decubiti (i.e. a resident exhibiting three or more of the following symptoms; underweight, incontinence, dehydration, disorientation or unconsciousness, or limited mobility).

    (2) For all residents with decubitus ulcers, the facility shall: (a) have developed an individualized treatment plan designed to alleviate the condition; (b) be provided active treatment to improve the condition in accordance with the treatment plan; (c) be evaluating the resident's progress and treatment at least weekly and revising the treatment plan as needed.

     - Colorado stipulates that for all residents who are incontinent or immobile, have impaired sensation, compromised nutritional or fluid status, or inadequate hygiene, the facility shall: (a) have completed an initial skin evaluation upon admission and re-evaluated the condition at least weekly; (b) be providing measures to prevent the excoriation, including: (1) maintenance of clean, dry, well lubricated skin;  (2) taking incontinent residents to the bathroom on a regular individualized schedule;  (3) evaluating the need for daily baths; (4) determining potential trouble spots where microbial growth may occur (breasts, gluteal folds, skin folds). For residents with excoriations, the facility shall: (a) develop and be implementing an individualized treatment plan as part of the care plan for the excoriation; (b) evaluate the resident's progress at least daily and review, and revise the treatment plan as needed; (c) enter a progress note at least weekly in the health record.

    - Colorado specifies that for residents requiring devices and/or personal assistance to ambulate, the facility shall provide and maintain the devices in good repair, and assist the residents to obtain appropriate footwear.  [NH Regs Plus Comment: Equipment is often in poor working order in nursing homes, and this is an important specification to promote individual functioning.]

     - In California, each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities, which shall include: (1) changing position of bedfast and chair-fast patients with preventive skin care in accordance with the needs of the patient; (2) encouraging, assisting and training in self-care and activities of daily living; (3) maintaining proper body alignment and joint movement to prevent contractures and deformities; (4) using pressure-reducing devices where indicated; (5) providing care to maintain clean, dry skin free from feces and urine;  (6) changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine; and (7)carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification.

    -  New Jersey provides definitions for wound care and for the various stages of pressure ulcer within its regulations. It requires that the measures to prevent contractures shall be used, and contractures shall be identified, documented, and managed by rehabilitative nursing and physical therapy. [NH Regs Plus Comment: This provision seems to suggest that rehabilitative nursing or PT should be in place to oversee programs of physical maintenance, not just Medicare-funded rehabititation.]

    ADL Care, Grooming and Personal Hygiene    (TOP)    (NEXT)

    The federal rules require assistance to retain and/or promote daily functioning and assistance with grooming, but provide little additional detail.  Some States supply that detail quite extensively.

    - Many States, namely ArkansasCaliforniaIdahoKansasMaineNew JerseyVirginia, and West Virginia specify that the resident shall be kept free from offensive odors.  Nebraska qualifies this with the statement that the resident should be “free of odors not caused by a clinical condition.

    - Some States stipulate a minimum number of baths or showers, usually weekly.  For example:

    - In Illinois, 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

    - In New Jersey, each resident shall receive at least one bath (tub or shower) per week unless contraindicated.

    - Indiana and Virginia require more frequent than weekly bathing as a minimum: mandate baths twice weekly:

    - In Indiana, each resident shall be bathed or assisted to bathe as frequently as is necessary, but at least twice weekly.  Also each resident shall have at least one (1) shampoo every week and more often if needed or requested as part of the resident's normal bathing schedule.

    - In Virginia, each resident shall receive tub or shower baths as often as needed, but not less than twice weekly. Residents whose medical conditions prohibit tub or shower baths shall have a sponge daily.   Further, residents who are incontinent shall have a partial bath, clean clothing and linens each time their clothing or bed linen is soiled. [NH Regs Plus Comment: In our nursing home research, we found that most nursing homes schedule baths weekly, and a few schedule them twice a week.  Relatively few States require a weekly bath and only two required baths twice a week.]

    - Other States besides Virginia specify frequency of linen changes and also assert that residents shall have clean clothing. 

    - In West Virginiabeds shall be made daily, with a complete change of linen to be provided as often as necessary, but at least once each week.  Residents shall have clean clothing as needed to present a neat appearance and to be free of odors.   Residents who are not bedfast shall be dressed each day, in their own clothing,  if available, as appropriate to their activities, preferences, and comforts.

    - In New Jersey, clean linens shall be provided for residents at least once a week or whenever linen are soiled or wet.  In Idaho, also bed linens must be changed weekly, and more if necessary.

    Further detail specifies what constitutes good hygiene. 

    -  In California each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails.

    -  In Maine, good personal hygiene is required, such as clean, well-groomed hair, cleaned, trimmed fingernails, clean skin, and freedom from offensive odors, clean mouth and teeth, and absence of dry cracked lips.; 

    - In Idaho, good grooming and cleanliness of body, skin, nails, hair, eyes, ears, and face, including the removal or shaving of hair in accordance with patient/resident wishes or as necessitated to prevent infection.  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.

    - In Arkansas, attention is given to keeping personal equipment clean.  Bedpans, urinals, and wash basins shall be name-labeled, cleaned after each use, properly stored in the patient's bedside cabinet, and sanitized at least weekly. Any of these utensils not name-labeled and stored in individual bedside cabinets must be sterilized after each use.

    - In Indiana, each resident shall be dressed in clean garments.  Residents who are not bedfast shall be encouraged to be dressed each day.  The resident shall be encouraged or assisted to be as independent as possible, including having self-help and ambulation devices readily available to meet the current needs of the resident with the devices in good repair.  Each resident shall have personal care items such as combs and brushes, cleaned as appropriate.  Also each resident may retain personal care items if in the original container labeled by the manufacturer.  [NH Regs Plus Comment: This last proviso is somewhat ambiguous, but if it refers to resident toiletries, the requirement that they be kept in the manufacturer’s packages seems to interfere with a resident’s common sense wish to keep things in drawers or in toilet bags on shelves.  The rationale for the requirement is understandable, however; to keep lists of ingredients and other use instructions intact.]

    Bowel and Bladder Care  (TOP)    (NEXT)

    Some States have specified bowel and bladder care in more detail.

    - In Alaska, a written assessment is done by a registered nurse within two weeks after admission of an incontinent resident's ability to participate in a bowel or bladder training program; an individualized bowel or bladder training plan for each resident is initiated , as appropriate; and  a monthly written summary of a resident's performance in the training program. 

    - In Nebraska, it is specified that the facility must residents free of fecal impactions and signs of discomfort from bowel constipation. 

    California is prescriptive in its regulations for bowel and bladder programs.   A written assessment by a licensed nurse to determine the patient's ability to participate in a bowel and/or bladder management program must be initiated within two weeks after admission of an incontinent patient. An individualized plan, in addition to the patient care plan, is initiated for each patient in a bowel and/or bladder management program.  A weekly written evaluation in the progress notes by a licensed nurse of the patient's performance in the bowel and/or bladder management program. ) Fluid intake and output shall be recorded for each patient if ordered by the physician, or for each patient with an indwelling catheter.  Intake and output records shall be evaluated at least weekly and each evaluation shall be included in the licensed nurses' progress notes.

    After 30 days the patient shall be reevaluated by the licensed nurse to determine further need for the recording of intake and output.

    Diet, Weight, Hydration and Feeding Tubes  (TOP)    (NEXT)

    Some States detail frequency and ways to monitor weight changes.

    - In Colorado the facility shall: (1) evaluate the resident to determine the cause of the weight change; (2) develop and implement an individualized plan of care as part of the care plan  (including appropriate intervention by other appropriate disciplines); evaluate resident progress and revise the plan, as needed; (3) observe food and fluid intake and provide encouragement to residents with eating problems; (4) provide reasonable choices of foods to meet personal preferences and religious needs; (5) if nourishments are provided as part of the care plan, between meals and at bedtime, document the nourishments provided, and whether they are consumed; (6) provide assistance in eating of adaptive eating devices and assist residents in obtaining dentures, or dental care, as appropriate to the individual resident; and for residents with mouth or gum problems, meet the requirements of the dental services section.   

    - In New Jersey, residents shall be weighed accurately every month. Whenever there is a gain or loss of five percent or more, a note shall be entered into the medical record stating whether the care plan should be modified.

    - In Oregon, facilities are required to weigh each resident on admission and quarterly, thereafter, or more if the resident’s condition warrants it. 

    Regarding fluids and hydration:

    - In Arkansas, fluids shall be offered at frequent intervals when the patient is unable to obtain them. Water pitchers shall be refilled at least once each shift and should be kept in reach of patients. Clean drinking glasses shall be kept with each water pitcher.

    - In New Jersey, each resident shall have access to fresh drinking water or juice at all times, unless contraindicated.   New Jersey also provides detail of a quality nutrition program for an Alzheimer’s unit. The Alzheimer's/dementia program provides nutritional intervention as needed, based upon assessment of the eating behaviors and abilities of each resident. Interventions may include 1) Verbal and non-verbal eating cues; 2) modified cups, spoons, or other assistive devices; and 3) simplified choices of foods or utensils. The Alzheimer's/dementia program provides a small dining room, separate room, or designated dining area furnished to meet the needs of the residents, with staff members or trained volunteers to assist.

    -   New Jersey provides considerable detail on nasogastric and percutaneous feedings, which are requiredrequired “to treat the individual’s condition after all non-invasive avenues to improve the nutritional status have been exhausted with no improvement.” The clinical record shall document the non-invasive measures provided and the individual’s poor response. The record shall also indicate the medical condition for which the feedings are ordered. Included in this service is the routine care of the tube site and surrounding skin of the surgical gastrostomy. Detail is also given for the use of IV tubes. 

    - New York regulations discuss appropriate use of enteral and nasogastric feeing tubes, including the complications to prevent (aspiration pneumonia, diarrhea, significant regurgitation, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers), and the stipulations for review of the use of such tubes and the restoration of normal feeding functions.  It is specified that the registered professional nurse, social worker, and dietitian assess patients using these tubes as needed but no less than every six weeks for possible return to normal feeding function. If the nasogastric feeding is continued longer than 95 days, permanent enteral feeding procedures such as surgical gastrostomy or jejunostomy shall be considered. Nasogastric tube feeding formulations shall be given in accordance with the manufacturer's instructions or at a rate appropriate to the physical size of the resident and the amount of fluid and nutrients necessary to meet the assessed caloric and fluid needs of the resident.   To minimize resident discomfort, nasogastric tubes used for resident feeding purposes shall: (i) be the smallest gauge appropriate for the patient and shall not exceed 3.96 millimeters (#12 French) in outside diameter unless medically indicated; (ii) be made of a soft, flexible material such as medical grade polyurethane or silicone; and (iii) be specifically manufactured for nasogastric feeding purposes.

    - The facility is to develop and follow policies and procedures for nasogastric tube feedings which are written in accordance with prevailing standards of professional practice and in consultation with the medical, nursing, dietary and pharmacy services of the facility. Medical practitioners shall be informed of such policies and procedures governing the use of nasogastric tubes for resident feeding. The policies and procedures shall address as a minimum: (i) types and sizes of nasogastric tubes and the various types of feeding formulations available at the facility; (ii) the need to assess each resident's clinical and nutritional status to determine the size of the nasogastric tube and type of feeding appropriate for that individual; (iii) standard techniques for inserting a nasogastric tube and confirming the correct placement of the tube; (iv) procedures for administering nasogastric feedings including positioning the resident and the need for resident observation and monitoring before, during and following the feeding; and (v) infection control policies related to tube feedings. 

    Medications  (TOP)    (NEXT)

    Alaska provides detail on the resident’s right to be free from psychoactive drugs administered for purposes of discipline.  The record must contain evidence of an interdisciplinary team's identification of less restrictive approaches to be used before or in conjunction with the use of psychoactive drugs.  If, after a trial period of less restrictive measures, a nursing facility decides that a psychoactive drug would enable and promote greater functional or social independence, the nursing facility must explain the use of the psychoactive drug to the resident, before its use. If the resident has a legal representative, the explanation must also be given to the resident's legal representative, before its use. The explanation must include a description of the risks and benefits of the use of the drug. Approval of the use of a psychoactive drug by a resident or legal representative must precede its use, except in the case of a medical emergency in which there is a risk of harm to the resident or others. The approval, or the circumstances of the emergency, must be documented in the resident's medical records at the nursing facility.  A resident's medical records must contain evidence of an interdisciplinary team's periodic reassessment of the psychoactive drug to determine its effectiveness and appropriateness for continued use.

    Indiana’s discusses “administration of drugs and treatments, including alcoholic beverages [emphasis supplied by NHRegsPlus], nutrition concentrates, and therapeutic supplements.  These are ordered by the attending physician and shall be supervised by a licensed nurse as follows and any error is recorded in the record.  (Thus it appears that non-prescribed use of alcohol is a medication error.)  The physician shall be notified of any error in medication administration when there are any actual or potential detrimental effects to the resident.  

    Nebraska includes a long section on ensuring quality of care when non-licensed staff are used as medication assistants.  

    Miscellaneous  (TOP)    (NEXT)

    - In Kentucky, a resident who displays psychosocial adjustment difficulty, receives appropriate treatment and services to achieve as much remotivation and reorientation as possible.

    - In Connecticut, every two  years, visual acuity is  grossly tested, for near and distant vision for sighted patients; and every five years screening audiometry is done for patients without a hearing aide; and tonometry for sighted patients 40 years and over. 

    Colorado requires that for residents at high risk for accidents, the facility shall have identified the risk in the care plan and taken reasonable precautions to prevent common accidents before the accident occurred.  The State specifies residents at high risk of accidents to include the blind, the deaf, those with seizure disorders, those with accidents in the last 6 months, the totally confused but ambulatory, new amputees, and residents on psychoactive drugs.

    New Jersey provides detailed requirements for ventilator services, including specification of pulmonary function testing and blood gas analysis when these procedures are performed within the ventilator care unit; requiring methods that assist in the removal of secretions from the bronchial tree, such as hydration, breathing and coughing exercises, postural drainage, therapeutic percussion and vibration, and mechanical clearing of the airway through proper suctioning technique; requiring recognition of and attention to the psychosocial needs of residents and their families; and requiring that facility shall ensure that each ventilator is equipped with an alarm, designed to alert the nursing station, on both the pressure valve and the volume valve. In order to operate a ventilator unit, a facility shall develop and the Department of Health shall approve a plan of operation which shall include: (a) a description of the services to be provided; (b) a description of the staffing pattern; (c) a description of the qualification, duties and responsibilities of personnel; (d) a quality assurance plan which shall include: (1) assignment of responsibility for monitoring and evaluation activities; (2) identification of indicators and appropriate clinical critical criteria for monitoring the most important aspects; and (3) establishment of thresholds (levels or trends) for the indicators that will trigger evaluation of care.  [NH Regs Plus Comment: The reference to meeting the psychosocial needs of residents and families when the resident is on ventilator care seems important.]

    Maryland has a similarly detailed set of requirements for ventilator units and the competences required for those who work in them. 

    - Various States have language requiring equipment of different kinds, or requiring that equipment is in working order.  Some of the requirements seem obvious, such as Georgia’s expectation that each patient shall be provided adequate supplies and equipment for proper oral hygiene, including a toothbrush or a denture brush and a denture receptacle when needed.  Georgia also requires that wheelchairs, walkers, and mechanical lifters be provided by the home when needed.  Massachusetts requires that all catheters, irrigation sets, drainage tubes, or other supplies or equipment for internal use, and as identified by the manufacturer as one-time use only, will be disposed of in accordance with the manufacture’s recommendations.  Disposable syringes used for feeding purposes shall also be disposed of in accordance with the manufacturer's recommendations. An adequate number of commode chairs, wheelchairs, walkers, foot soak basins, foot boards, cradles, armboards, and other such equipment to meet patient or resident needs.

    Illinois requires 60 hours of training for the nurse in charge of the restorative nursing program. 

    Iowa establishes requirements that colostomy or ileostomy care or oral suctioning may only be performed only by a registered nurse or licensed practical nurse or by a qualified aide under the direction of a registered nurse or licensed practical nurse.

    Table Comparing States    (TOP)

    Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Quality of Care by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State requirements on Quality of Care.

    483.25 Quality of Care

    State Goes beyond Federal Regulations? Subjects Addressed: How State Differs From or Expands On Federal Regulations
    Alabama No Alabama regulations mirror the Federal regulations on quality of care.
    Alaska Yes Bowel &bladder training; unnecessary medication.
    Arizona Yes Nursing services, medical services required including vaccinations and medications.
    Arkansas Yes Decubitus ulcer prevention; OT equipment; being out of bed for a period each day; routine care and services; treatment and medications.
    California Yes Patient is to be free of offensive odors; decubitus ulcer and contracture prevention details; bowel and bladder training programs; required services; special treatment program services;
    Colorado Yes Accident prevention (including identification of those at high risks for accidents; behavior problem care; Contracture care; weight changes; promotion of mobility; Grooming ; Indwelling catheters; pressure ulcer prevention and care; behavior problem care; contracture care; promotion of mobility; indwelling catheter care; weight changes; grooming; excoriation prevention and care; fluid management;
    Connecticut Yes Frequency of vision and hearing exams; required services and immunization.
    Delaware Yes Immunizations and CPR certification.
    District of Columbia Yes Promotion of mobility; preventing decubitus ulcers; body alignment; ventilator care and tracheostomy care; restorative care program, nursing personnel; care policies; ventilator care services; podiatry services program.
    Florida Yes State’s Gold Seal program for publicizing excellent quality; access for pneumococcal vaccination.
    Georgia Yes Definitions of skilled nursing and rehabilitative nursing; equipment for mobility, mechanical lifts, and oral hygiene.
    Hawaii Yes Weight requirements; completion of orders and supportive services.
    Idaho Yes Nursing responsibilities for hygiene, body alignment, and fluid and nutritional intake; details on prevention of bed sores; skin care, rehabilitative nursing required; accident or injury
    Illinois Yes Psychotropic Medication; Restorative Nursing credentials and program; hygiene requirements; vaccinations.
    Indiana Yes Details on ADL care and hygiene, including frequency of baths & shampoos; decubitus ulcer prevention and care; tube feeding & its monitoring; details on hydration (drinking water, ice). Activities of daily living assessment; vision and hearing; pressure sores; urinary incontinence; range of motion; mental and psychosocial functioning; naso-gastric tubes; accidents; nutrition and hydration; special needs.
    Iowa Yes Aseptic techniques for feeding syringes, urine collection bags, IV’s, and urinary catheters; requirements for colostomy care, ileostomy care, or oral suctioning; nursing care; duties of supervisor.
    Kansas Yes Slight addition on hygiene; requirements for who can administer parenteral feedings or IVs.
    Kentucky Yes Remotivation therapy to be done as much as possible; mentioned; specifies who can administer intramuscular injections
    Louisiana Yes Disposal of certain equipment; detail on goals of skin care; restorative nursing required.
    Maine Yes Detail on hygiene; Prevention of decubitus ulcers and contractures; alludes to Standards of Gerontological Practice established by American Nurses Association.
    Maryland Yes Slightly different language on responsibility of nursing departments to identify certain changes in health condition; restorative nursing roles; use of protective device or devices require written physician’s order.
    Massachusetts Yes Additional language on turning to prevent bedsores and contractures; adequate equipment; podiatric services; dietary; patient care and safety.
    Michigan Yes Clarification on how State will determine whether a condition was “unavoidable” under the regulations; oxygen administration; blood administration; rehabilitative nursing care
    Minnesota Yes The use of oxygen; unnecessary drug usage.
    Mississippi Yes The Mississippi regulations on Quality of Care mirror the Federal regulations;  if the facility does not have the capacity to provide the needed care, it must make prompt efforts to transfer the patient.
    Missouri Yes Personal attention and nursing care in accordance with condition.
    Montana Yes Services furnished; medications; use of safety devices.
    Nebraska Yes Care and treatments; resident abilities and equipment.
    Nevada No The Nevada regulations on Quality of Care mirror the Federal regulations.
    New Hampshire Yes Required services; medication services.
    New Jersey Yes Definitions and classification of bedsores, tracheostomy care, and intravenous injections; includes pain management in overall quality of care definition; weight maintenance and monitoring; ADL care and hygiene, including frequency of bathing; Alzheimer’s care, including eating assistance.
    New Mexico Yes Equipment needed; individual care; treatment and orders; rehabilitative measures; nourishment.
    New York Yes Enteral feeding and nasogastric tubes; quality of care.
    North Carolina Yes Responsibility to identify acute changes; sufficient dietician time to take responsibility for quality of care and nutritional status; safety; cardio-pulmonary resuscitation.
    North Dakota No North Dakota does not address Quality of Care in its nursing home regulations.
    Ohio Yes Ohio does not address Quality of Care in its nursing home regulations.
    Oklahoma Yes Additions on frequency of turning bedbound or chair bound residents; reference to identifying acute illness; influenza and pneumococcal vaccinations.
    Oregon Yes Documentation;  pain control; frequency of weighing; questionable care; standards of care; acute condition change; restorative care.
    Pennsylvania Yes Requires annually updated Resident Care Policies.
    Rhode Island Yes Incontinence care; safe resident handling; assistance with eating and hydration; pain assessment and equipment.
    South Carolina Yes Resident care and treatment services; oxygen therapy; vaccinations and pharmacy services.
    South Dakota Yes Prevention and control of influenza.
    Tennessee Yes Basic services and pharmaceutical services.
    Texas Yes Quality of care; reports of medication errors and adverse reactions; restorative nursing care; infection control.
    Utah Yes The nursing or health care services for small facilities.
    Vermont No The Vermont regulations on Quality of Care mirror the Federal regulations.
    Virginia Yes Added detail on ADL care, including minimum number of baths.
    Washington No The Washington regulations on Quality of Care mirror the Federal regulations.  A caveat is added: “as consistent with resident rights."
    West Virginia No The West Virginia regulations on Quality of Care mirror the Federal regulations.
    Wisconsin Yes Slight additions on frequency of linen changes and details of preventing decubitus ulcers; basic nursing care; nourishment; use of oxygen.
    Wyoming Yes Brief addition on frequency of position changes.

    Complete Transcript of State Requirements on Quality of Care    (TOP)