Texas Department of Aging and Disability Services
Day Activity and Health Services Provider Manual
Revision: 04-1
Effective: April 2, 2004

Section 4000

Staffing

4100  Staff Qualifications

Revision 95-1; Effective January 1, 1995

This section provides you with additional guidelines for staff qualifications and/or requirements. It only supplements and does not substitute and/or replace any qualifications or requirements in the adult day care and adult day health care licensing standards.

4110  Director

Revision 95-1; Effective January 1, 1995

You must have a director who is responsible for the overall management of the day activity and health services program.

A licensed vocational nurse (LVN) may qualify to serve as a director only if he meets the qualifications for director. An LVN without a degree does not qualify.

To qualify for director, the director must have worked for the required time with people in a human service or medically-related program. The definitions in the adult day care and adult day health care licensing standards provide you with guidelines for determining a person's qualifications to be a facility director. Each applicant must be considered individually.

Note: The definitions are based on material in:

  • Russo, F.X. and Willis, G. (1986) Human Services in America, Englewood Cliffs, N.J.: Prentice-Hall
  • Sauber, S.R. (1983) The Human Services Delivery System, New York, Columbia University Press

4120  Activities Director

Revision 95-1; Effective January 1, 1995

You must have an activities director who is responsible for planning and directing the daily program of activities, etc.

§98.42(a)(1)(C) — The activities director may fulfill the function of facility director if he meets the other qualifications for facility director.

4130  Nurse

Revision 95-1; Effective January 1, 1995

You must have a nurse who is responsible for assessing the client's initial and continued medical needs, developing a client's plan of care, etc.

§98.42(a)(2) — The facility nurse must be a registered nurse (RN) or a licensed vocational nurse (LVN).

The nurse may also fulfill the functions of the director if he meets the qualifications for director.

4140  RN Consultant

Revision 95-1; Effective January 1, 1995

If the facility nurse is an LVN, you must have an RN consultant four hours per week. The RN consultant can serve as a substitute for the LVN.

4200  Staff Requirements

Revision 99-1; Effective May 1, 1999

The intent of the facility staffing requirement is to ensure that a responsible professional is at the facility when clients are present. The nurse uses professional judgment to determine where he needs to be to meet the needs of the clients (such as accompanying clients on outings or staying at the facility).

Because you must have services available for at least 10 hours each day (see Section 1400, Required Services), a professional staff person must remain at the facility when clients are present. A professional staff person is the

  • facility nurse,
  • facility director, or
  • activities director.

Any time a client is at the facility, the nurse, the director, or the activities director must be on site, although the client may be supervised by an attendant.

§98.62(a)(1) —

(C)
One person may not serve as facility nurse, activities director, and facility director, regardless of qualifications.
(D)
The facility must have a policy regarding the delegation of responsibility in the administrator's absence, not to exceed 10 working days.
(E)
The facility must request a waiver from Long Term Care-Regulatory (LTC-R) Regional Office for exceptional circumstances. Exceptional circumstances include, but are not limited to, hospitalization, death, etc.

§98.62 — Program Requirements

(c)
Staff health. All direct staff must be free of communicable diseases.

4210  Director

Revision 99-1; Effective May 1, 1999

§98.62(b)(3) — The facility must ensure that the facility director works a minimum of 40 hours per week performing duties relating to the provision of adult day care services.

§98.62 — Program Requirements

(a)
Staff qualifications.
(1)
Director.
(A)
The director must:
(i)
have graduated from an accredited four-year college or university and have no less than one year of experience in working with people in a human service or medically-related program, or have an associate degree or 60 semester hours from an accredited college or university with three years of experience in working with people in a human service or medically-related program; or
(ii)
be a registered nurse with one year of experience in a human service or medically-related program; or
(iii)
meet the training and experience requirements for a license as a nursing facility administrator under the rules of the Texas Board of Licensure for Nursing Facility Administrators; or
(iv)
have met, on July 16, 1989, the qualifications for the position under the requirements in effect at that time and have served continuously in the capacity of director of a Texas Department of Human Services-certified facility since that date.

The director must perform duties relating to the provision of DAHS for at least 40 hours per week. A director who has a full-time job outside the DAHS facility from 8:00 a.m. to 5:00 p.m., Monday through Friday, does not fulfill the requirement that the director performs duties relating to the provisions of DAHS for at least 40 hours per week. A director who has a full-time job outside the DAHS facility cannot be responsible for the overall management of the facility. The DAHS facility must have services available at least 10 hours each day, five days per week (Monday through Friday). More than one part-time director may fulfill the 40-hour/week requirement.

§98.62 — Program Requirements

(d)
Staff responsibilities.
(1)
Facility director. The facility director is responsible for:
(A)
managing the adult day care program and/or the facility;
(B)
training and supervising facility staff;
(C)
monitoring the facility building and grounds to ensure compliance;
(D)
maintaining all financial and client records;
(E)
developing relationships with community groups and agencies for identification and referral of clients;
(F)
maintaining communication with the client's family members or responsible parties;
(G)
assuring the development and maintenance of the individual plan of care; and
(H)
ensuring that, if he serves as the nurse consultant during the same eight-hours-per-day period, he is fulfilling his responsibility as director.

4220  Activities Director

Revision 99-1; Effective May 1, 1999

§98.62(b)(4) — The facility must ensure that the activities director works 40 hours a week.

§98.62(a)(1)(B) — The activities director may fulfill the function of facility director if he meets the qualifications for facility director.

§98.62(a)(3) — Activities director

(A)
The activities director must be a high school graduate (or equivalent) and have:
(i)
a bachelor's degree from an accredited college or university, plus one year of full-time experience in working with the elderly or people with disabilities in a human service or medically-related program; or
(ii)
60 semester hours from an accredited college or university, plus two years of full-time experience in working with the elderly or people with disabilities in a human service or medically-related program; or
(iii)
completed a state-approved activities director's course, plus two years of full-time experience in working with the elderly or people with disabilities in a human service or medically-related program.

The activities director must perform the duties related to the provision of DAHS for at least eight hours per day.

§98.62 — Program Requirements.

(d)
Staff responsibilities.
(3)
Activities director. The activities director is responsible for:
(A)
planning and directing the daily program of activities, including physical fitness exercises or other recreational activities;
(B)
recording the client's social history;
(C)
assisting the client's related support needs;
(D)
assuring that the identified related support services are included in the client's individual plan of care; and
(E)
signing and dating monthly progress notes about social and related support services activities provided.

4230  Nurse

Revision 99-1; Effective May 1, 1999

The nurse must be present at the facility at least eight hours a day when one or more clients are present to provide health care expertise, both ongoing and in case of emergency.

§98.62(b)(2) — The facility must ensure that at a minimum, one registered nurse or licensed vocational nurse must be working on site, eight hours per day. The facility may schedule nursing hours according to client needs. Sufficient licensed nursing staff must be on site to meet the nursing needs of the clients.

§98.62(a)(2)(C) — If a nurse serving as director leaves the facility to perform other duties related to the provisions of the day care program, an LVN or another RN must fulfill the duties of the facility nurse.

The facility nurse may leave the premises during a lunch break if the facility director or activities director is at the facility.

§98.62 — Program Requirements.

(d)
Staff responsibilities.
(2)
Facility nurse. The facility nurse is responsible for:
(A)
assessing the client's nursing and medical needs;
(B)
developing a client's individual plan of care;
(C)
obtaining physician's orders for medication and treatments to be administered;
(D)
determining whether self-administered medications have been appropriately taken, applied, or used;
(E)
entering, dating, and signing monthly progress notes on medical care provided;
(F)
administering medication and treatments;
(G)
providing health education; and
(H)
maintaining medical records.

4240  RN Consultant

Revision 99-1; Effective May 1, 1999

The RN consultant must provide consultation when clients are present in the facility.

§98.62(d)(7) — Registered nurse consultant. In facilities where the nurse is a licensed vocational nurse, a registered nurse consultant must provide on-site consultation four hours per week. The RN consultant must document the consultation provided. The RN consultant must provide the consultation during the time when clients are present in the facility. The RN consultant may provide the following types of assistance:

(A)
reviewing plans of care and suggesting changes, if appropriate;
(B)
assessing clients' health conditions;
(C)
consulting with the LVN in solving problems involving client care and service planning;
(D)
counseling clients on their health needs;
(E)
training, consulting, and assisting the LVN in maintaining proper medical records; and
(F)
providing in-service training for direct service staff.

Facilities staffed with an RN are not required to have RN consultation.

4250  Attendants

Revision 99-1; Effective May 1, 1999

§98.62(a)(4) — Attendants. Attendants must be 18 years old or older and may include, but are not limited to, bus drivers, aides, cooks, janitors, porters, maids, and laundry workers.

At least one attendant or other direct service staff must be present at the facility when one client is present.

§98.62 — Program Requirements.

(d)
Staff responsibilities.
(4)
Attendant. The attendant is responsible for:
(A)
providing personal care services (assistance with activities of daily living);
(B)
assisting the activities director with recreational activities; and
(C)
providing protective supervision (observation and monitoring).

§49.3(c)(2) — A provider agency must not allow direct services staff, with communicable diseases or open infectious wounds, to come into direct contact with clients or with products to be consumed or handled by clients.

4260  Registered Dietitian/Consultant

Revision 99-1; Effective May 1, 1999

§98.62(d)(6) — Dietitian consultant.

(A)
The facility must receive consultation at least four hours each month from a dietitian. The dietitian consultant plans and/or reviews menus and must:
(i)
prior approve and sign each snack and luncheon menu;
(ii)
review menus monthly to ensure that substitutions were appropriate; and
(iii)
develop any special diets ordered by physicians for individual clients.
(B)
The dietitian consultant is required for all facilities, even those that have their meals delivered from another facility with its own dietitian consultant. A consultant may provide consultation to several facilities as long as each facility receives at least four hours a month. The four hours cannot be "shared" by several facilities.
(C)
Facilities that contract for the preparation and delivery of meals with management companies employing their own registered dietitians are required to have the four hours of consultation from a dietitian consultant.

Although the dietitian may provide individual nutritional consultation to clients, the dietitian's main task is to

  • plan and/or review menus, and
  • develop special diets for clients that were ordered by their physician.

4270  Housekeeper

Revision 99-1; Effective May 1, 1999

§98.62(a)(6)(A) — A DAHS facility may employ a part-time or full-time housekeeper.

4280  Driver

Revision 99-1; Effective May 1, 1999

§98.62(a)(6)(B) — If a DAHS facility employs a part-time or full-time driver, the driver must:

(i)
operate the facility's vehicles in a safe manner; and
(ii)
maintain adult cardiopulmonary resuscitation (CPR) certification.

§98.62(a)(4)(A) — If the facility employs a bus driver, the driver must have a current operator's license, issued by the Texas Department of Public Safety, which is appropriate for the class of vehicle used to transport clients.

4290  Volunteers

Revision 99-1; Effective May 1, 1999

4291  Under 18 Years of Age

Revision 99-1; Effective May 1, 1999

Summer youth students under 18 years of age may volunteer their services. However, they cannot serve as substitutes for regular staff. The volunteers may

  • help with group activities (educational, social, recreational, etc.); and
  • assist with administrative tasks.

Volunteers may not assist and/or provide any personal care tasks. These volunteers may not be included in the staff-client ratio because they do not meet staff qualifications.

4292  18 Years of Age or Older

Revision 99-1; Effective May 1, 1999

Volunteers must be able to perform duties prescribed. They must also receive the training required of direct delivery staff. These volunteers may be included in the staff-client ratio. Note: A client cannot perform any duties related to the delivery of DAHS services.

4300  Staff-Client Ratios

Revision 99-1; Effective May 1, 1999

To safeguard the health and/or safety of clients, a certain number of direct service staff must be present at the facility at all times. The number of staff required is determined by the number of clients present each day.

§98.62(b) — The facility must ensure that:

(1)
the ratio of direct service staff to clients is at least one to eight, which must be maintained during provision of all covered services except during facility-provided transportation.

Direct service staff include the director, licensed nurse, activity director, and attendants.

You must maintain the required staff-client ratio at the facility at all times. For staffing purposes, any individuals receiving DAHS, including DHS clients and/or private-pay clients, are included in the ratio.

Although the staff-client ratio does not apply when clients are in transit, you must assure the client's health and/or safety outside the facility. When you take the client on activities outside the facility, such as zoos, movies, malls, etc., you must maintain the required staff-client ratio at the destination.

4400  Criminal History Checks

Revision 04-1; Effective April 2, 2004

§98.61 — General Requirements.

(a)
All facilities are required to meet the following:
(2)
the Health and Safety Code, Chapter 250, concerning conducting criminal history checks.

House Bill 1510 requires that persons convicted of certain crimes may not be employed in most facilities and agencies providing care to the aged and disabled. Therefore, criminal history checks on certain employees must be performed prior to an offer of employment except in emergency situations.

The law requiring criminal history checks provides protection of confidentiality, which prevents you or DHS from sharing the results of a criminal history check with anyone. Information obtained as a result of a criminal history check may not be shared with anyone except the employee affected and DHS.

If you receive inquiries from a client, client's family, potential employer, or other interested parties, explain the following:

  • that you are required by law to conduct criminal history checks on all attendants,
  • that you are complying with the law, and
  • that you are being monitored for compliance with the law.

You must not share the reason for termination of the attendant with a client or a client's family if the termination is the result of a criminal history check. If the attendant shares the information with a client, you may not confirm the reason for termination.

Procedures for conducting criminal history checks may be found in Appendix VII, Criminal History Check of Employees in Certain Agencies/Facilities Serving the Elderly or Persons with Disabilities.

4410  HIV/AIDS and Related Conditions in the Workplace

Revision 99-1; Effective May 1, 1999

§98.61 — General Requirements.

(a)
All facilities are required to meet the following:
(3)
workplace standards to comply with HIV/AIDS and related conditions in the workplace.

Senate Bill 959, the Human Immunodeficiency Act (Tex. Rev. Civ. Stat. Ann. art. 4419b-4), which was effective March 1990, requires DHS and any entities that are funded by DHS or contract with DHS to provide direct client services, to develop and implement

  • human immunodeficiency virus (HIV) workplace guidelines,
  • confidentiality guidelines, and
  • HIV/AIDS education programs for employees and clients.

DHS guidelines must be based on Texas Department of Health HIV/AIDS Model Workplace Guidelines. The guidelines are found in Appendix IV, HIV/AIDS and Related Conditions in the Workplace.

4420  Occupational Exposure to Bloodborne Pathogens

Revision 99-1; Effective May 1, 1999

Occupational Safety and Health Administration (OSHA) standards, which became effective June 4, 1992, require that employers make available the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure.

If you provide the vaccine, the full cost of vaccination expenses incurred may be reported on the cost report. The cost to provide vaccinations is currently included in the reimbursement rate.

4430  Training

Revision 99-1; Effective May 1, 1999

§98.62 — Program Requirements.

(e)
Training.
(1)
Initial training.
(A)
The facility must:
(i)
provide all staff with training in the fire, disaster, and evacuation procedures within three workdays of employment. The training must be documented in the facility records.
(ii)
provide direct delivery staff a minimum of 18 hours of training during the first three months of employment. Training must be documented in the facility records. Training must include:
(I)
any nationally or locally recognized adult cardiopulmonary resuscitation (CPR) course/certification;
(II)
first aid; or
(III)
orientation to health care delivery including the following components:
(-a-)
safe body function and mechanics;
(-b-)
personal care techniques and procedures; and
(-c-)
overview of client population served at the facility; and
(IV)
identification and reporting of abuse, neglect, or exploitation.
(B)
Staff employed as substitutes on an infrequent and irregular basis are not required to have 18 hours of initial training. Substitute and consultant staff must receive a minimum of three hours of orientation. Substitutes for direct service staff used by a facility on a regular basis must meet all training requirements as specified under this subsection.
(2)
Ongoing training.
(A)
The facility must provide a minimum of three hours of ongoing training to direct service staff quarterly. The facility must ensure that direct delivery staff maintain current certification in CPR.
(B)
The facility must practice evacuation procedures with staff and clients quarterly. The evacuation results must be documented in the facility records.