Texas Department of Aging and Disability Services
Nursing Facility Requirements for Licensure and Medicaid Certification Handbook
Revision: 07-3

Subchapter J

§19.901  Quality of Care

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, as defined by and in accordance with the comprehensive assessment and plan of care. If children are admitted to the facility, care and services must be provided to meet their unique medical and developmental needs.

(1)
Activities of daily living. Based on the comprehensive assessment of the resident, the facility must ensure that:
(A)
a resident's abilities in activities of daily living do not diminish unless the circumstances of the individual's clinical condition demonstrate that diminution is unavoidable. This includes the resident's abilities to:
(i)
bathe, dress, and groom;
(ii)
transfer and ambulate;
(iii)
toilet;
(iv)
eat; and
(v)
use speech, language, or other functional communication systems.
(B)
the resident is given the appropriate treatment and services to maintain or improve his abilities specified in paragraph (1) of this section.
(C)
a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
(2)
Vision and hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident:
(A)
in making appointments; and
(B)
by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
(3)
Pressure sores. Based on the comprehensive assessment of the resident, the facility must ensure that:
(A)
a resident who enters the facility without pressure sores does not develop pressure sores unless his clinical condition demonstrates that they are unavoidable; and
(B)
a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.
(4)
Urinary incontinence. Based on the comprehensive assessment of the resident, the facility must ensure that:
(A)
a resident who enters the facility without an indwelling catheter is not catheterized unless his clinical condition demonstrates that catheterization is necessary; and
(B)
a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.
(5)
Range of motion. Based on the comprehensive assessment of the resident, the facility must ensure that:
(A)
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; and
(B)
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.
(6)
Mental and psychosocial functioning. Based on the comprehensive assessment of the resident, the facility must ensure that:
(A)
a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem; and
(B)
a resident whose assessment does not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless his clinical condition demonstrates that such a pattern is unavoidable.
(7)
Naso-gastric tube. Based on the comprehensive assessment of the resident, the facility must ensure that:
(A)
a resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless his clinical condition demonstrates that use of a naso-gastric tube is unavoidable; and
(B)
a resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers, and to restore, if possible, normal eating skills.
(8)
Accidents. The facility must ensure that:
(A)
the resident environment remains as free of accident hazards as possible; and
(B)
each resident receives adequate supervision and assistive devices to prevent accidents.
(9)
Nutrition. Based on the comprehensive assessment of the resident, the facility must ensure that a resident:
(A)
maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless his clinical condition demonstrates that this is not possible; and
(B)
receives a therapeutic diet when there is a nutritional problem.
(10)
Hydration. The facility must ensure that the resident is provided with sufficient fluid intake to maintain proper hydration and health.
(11)
Special needs. The facility must ensure that residents receive proper treatment and care for the following special services:
(A)
injections;
(B)
parenteral or enteral fluids;
(C)
colostomy, ureterostomy, or ileostomy care;
(D)
tracheostomy care;
(E)
tracheal suctioning;
(F)
respiratory care;
(G)
foot care; and
(H)
prostheses.
(12)
Unnecessary Drugs.
(A)
General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
(i)
in excessive dose (including duplicate drug therapy); or
(ii)
for excessive duration; or
(iii)
without adequate monitoring; or
(iv)
without adequate indications for its use; or
(v)
in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(vi)
any combination of the circumstances in clauses (i)-(v) of this subparagraph.
(B)
Antipsychotic drugs. Based on the comprehensive assessment of the resident, the facility must ensure that:
(i)
residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and
(ii)
residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue use of these drugs.
(13)
Medication errors. The facility must ensure that:
(A)
it is free of medication error rates of five percent or greater, and
(B)
residents are free of significant medication errors.
(14)
Pediatric care.
(A)
Licensed nursing care of children. A facility caring for children must have twenty-four hour a day on-site licensed nursing staff in numbers sufficient to provide safe care. For any facility with five or more children under 26 pounds, at least one nurse must be assigned solely to the care of those children.
(B)
Fewer than five pediatric residents. Facilities with fewer than five pediatric residents must assure that the children's rooms are in close proximity to the nurses' station.
(C)
Respiratory care of children.
(i)
To facilitate the care of ventilator-dependent children or children with tracheostomies, a facility must group those children in rooms contiguous or in close proximity to each other. An exception to this rule is children who are able to be schooled off-site.
(ii)
Facilities must assure that alarms on ventilators, apnea monitors, and any other such equipment uniquely identify the child or the child's room.
(iii)
A facility caring for children with tracheostomies requiring daily care (including ventilator-dependent children with tracheostomies) must have twenty-four hour a day on-site respiratory therapy staff in numbers sufficient to provide a safe ratio of respiratory therapist per these residents. For the purposes of this rule, respiratory therapy staff is defined as a registered respiratory therapist (RRT), a certified respiratory therapy technician (CRT), or a licensed nurse whose primary function is respiratory care.
(I)
If the facility cares for nine or more children with tracheostomies requiring daily care (including ventilator-dependent children with tracheostomies), the facility must maintain a ratio of no less than one respiratory therapy staff per nine tracheostomy residents twenty-four hours a day.
(II)
If the facility cares for six or more ventilator dependent children, the facility must:
(-a-)
designate a respiratory therapy supervisor, either on staff or contracted who must be credentialed by the National Board for Respiratory Care (either CRT or RRT).
(-b-)
provide and document that all respiratory therapy staff is trained in the care of children who are ventilator dependent. This training must be reviewed annually.
(-c-)
assure that appropriate care, maintenance, and disinfection of all ventilator equipment and accessories occurs.

§19.910  Quality Assurance Early Warning System

The Department of Aging and Disability Services (DADS) uses an early warning system to detect conditions that could be detrimental to the health, safety, and welfare of residents.

(1)
Quality-of-care monitors are based in regional offices and monitor long-term care (LTC) facilities on visits that may be announced or unannounced and may occur on any day and at any time, including nights, weekends, and holidays.
(2)
Priority for monitoring visits is given to LTC facilities with a history of resident care deficiencies.
(3)
Quality-of-care monitors assess:
(A)
the overall quality of life in the facility; and
(B)
specific conditions in the facility directly related to resident care.
(4)
The quality-of-care monitor assessment visits include:
(A)
observation of the care and services rendered to residents; and
(B)
formal and informal interviews with residents, family members, facility staff, resident guests, volunteers, other regular staff, and resident representatives and advocates.
(5)
The identity of a resident or a family member of a resident interviewed by a quality-of-care monitor is confidential and may not be disclosed.
(6)
The findings of a monitoring visit, both positive and negative, will be provided orally and in writing to the facility administrator or, in the absence of the facility administrator, to the administrator on duty or the director of nursing.
(7)
The quality-of-care monitor may recommend to the facility administrator procedural and policy changes and staff training to improve the care or quality of life of residents.
(8)
Conditions observed by the quality-of-care monitor that may constitute an immediate threat to the health or safety of a resident will be immediately reported to the regional office supervisor for appropriate action and, as appropriate or as required by law, to law enforcement, adult protective services, other divisions of DADS, or other responsible agencies.

§19.911  Rapid Response Teams

(a)
Rapid response teams are comprised of one or more quality-of-care monitors who can visit long-term care (LTC) facilities identified through the Department of Aging and Disability Services' (DADS') early warning system.
(b)
Rapid response teams may visit facilities that request DADS' assistance. A visit under this subsection may not occur before the 60th day after the date of an exit interview following an annual or follow-up survey or inspection.
(c)
Rapid response teams may not be deployed for the purpose of helping an LTC facility prepare for a regular inspection or survey conducted under the Health and Safety Code, Chapters 242, 247, or 252, or in accordance with the Human Resources Code, Chapter 32.