Texas Department of Aging and Disability Services
Nursing Facility Requirements for Licensure and Medicaid Certification Handbook
Revision: 14-1

Subchapter W

§19.2204  Voluntary Certification of Facilities for Care of Persons with Alzheimer's Disease

(a)
A facility may apply for certification as a facility that provides specialized care for Alzheimer's disease and related disorders either at the time of the initial application for a license or at any time subsequent to the issuance of a license under this chapter.
(b)
Application must be made on forms prescribed by the Texas Department of Human Services (DHS). The application fee must accompany the application as provided in §19.216(c) of this title (relating to License Fees).
(c)
A facility licensed under this chapter is not required to apply for certification under this section in order to provide care and treatment of persons with Alzheimer's disease and related disorders.
(d)
A facility may not advertise or otherwise communicate that the facility is certified by DHS to provide specialized care for persons with Alzheimer's disease or related disorders unless the facility is certified under this subchapter.

§19.2206  General Requirements for a Certified Facility

(a)
Resident admission. The facility must admit and retain only residents whose needs can be met through service from the facility staff, or in cooperation with community resources or other providers under contract.
(b)
Allowable number of residents. Each certificate must specify the maximum allowable number of residents to be cared for at any one time in the certified area. No greater number of residents must be kept in the certified area than is authorized by the certificate.
(c)
Nullification of certificate. When a certificate becomes null and void, the facility must remove the certificate from display and advertising, and the certificate must be surrendered to DADS on request. A certificate is nontransferable and nonassignable; therefore, a certificate existing at the time of change of ownership becomes null and void.
(d)
Display of certificate. A certificate must be displayed in a prominent location for public view. The facility may advertise as long as the certificate is in effect; however, the type of advertising must be such that the advertising can be withdrawn if the certificate becomes null and void. Upon removal of the certificate it is the responsibility of the facility to inform interested persons of the revised status. The certificate is the property of DADS.
(e)
Cancellation of certificate. A certificate must be canceled if DADS finds that the certified unit is not in compliance with applicable laws and rules.
(f)
Effective period of certificate. An initial certificate that is based on an application submitted to DADS on or after January 1, 2014, or a renewal certificate that has an effective date on or after January 1, 2014, is valid for three years.

§19.2208  Standards for Certified Alzheimer's Facilities

(a)
General requirements.
(1)
Residents eligible for admission to Alzheimer's units will have a diagnosis of Alzheimer's disease or related dementing disorders. The need for admission to the Alzheimer's unit must be documented by the attending physician.
(2)
Security and safety measures are provided to prevent the residents from harming themselves or leaving designated indoor or outdoor areas without supervision by staff members or other responsible escort. Policies will also be provided to prevent abuse of the rights and property of other residents.
(3)
Understanding that security measures to prevent wandering may infringe on resident rights, care must be exercised in the use of physical restraint or barriers, or chemical restraint. The specific purpose and time-limited orders for any additional physical or chemical restraint must be written and renewed according to facility policy. The frequency of such renewal must not exceed 60 days.
(4)
Activity and recreational programs will be provided and utilized to the maximum extent possible for all residents in order to promote physical well being and help with behavior management. The program must be tailored to the individual resident's needs, being appropriate for his specific impairment and stage of disease.
(5)
Residents are provided privacy in treatment and in care for his or her personal needs.
(6)
Access to outdoor areas must be provided and such areas must have suitable walls or fencing that do not allow climbing or present a hazard. If the enclosed area involves exit doors from the building, the following must be met:
(A)
The minimum distance of the fence from the building must be:
(i)
8'-0" from the building exit if the fence is parallel to the building and there are no window openings; or
(ii)
20'-0" from bedroom window(s) if the fencing is solid and 15'-0" from bedroom window(s) if the fencing is open similar to chain-link (parallel with building walls).
(B)
The minimum area of enclosure must be 800 square feet. Exception: If the enclosed space has an area of refuge which extends beyond a minimum of 20'-0" from the building and the area of refuge is equal to or greater than 15 square feet per resident for the wing(s) enclosed.
(C)
Exit gate(s) from the enclosure to a public way must comply with the following criteria:
(i)
A minimum of two gates must be remotely located from each other if only one wing or exit is enclosed. If the enclosed space between the building and the fence is less than 10'-0", one of the remotely located exit gates must be directly in line with the building exit door.
(ii)
If two or more wings are enclosed by the fencing and entry access can be made at each door, a minimum of one gate is required.
(iii)
The gate(s) must be located to provide a continuous path of travel from the building exit to a public way including walkways of concrete, asphalt, or other approved materials suitable for wheeled beds, chairs, and stretchers. Gates and walkways must be wide enough to accommodate beds and wheelchairs.
(D)
If gates are locked, the gate nearest the exit from the building must be locked with an electronic lock which operates the same as electronic locks on corridor control doors and/or exit doors and is in compliance with the National Electrical Code for exterior exposure. Additional gates may also have electronic locks or may have keyed locks provided staff carry the keys. A gate between two enclosed wings may have a keyed lock provided access can be gained into both wings from the exterior.
(E)
Fencing material must comply with the following:
(i)
Wood — no limit on height, should be constructed with posts and support members on the exterior to deter residents from climbing over fence.
(ii)
Wire — if chain-link type fence, provide protection on top of the fence to prevent resident injury from pointed wire.
(7)
Any security measures taken to provide for the safety of wandering patients should be as unobtrusive as possible.
(8)
Toxic garden plantings must be prohibited.
(b)
Staff.
(1)
All assigned staff members and consultants to the unit must have documented training in the care and handling of Alzheimer's residents, including at least:
(A)
eight hours of orientation to cover the following:
(i)
facility Alzheimer's policies;
(ii)
etiology and treatment of dementias;
(iii)
stages of Alzheimer's disease;
(iv)
behavior management; and
(v)
communication; and
(B)
four hours of the required annual continuing education must be in Alzheimer's disease or related disorders.
(2)
A social worker, licensed or temporarily licensed by the State of Texas, must be utilized as Community/Family Support Coordinator whose functions must include:
(A)
evaluation of resident's initial social history on admission;
(B)
utilization of community resources;
(C)
conducting quarterly family support group meetings; and
(D)
identification and utilization of existing Alzheimer's network.
(3)
Specially trained staff will be maintained and assigned exclusively to the Alzheimer's unit. Although emergency scheduling may require substitution of staff, every effort should be made to provide residents with familiar staff members in order to minimize resident confusion. Staff training will meet at least the minimum requirements in subsection (a)(2) of this section.
(4)
Required overall minimum staffing ratios for direct care in certified Alzheimer's units in nursing facilities are as follows:

SHIFT STAFF : RESIDENTS
7:00 a.m. - 3:00 p.m.
(Day)
1 : 6
3:00 p.m. - 11:00 p.m. 1 : 10
11:00 p.m. - 7:00 a.m. 1 : 18


(c)
Physical plant. Alzheimer's units must be segregated from other parts of a facility with appropriate security devices and/or measures and must meet the following requirements.
(1)
Living rooms, day rooms, lounges, and sun rooms, must be provided on a sliding scale as follows:

Number of Beds Area Per Bed (Minimum)
4 - 15 18 square feet (Minimum 144 square feet)
16 - 20 17 square feet
21 - 25 16 square feet
26 - 30 15 square feet
31 - 35 14 square feet
36 - 40 13 square feet
41 - 50 12 square feet
51 - 60 11 square feet
61 and over 10 square feet (Example: 100 beds equals
1,000 square feet)

(2)
A dining area must a minimum of 10 square feet per resident with at least one exterior window(s).
(3)
Bathtubs or showers must be provided at a minimum rate of one for each 20 beds in nursing facilities.
(4)
Water closets and lavatories must be provided at a minimum rate of:
(A)
one for each eight beds in nursing facilities; and
(B)
one for each 15 clients in adult day health care facilities.
(5)
In all facilities a lavatory must be provided in or adjacent to each area having a water closet.
(6)
A monitoring station for staff must be provided with the following:
(A)
writing surface such as a desk or built-in counter top;
(B)
chair;
(C)
task illumination;
(D)
communication system such as a telephone or intercom to the main staff station of the facility; and
(E)
storage for resident records such as a lockable metal cabinet or storage closet.
(7)
Two remote exits must be provided in order to meet Life Safety Code requirements.
(8)
Corridor control doors, if used for security of the residents, must be similar to smoke doors, that is, be 44 inches in width each leaf, and must swing in opposite directions. A latch or other fastening device on a door must be provided with a knob, handle, panic bar, or other simple type of releasing device, the method of operation of which is obvious, even in darkness.
(9)
Locking devices may be used on the control doors provided the following criteria are met.
(A)
The building must have a complete sprinkler system and/or a complete fire alarm system including a corridor smoke detection system or smoke detectors located in each resident bedroom, which are interconnected into the fire alarm system.
(B)
The locking device must be electronic and must be released when the following occurs:
(i)
activation of the fire alarm or sprinkler systems;
(ii)
power failure to the facility; and
(iii)
pressing a button located at the main staff station and at the monitoring station.
(C)
Key pad or buttons may be located at the control doors for routine use by staff for service.
(D)
Upon loss of primary power, the control doors must not automatically reset on emergency power, but must be reset by manual means only. An exception is when the control doors are not in an exit access, they may automatically reset on emergency power. There must be at least two remote exits (on each side of the control doors) which meet all of the requirements for exits, such as proper width of egress and proper size of exterior doors, according to the 1985 Life Safety Code.
(10)
The exit door(s) may be equipped with a locking device provided one of the following methods is met:
(A)
the locking arrangement meets Section 5-2.1.6 of the Life Safety Code, or
(B)
the following criteria which have been approved by the Health Care Financing Administration (HCFA):
(i)
The building must have a complete fire alarm system including a corridor smoke detection system or smoke detectors located in each resident bedroom and/or a complete sprinkler system which are interconnected to the fire alarm system.
(ii)
The locking device must be electro-magnetic; that is, no type of throw-bolt is to be used.
(iii)
The device must release when the following occur(s):
(I)
activation of the fire alarm or sprinkler system;
(II)
power failure to the facility; and
(III)
activating a switch located at the main staff station and at the monitoring station.
(iv)
Upon loss of primary power, the exit door(s) must not automatically reset on emergency power, but must be reset by manual means only.
(v)
A manual fire alarm pull must be located within 5'0" of the exit door with a sign stating, "Pull to release door in an emergency."
(vi)
A key pad, card, control button, or other electronic device may be located at the exit door for routine use by staff.
(vii)
Staff are to be trained in the methods of releasing the locking device.