RULES AND REGULATIONS FOR LICENSURE OF MEDICAL ASSISTANCE FACILITIES

CHAPTER 14

  Section 1. Authority. These rules are promulgated by the Department of Health pursuant to the Health Facilities Licensure Act at W. S. 35-2-901 et seq. and the Wyo- ming Administrative Procedures Act at W. S. 16-3-101 et seq.

  Section 2. Purpose. These rules have been adopted for the licensure of Medical Assistance Facilities. The purpose of these standards is to provide minimum requirements for services, structure, operation and personnel practices designed to protect the health and safety of patients and employees.

  Section 3. Severability. If any portion of this rule is found invalid or unenforce- able, the remainder shall continue in effect.

  Section 4. Definitions.

  (a) “Administrator” is the person in charge of the operation of the facility twenty-four hours per day; and is:

    (i) A Physician,

    (ii) A Mid-level Practitioner,

    (iii) A registered nurse, or

    (iv) aAn individual with training and experience in health service adminis- tration.

  (b) “Central Registry” means the registry operated by the Wyoming Department of Family Services pursuant to Wyoming Statute §14-3-213, which indexes perpetrators of child abuse or neglect and abuse, neglect, exploitation or abandonment of disabled adults. The registry information is available by calling 307-777-5366.

  (c) “Certified Nurse Aide” means a person who has successfully completed Wyoming Board of Nursing training program and competency evaluation.

  (d) “Clinical Laboratory Improvement Act (CLIA)” means the clinical laboratories approved by the U.S. Department of Health and Human Services, Health Care Financing Administration as required by 42 CFR Part 493, Section 1861 (e) and (j), the sentence following section 1861 (s)(13), and 1902(a)(9) of the Social Security Act and Section 353 of the Public Health Service Act.

  (e) “Collaborative Practice” means the implementation of the formal written plan that outlines procedures for consultation and collaboration with other health care professionals, e. g., licensed physicians and mid-level practitioners.

  (f) “Collaborative Plan” means the formal written plan between the mid-level practitioners and a licensed physician.

  (g) “Dietitian” means a person who is registered by the American Dietetic Asso- ciation and provides nutritional and dietary consultation services.

  (h) “Facility” means a medical assistance facility.

  (i) “Hospital” means an institution licensed pursuant to W.S. 35-2-901 et seq.

  (j) “Licensed Practical Nurse” (LPN) means, a person who is licensed to practice as a licensed practical nurse by the Wyoming Board of Nursing pursuant to W.S. §33-21- 120.

  (k) “Medical Assistance Facility” means a facility which provides inpatient care to ill or injured persons prior to their transportation to a hospital, or provides inpatient care to persons needing care for a period of no longer than sixty hours, and is located more than thirty miles from the nearest Wyoming hospital.

  (l) “Mid-level practitioner” means either an advanced practitioner of nursing or a physician assistant.

  (l) “Registered Nurse” is a graduate of an approved school of professional nurs- ing, who is currently licensed to practice as a registered nurse by the Wyoming Board of Nursing pursuant to W.S. §33-21-120.

  (m) “Physician” means a person licensed to practice medicine in Wyoming by the Wyoming Board of Medicine.

  (n) “Physician assistant” means a person who is approved by the Wyoming Board of Medicine to practice as a physician assistant.

  (o) “Practitioner” means a physician, mid-level practitioner of nursing, or physi- cian assistant.

  Section 5. Licensing.

  (a) Licensing requirements. The Wyoming Department of Health, Office of Health Quality, Planning and Program Evaluation (Office of Health Quality) has been duly authorized to issue licenses to Medical Assistance Facilities. The Office of Health Quality has established a system of licensure to comply with minimum requirements for the pur- pose of protecting the health, welfare and safety of patients receiving this type of service.

  (b) Licensing procedure.

    (i) For an initial license to be issued the Office of Health Quality shall receive:

      (A) A completed application form shall be submitted to the Office of Health Quality.

      (B) Licensure fee. Each application shall be accompanied by the required licensure fee outlined in Chapter 1 Rules and Regulations for Health Care Facili- ties Licensure Fees. The check or money order shall be made payable to the Treasurer, State of Wyoming.

      (C) Shall demonstrate compliance with the requirements for licen- sure as required in paragraph (c) of this section.

    (ii) For renewal of a license the Office of Health Quality shall require:

      (A) A completed application form returned by the date indicated in the cover letter.

        (I) The application forms shall be mailed by the Office of Health Quality to the facility.

      (B) License fee. Each application shall be accompanied by the required licensure fee outlined in Chapter 1, Rules and Regulations for Health Care Facili- ties Licensure Fees. The check shall be made payable to the Treasurer, State of Wyo- ming.

      (C) Must demonstrate compliance with the requirements for licen- sure as required in paragraph (c) of this section.

  (c) Requirements for licensure. The Office of Health Quality shall require:

    (i) The medical assistance facility shall be in conformity with all laws and standards relating to communicable and reportable diseases as promulgated by the De- partment of Health, Division of Preventive Medicine.

    (ii) Existing deficiencies shall not create a hazard to the health, safety or welfare of the patients.

    (iii) The medical assistance facility shall make a positive effort to correct all existing deficiencies.

    (iv) Policies and procedures shall be in place to guide operations.

    (v) There is adequate and appropriately trained staff.

    (vi) The medical assistance facility shall have an organized and imple- mented quality improvement plan.

    (vii) There shall be an approved plan of correction for all cited deficiencies.

  (d) Issuance of license.

    (i) For initial licensure the date of the license shall be:

      (A) The date of the survey, if there are no deficiencies, or

      (B) If deficiencies exist, the date that an acceptable plan of correc- tion is developed.

      (C) The period of the license shall be one year beginning on July 1st, and unless suspended or revoked, shall expire on June 30th of the following year.

  (e) Transfer of license.

    (i) No license granted shall be assignable or transferrable. A license shall apply only to the geographical location described in the license application.

      (A) Whenever ownership of a facility is transferred from the indi- vidual or entity named in the license application to any other individual or entity, written notification of change of ownership shall be made to the Office of Health Quality. The transferee shall notify the Office of Health Quality of the transfer and apply for a new license.

        (I) Any license granted to the transferee shall be subject to the plan of correction submitted by the previous owner as approved by the Office of Health Quality.

      (B) The transferor shall notify the Office of Health Quality at least thirty (30) days before the final transfer.

    (ii) If the medical assistance facility’s name is changed, the Office of Health Quality shall be advised in writing and a new license shall be issued upon receipt of the licensure fee and application.

  (f) Conditioning or revoking a license.

    (i) Denial of application - suspension or revocation of license.

      (A) An application for license may be denied or a previously issued license may be suspended or revoked for noncompliance with minimum standards as herein set forth when noncompliance jeopardizes the health, safety or welfare of patients.

    (ii) Suspension of admissions.

      (A) The Office of Health Quality may suspend new admissions or re-admissions to a medical assistance facility when conditions in the facility are such that patient needs cannot be met. Conditions in a medical assistance facility shall not jeopar- dize the patients’ health and/or safety.

    (iii) Hearings.

      (A) Any medical assistance facility aggrieved by a decision of the Office of Health Quality may request a hearing by submitting a written request within thirty (30) days of the date of the decision.

      (B) Except in matters concerned with the spread of communicable disease, as required in Sections (c) (i), the Senior Management Consultant of the Office of Health Quality shall present the preliminary decisions and reasons to the parties concerned and provide an opportunity for a hearing, if a hearing is requested, within thirty (30) days.

      (C) Hearings requested under the terms of these rules and regula- tions shall be held by the Office of Health Quality according to the provisions of the Wyo- ming Administrative Procedures Act at W.S. 16-3-113, and with the contested case rules and regulations of the Wyoming Department of Health.

  (g) Posting of license.

    (i) The current license issued by the Office of Health Quality shall be displayed in a public area within the medical assistance facility.

  (h) Survey of the medical assistance facility.

  (i) The survey of the medical assistance facility shall be arranged by the Office of Health Quality. The survey shall be performed periodically. All records of the facility shall be available to the surveyor.

    (i) Requirements of the Office of Health Quality.

    (i) The Office of Health Quality shall provide each medical assistance facility with:

      (A) A copy of these standards; and

      (B) A copy of any deficiencies found.

  Section 6. Organization and Management.

  (a) Governing Body. The medical assistance facility shall have a governing body which has the legal authority and responsibility to operate the medical assistance facility. The governing body shall:

  (i) Appoint an administrator who is responsible for managing the facility.

    (ii) Obtain a fidelity bond for client protection arising from the want of honesty, integrity or fidelity of an employee. The bond shall consist of no less than $2500 and shall be augmented in relation to the number of employees.

    (iii) Provide verification of a central registry and criminal background infor- mation check on all employees hired at the time of or after the filing of these rules. The individual agencies or corporations are responsible to initiate and follow this process to completion.

Central registry information can be obtained by contacting The Depart- ment of Family Services at 307-777-5366. (This number is subject to change.)

    (iv) Adopt, revise, and approve personnel policies; including:

      (A) Frequency of evaluations;

      (B) Insuring confidentiality of a central registry information checks.

    (v) Prepare an organizational chart that reflects the administrative control and lines of authority for the delegation of responsibility from management down to the client care level.

    (vi) The governing body shall ensure that all services provided are consis- tent with accepted standards of practice.

    (vii) The governing body shall be accountable for the quality of care pro- vided to the patient.

    (viii) There shall be policies and procedures for services offered, which shall be reviewed annually by the governing body. Policies required but not limited to:

      (A) Every patient shall be under the care of a physician or under the care of a mid-level practitioner supervised by a physician;

      (B) Whenever a patient is admitted to the facility by a mid-level practitioner, the facility’s sponsoring physician shall be notified of that fact, by phone or otherwise, within 24 hours, and a written notation of the consultation and of the physician’s approval or disapproval shall be maintained in the patient’s record;

      (C) A physician, a mid-level practitioner or a registered nurse shall be on duty and be physically available in the facility.

      (D) No patient is cared for in the facility for more than 60 hours.

    (ix) ab Personnel Records.

      (A) ab There shall be one person designated responsible for maintaining the confidentiality.

  (x) Employee Health. The medical assistance facility shall:

      (A) Develop policies and procedures for employee health including a policy identifying communicable diseases that could put the client population at risk.

    (xi) Advanced Directives.

      (A) The medical assistance facility shall adopt policies which assure that they provide information on advanced directives to clients. If the client’s advanced directives are known they shall be followed by the medical assistance facility.

    (xii) Services:

      (A) Furnished services, including the contracted services, shall comply with all applicable licensure standards; and

      (B) Medical and nursing staff shall be licensed, certified, or regis- tered according to Wyoming law and rules.

      (C) Staff member shall provide health services only within the scope of his or her license, certification or registration.

  Section 7. Medical Staff

  (a) The facility shall have a medical staff that includes at least one physician, and may also include one or more mid-level practitioners, and does the following:

    (i) Examines the credentials of candidates for medical staff membership and makes recommendations to the governing body on the appointment of the candidate;

    (ii) Adopts a collaborative plan containing the following, and enforces the collaborative plan after approval by the governing body;

      (A) A statement of the duties and privileges of each category of medical staff (e.g., physician and mid-level practitioner); and

      (B) A requirement that a physical examination be made and medical history taken of a patient by a member of the medical staff no more than 24 hours after the patient’s admission to the facility.

  (b) A physician on staff shall:

    (i) Provide medical direction for the facility’s health care activities and consultation for non-physician health care providers;

    (ii) In conjunction with the mid-level practitioner staff members, partici- pate in developing, executing, and periodically reviewing the facility’s written policies and the services provided to patients;

    (iii) Review and sign the records of each patient admitted and treated by a mid-level practitioner no later than fifteen (15) days after that patient’s discharge from the facility;

    (iv) Provide health care services to the patients in the facility, whenever needed and requested;

    (v) Prepare guidelines for the medical management of health problems, including conditions requiring medical consultation and/or patient referral; and

    (vi) At intervals no more than two weeks apart, be physically present in the facility for a sufficient time to provide the medical direction, medical care services, and staff consultation required by the collaborative plan;

      (A) When not present, either be available through direct telecommu- nication for consultation and assistance with medical emergencies, and patient referral, or ensure that another physician is available for the purpose;

      (B) However, the physical site visit for a given two week period is not required if, during that period, no inpatients have been treated in the facility.

  (c) A mid-level practitioner on staff shall:

    (i) Participate in the development, execution, and periodic review of the guidelines and written policies governing the services furnished by the facility;

    (ii) Participate with a physician in a review of each patient’s health records;

    (iii) Provide health care services to patients according to the facility’s policies;

    (iv) Arrange for, or refer patients to needed services that are not provided at the facility; and

    (v) Assure that adequate patient health records are maintained and trans- ferred as necessary when a patient is referred.

  Section 8. Nursing Services.

  (a) A medical assistance facility shall have a nursing service program that pro- vides 24-hour services whenever a patient is in the facility and meets the following requirements:

    (i) The director of nursing services shall:

      (A) Be a Wyoming licensed registered nurse.

      (B) Determine the type and number of nursing personnel and staff necessary to provide nursing care; and

      (C) Schedule adequate numbers of licensed registered nurses, li- censed practical nurses, certified nursing assistants and other personnel to provide nurs- ing care as needed.

    (ii) A registered nurse shall be on duty at least eight hours per day, and the director of nursing or another registered nurse designated as the director’s alternate shall be on call and available within 20 minutes at all times.

    (iii) All drugs and biologicals shall be administered by a nurse, a physician, or a mid-level practitioner according to;

        (A) Federal and state law and regulations, including applicable li- censing requirements.

  Section 9. Pharmaceutical Services.

  (a) The facility shall have pharmaceutical services that meet the needs of the patients and comply with the following standards:

    (i) A drug storage area under the supervision of the Director of Nursing who shall develop, supervise, and coordinate all of the pharmacy services.

    (ii) The pharmacy or drug storage area shall be administered according to accepted professional standards.

    (iii) All compounding, packaging, and dispensing of drugs and biologicals shall be consistent with federal and state law.

    (iv) Drugs and biologicals shall be kept in a locked storage area.

    (v) Outdated, mislabeled, or otherwise unusable drugs and biologicals shall be destroyed by grinding in a garbage disposal or incineration; and

    (vi) Drug administration errors, adverse drug reactions, and incompatibili- ties shall be immediately reported to the attending practitioner.

  Section 10. Radiologic Services.

  (a) The facility shall maintain, or have available, diagnostic radiologic services, which shall meet the following standards:

    (i) The radiologic services shall be free from radiation hazards for patients and personnel.

    (ii) Annual inspection of equipment shall be made and hazards identified are promptly corrected.

    (iii) Radiation workers shall continuously wear monitoring badges that are to be checked quarterly to determine the amount of radiation to which they are routinely exposed.

    (iv) A qualified full-time, part-time, or consulting radiologist shall be uti- lized to interpret those radiographic tests that are determined by the medical staff to require a radiologist’s specialized knowledge.

      (A) The radiologist or other practitioner who provides radiology services shall sign each report containing his/her interpretations.

    (v) Only personnel designated as qualified by the medical staff, and meet- ing requirements of state law, may use the radiographic equipment and administer proce- dures.

    (vi) The facility shall maintain any radiographic studies and their interpreta- tions for at least five years.

  Section 11. Laboratory Services.

  (a) The facility shall maintain, or have available, clinical laboratory services ad- equate to fulfill the needs of its patients and meeting the following standards:

    (i) The facility, at a minimum, shall provide basic laboratory services essential to the immediate diagnosis and treatment of patients, including:

      (A) Chemical examinations of urine by stick or tablet methods, or both (including urine ketones);

      (B) Microscopic examinations of urine sediment;

      (C) Hemoglobin or hematocrit;

      (D) Blood sugar;

      (E) Gram stain;

      (F) Examination of stool specimens for occult blood;

      (G) Pregnancy tests;

      (H) Primary culturing for transmittal to a CLIA certified laboratory;

      (I) Sediment rate, and

      (J) CBC.

    (ii) The facility shall have a contractual agreement with a CLIA approved hospital or independent laboratory for any additional laboratory services that are needed by a patient.

    (iii) Emergency provision of basic laboratory services shall be available 24 hours a day.

    (iv) Only personnel designated as qualified by the medical staff by virtue of education, experience, and training may perform and report laboratory test results.

    (v) The laboratory shall be a CLIA certified laboratory.

  Section 12. Food and Dietetic Services.

  (a) The facility shall have dietary services that are directed and staffed by ad- equate personnel and meet the following standards:

    (i) The facility shall assign an employee or contract with a consultant to direct the food and dietetic service and to be responsible for the daily management of the dietary service.

      (A) The minimum qualifications would be an individual qualified by experience and training as a food service supervisor.

    (ii) The facility shall utilize a qualified dietitian, full-time, part-time, or on consultant basis.

    (iii) A therapeutic diet for a patient shall be prescribed by the practitioner responsible for the care of the patient.

    (iv) Nutritional needs shall be met in accordance with recognized dietary practices and, at a minimum, the recommended daily dietary allowances established by the Food and Nutrition Board of the National Research Council, National Academy of Sciences, 1989.

    (v) A current therapeutic diet manual approved by the dietitian and medi- cal staff shall be readily available to all medical, nursing, and food service personnel.

  Section 13. Required Contracted Services.

  (a) The facility shall enter into agreements with one or more hospitals participat- ing in Medicare/Medicaid program to provide services which the facility itself is unable to provide.

  Section 14. Medical Records.

  (a) The facility shall maintain a medical records system in accordance with writ- ten policies and procedures:

    (i) The facility shall employ adequate personnel to ensure professional standards of practice for medical records are met.

    (ii) The facility shall create and maintain a record for each person receiv- ing health care services from the facility that includes, if applicable:

      (A) Identification and social data;

      (B) Admitting diagnosis;

      (C) Pertinent medical history;

      (D) Properly executed consent forms;

      (E) Reports of physical examinations, diagnostic and laboratory test results, and consultation findings;

      (F) All physician’s orders, nurse’s notes, and reports of treatments and medications;

      (G) Final diagnosis;

      (H) Discharge summary; and

        (I) Any other pertinent information necessary to monitor the patient’s prognosis.

    (iii) Each record shall include the signatures of the physician and the health care professionals documentation.

    (iv) Records of a discharged patient shall be completed within fifteen (15) days of the discharge date.

    (v) The facility shall have written policies and procedures ensuring the confidentiality of patient records, safeguards against loss, destruction, or unauthorized use, in accordance with applicable state and federal law and including policies and proce- dures which:

      (A) Govern the use and removal of records from the record storage area;

      (B) Specify the conditions under which record information may be released and to whom;

      (C) Specify when the patient’s written consent is required for re- lease of information.

  Section 15. Quality Improvement

  (a) The governing body in accordance with State Statute 35-2-910, shall ensure there is an effective, on-going, facility-wide, written quality improvement program which ensures and evaluates the quality of the patient care provided and includes:

    (i) At least annually the quality improvement program shall review the following:

      (A) The utilization of facility services, including at least the number of patients served and volume of services.

      (B) The facility’s health care policies.

  (b) The taking and documentation of appropriate remedial action to address deficiencies found through the quality assurance program, as well as documentation of the outcome of remedial action.

  Section 16. Infection Control.

  (a) The facility shall:

    (i) Maintain a sanitary environment which prevents the transmission and sources of infections and communicable diseases.

    (ii) Develop and implement policies governing control of infections and communicable diseases.

    (iii) Maintain a log of incidents related to infections and communicable diseases.

  Section 17. Physical Environment

  (a) ab The medical assistance facility shall be constructed, arranged, and maintained to ensure the health and safety of the patient, and to provide for diagnosis and treatment.

    (i) The building interior and exterior shall be clean, orderly, sanitary, and free of odors.

    (ii) Each patient room must have a nurse call system which has an indica- tion light outside of the room and sounds an alarm at the nurses’ station.

      (A) The nurse call system shall only be turned off in the patient’s room.

      (B) The nurse call system shall function also in toilet and bath ar- eas.

    (iii) A comfortable room temperature not to exceed 78o or less than 70o at 36 inches above the floor.

    (iv) All essential mechanical and electrical equipment shall be maintained in safe operating condition.

    (v) Continuous mechanical ventilation shall be provided.

    (vi) Corridors shall be equipped with firmly secured handrails on each side.

    (vii) Single patient rooms shall have at least 100 square feet of floor space and multiple patient rooms shall have at least 80 square feet of floor space per patient.

      (A) The following areas shall not be counted in the floor space requirements:

        (I) Floor space in a vestibule,

        (II) Floor space under a door swing area,

        (III) Floor space under permanent fixtures (e.g. closets);

        (IV) Other floor space not usable by the patient.

  (b) The medical assistance facility shall meet the 1994 edition of the Life Safety Code of the National Fire Protection Association applicable to health care facilities.

  (c) A written facility fire safety plan shall provide:

    (i) Use of fire alarms;

    (ii) Transmission of firm alarm to fire department;

    (iii) Response to fire alarms;

    (iv) Isolation of fire;

    (v) Evacuation of area;

    (vi) Preparing building for evacuation;

    (vii) Fire extinguishment;

    (viii) Protection of patients, visitors, staff; and

    (ix) Cooperation with local fire fighting authorities.

  Section 18. Construction/Remodeling

  (a) If the physical plant was a Medicare/Medicaid certified hospital within twenty-four months prior to opening as a medical assistance facility and no renovation has been done, then the physical plant will be grandfathered.

  (b) If there has been:

    (i) Renovation to the physical plant; or

    (ii) The building has been closed as a Medicare/Medicaid certified hospital for more than twenty-four months; or

    (iii) The building is new construction;

    (iv) Then the building shall meet all requirements established in:

      (A) Current edition of Section 9. 6 Freestanding Emergency Facility of Guidelines for Construction of Hospitals and Medical Facilities, and

      (B) Chapter III Construction Rules for Health Facilities.

  (c) All plans and specifications for construction and/or remodeling shall be ap- proved by the Office of Health Quality prior to construction.