902 KAR 20:280. Standards for prescribed pediatric extended care.

 

      RELATES TO: KRS 216.875, 216.880, 216.885

      STATUTORY AUTHORITY: KRS 216.042, 216.890

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 216.042 mandates that the Kentucky Cabinet for Human Resources regulate health facilities and health services. KRS 216.890 mandates that the Kentucky Cabinet for Human Resources promulgate standards to regulate prescribed pediatric extended care (PPEC) services.

 

      Section 1. Definitions. (1) "Developmentalist" is a master's prepared individual with current experience in transdisciplinary evaluation and treatment planning for children who are at risk for or experiencing developmental delay.

      (2) "Protocol of care" is the comprehensive plan for implementation of medical, nursing, psychosocial, developmental, and educational therapies to be provided by the PPEC. An individualized protocol of care shall be developed upon admission and shall be revised to include recommended changes in the therapeutic plans. The disposition to be followed in the event of emergency situations shall be specified in the protocol of care.

      (3) "Prescribing physician" is the physician, licensed pursuant to KRS 311.571, who signs the order admitting the child to the PPEC.

      (4) "Primary physician" is the physician, licensed pursuant to KRS 311.571, who maintains overall responsibility for the child's medical management and is available for consultation and collaboration with the PPEC staff.

      (5) "Medical director" is a board certified pediatrician who serves as the liaison between the PPEC and the medical community, reviews the quality and appropriateness of PPEC services, and is available for consultation to the PPEC staff.

      (6) "Nursing director" is a licensed registered nurse, pursuant to KRS 314.041, responsible for providing continuous supervision of PPEC services and managing the daily operations of the facility.

      (7) "Occupational therapist" means a person who is licensed pursuant to KRS 319A.080.

      (8) "Speech pathologist" means a person who is licensed pursuant to KRS 334A.050.

      (9) "Social worker" means a person who is licensed pursuant to KRS 335.090, if applicable, and who is a graduate of a school of social work accredited by the Council on Social Worker Education.

      (10) "Physical therapist" means a person who is licensed pursuant to KRS 327.050.

      (11) "Child life specialist" is an individual with baccalaureate preparation in child life, early childhood education, or a related field and current experience in planning and implementing developmental stimulation programs for children.

 

      Section 2. Scope of Operation and Services. The prescribed pediatric extended care (PPEC) center is a nonresidential health care service which provides an important link in the continuum of care for medically or technologically dependent children. The (PPEC) center provides the following triad of necessary services for dependent children and their parents: day health care, developmental interventions, and parental training.

 

      Section 3. Applicability. (1) All prescribed pediatric extended care facilities shall be equipped and staffed to accommodate no fewer than three (3) medically/technologically dependent children and shall meet standards established herein.

      (2) All PPEC facilities shall have a minimum full-time equivalent staff of two (2) registered nurses and one (1) nursing assistant. Thereafter, the ratio of staff to children shall be maintained at:

 

3-12 children

2 RN's plus 2 others

13-18 children

3 RN's plus 3 others

19-24 children

4 RN's plus 4 others

 

      Section 4. Criteria for Admission. (1) Infants and children considered for admission to the PPEC facility shall be those with complex medical conditions requiring continual care, including but not limited to, supplemental oxygen, ventilator dependence, cystic fibrosis, apnea, spinal cord injury and malignancy, etc.

      (2) Children with risk of infection shall not be admitted unless authorized by the prescribing physician.

      (3) The primary physician, in consultation with the parent(s) or legal guardian(s), shall recommend placement in a PPEC facility, taking into consideration the medical, emotional, psychosocial and environmental factors.

      (4) The child shall be medically stabilized, require ongoing nursing care, and other interventions.

 

      Section 5. Preadmission Conference. (1) If the child meets the admission criteria, the primary physician or his/her designate shall contact the medical or nursing director of the PPEC to schedule a preadmission conference.

      (a) If the child is hospitalized at the time of referral, preadmission planning shall include the parent(s) or guardian(s), relevant hospital medical, nursing, social services and developmental staff to assure that the discharge plans shall be accommodated following placement in the PPEC.

      (b) If the child is not hospitalized at the time of referral, preadmission planning shall be conducted with the primary physician, parent(s) or guardian(s), PPEC representatives and representatives of other relevant agencies as determined by the primary physician, and nursing director of the PPEC.

      (c) Preadmission planning shall be scheduled within seventy-two (72) hours and allow sufficient time to assure that the therapeutic plan can be implemented upon placement in the PPEC.

      (d) The protocol for care shall be developed by the PPEC staff following preadmission planning.

      (e) The protocol for care shall include specifications of criteria for discharge from the PPEC.

      (2) A consent form, outlining the purpose of a PPEC facility, family responsibilities, authorized treatment and appropriate liability releases, and emergency disposition plans shall be signed by the parent(s) or guardian(s) and witnessed prior to admission to the PPEC facility. The parent(s) or guardian(s) and the PPEC facility shall be provided a copy of the consent form.

 

      Section 6. Admission Procedure. (1) Infants and children shall be considered for admission to the PPEC facility if they have complex medical conditions requiring skilled nursing care, e.g., children with conditions including but not limited to, supplemental oxygen, ventilator dependence, cystic fibrosis, apnea, spinal cord injury and malignancy, etc.

      (2) In consultation with the parent(s) or legal guardian(s), a child may be referred to the PPEC medical or nursing director for determination of placement.

      (3) All children placed in the PPEC facility shall have documentation of a physician's written order placed in the child's medical record. A copy of the order shall be provided to the child's parent(s) or guardian(s).

      (4) Prior to placement, preadmission planning conferences shall be held for the purpose of developing a protocol for care.

      (5) The protocol for care shall be developed under the direction of the PPEC nursing director and shall specify the treatment plan needed to accommodate the medical, nursing, psychosocial and educational needs of the child and family. Specific goals for care shall be identified. Plans for achieving the goals shall be determined and a schedule for evaluation of progress shall be established. The protocol shall include specific discharge criteria.

      (6) The protocol shall be signed by the physician, authorized representative of the PPEC and parent(s) or guardian(s). Copies of the protocol shall be given to the parent(s) or guardian(s). Copies of the protocol shall be given to the parent(s) or guardian(s) primary physician, PPEC staff and other agencies as appropriate.

      (7) A consent form, outlining the purpose of a PPEC facility, family responsibilities, authorized treatment, appropriate liability releases, and emergency disposition plans shall be signed by the parent(s) or guardian(s) and witnessed prior to admission to the PPEC facility. The parent(s) or guardian(s) and the facility shall be provided a copy of the consent form.

 

      Section 7. Provision of Services. (1) Medical staff services.

      (a) Children shall be admitted to the PPEC upon prescription by the child's primary physician or by the medical director.

      (b) The child's primary physician shall maintain responsibility for the overall medical therapeutic plan and shall be available for consultation and collaboration with the PPEC medical and nursing personnel.

      (c) The medical director shall participate in reviews of the protocol for care. Prescribed therapies shall be adjusted in consultation with the primary physician to accommodate the child's condition.

      (d) The PPEC shall coordinate the prescribed therapies for the child.

      (2) Nursing staff services.

      (a) A PPEC nursing staff member shall participate in preadmission planning.

      (b) Nursing personnel, under the direction of the nursing director, shall be responsible for implementing the nursing care.

      (c) Nursing personnel shall be responsible for monitoring and documenting the effects of prescribed therapies.

      (d) Nursing personnel shall inform the primary physician and medical director of the results of therapeutic interventions.

      (e) Nursing personnel shall participate in interdisciplinary staffings regarding the child's progress.

      (f) Nursing personnel shall assure that the PPEC provides an environment conducive to the stabilization of the child's medical condition and the promotion of the child's development.

      (g) Nursing personnel shall be responsible for maintaining the child's record in accordance with facility policies and procedures.

      (h) Nursing personnel shall instruct the parent(s) or guardian(s) in how to provide the necessary therapies in the home.

      (3) Developmental services.

      (a) Each child shall have a functional assessment and an individualized program plan to accommodate the child's developmental needs. The following functional areas shall be included as appropriate: self care, communication skills, social skills, motor skills, preacademic areas, play with toys/objects, growth and development appropriate for age.

      (b) The child's program plan shall include specific programs and action steps to facilitate developmental progress and shall be reviewed at least quarterly.

      (c) The child's developmental and educational needs shall be incorporated into the protocol for care.

      (d) The child's program plan shall include:

      1. Measurable goals in need areas or goals to enhance and normalize independent functioning in daily activities.

      2. A description of the patient's strengths and present performance level with respect to each goal;

      3. Skill areas in priority order;

      4. Anticipatory planning for specific areas identified as at-risk for future problems.

      (e) The child life specialist shall participate in regularly scheduled interdisciplinary staffings.

      (f) A program for parent(s) or guardian(s) shall be provided to prepare parent(s) or guardian(s) to accommodate the child's developmental needs.

      (g) The PPEC shall provide parent(s) or guardian(s) education services by including them in care-related conferences and teaching them how to perform necessary therapies and how to meet the developmental and psychosocial needs of their child at home.

      (h) PPEC staff shall make referrals to appropriate resources, facilitate access to community, social, educational and financial services, and shall provide counseling to enhance coping skills, interpersonal relationships and family functioning.

      (4) Nutritional services.

      (a) Therapeutic diets shall be maintained in the patients file.

      (b) The services of a registered dietician shall be available regarding the nutritional needs, the special diets of individual children, and to assist in the development of policies and procedures for the handling, serving, and storage of food.

      (c) All food and formula except for specialized formula shall be provided by PPEC staff under the supervision of the nursing director.

      (d) Prepared foods shall be kept under refrigeration with identifying dates and patient names.

 

      Section 8. Quality Assurance. (1) The PPEC center shall ensure that there is an effective, quality assurance program to evaluate the provision of patient care.

      (2) The quality assurance program shall be ongoing and have a written plan of implementation.

      (a) All organized services related to patient care, including services furnished by a contractor, shall be evaluated, semiannually.

      (b) Nosocomial infections and medication therapy shall be evaluated.

      (c) Evidence of parent(s) or guardian involvement shall be evaluated semiannually.

 

      Section 9. Administration. (1) The administrative structure of the PPEC shall include a policy and procedure manual which reveal all operational aspects of the service.

      (2) Personnel policies and procedures shall specify qualifications and required ratios of staff members employed by PPEC and shall include: a current personnel file, positions descriptions, employee benefits, policies for overtime, compensatory time, performance evaluations, termination of employment.

      (3) A formal orientation and development program is required for all PPEC employees and staff.

      (4) The facility shall be administered on a sound financial basis consistent with good business practice. Financial records which identify all income by source and describe all expenditures by category in such a manner as to be auditable by commonly recognized procedures.

      (5) Policies and procedures pertaining to PPEC services shall be available to the public and shall include:

      (a) A procedure manual with specifications for each therapeutic intervention shall be available for use by all staff involved in the care of the children; the manual shall be reviewed every six (6) months to assure that procedures conform to prevailing and acceptable treatment modalities.

      (b) An admission and discharge register, listing clients admitted by name with identifying information about each and the source from which the child was admitted, the reason for disposition, adequate identifying information and the place to which the individual is to be discharged;

      (c) A daily census record;

      (d) An accident and incident record;

      (e) A complete medical and nursing history shall be maintained for each child;

      (f) Periodic review of each child's protocol of care to update the protocol in consultation with other professionals involved in the child's care. Changes in the orders shall be documented and signed by the primary physician;

      (g) Prior to a discharge, conferences involving PPEC staff, the primary physician, the parent(s) or guardian(s) and staff of other agencies involved in the patient's care shall be held to discuss postdischarge care and follow-up;

      (h) A discharge order written by the primary physician shall be documented and entered in the child's record. A discharge summary, which includes the reason for discharge, shall also be included in the record.

      (i) Except in emergency situations, other agencies involved in the care of the patient/family shall be notified prior to the discharge date.

      (j) The center shall have linkage agreements through written agreements with providers of other levels of care which may be medically needed to supplement the services available at the center.

      (k) The center shall have written policies which assure the reporting of cases of abuse, neglect, or exploitation of children to the Cabinet for Human Resources pursuant to KRS 199.335.

 

      Section 10. Personnel. (1) A board certified pediatrician shall serve as the medical director for the PPEC facility. Responsibilities shall include:

      (a) Participation in preadmission planning to establish a protocol of care with the primary physician, parent(s) or guardian(s) and staff of the PPEC center;

      (b) Periodic review of services to assure acceptable levels of quality;

      (c) Maintenance of a liaison role with the medical community;

      (d) Advisement on the development of new programs and modifications of existing programs; and

      (e) Assurance that medical consultation shall be available in the event of his/her absence.

      (2) A nursing director shall be employed to provide continuous supervision of PPEC services and shall be responsible for daily operations of the facility.

      (a) In addition the nursing director shall be responsible for:

      1. All services rendered at the center;

      2. Personnel management;

      3. Organization and implementation of in-service education programs for staff;

      4. Assistance to medical director in determining patient eligibility for admission to PPEC;

      5. Assurance of adequate nursing representation at preadmission conference; and

      6. Supervision of all patient records and documentation of center's activities to assure compliance to rules and administrative regulations.

      (b) Credentials and training.

      1. Registered nurse with a current license in the state of Kentucky.

      2. Nursing services shall be provided within their respective scope of practice pursuant to KRS Chapter 314 and any administrative regulations promulgated thereunder.

      3. The nursing director shall have at least two (2) years nursing experience of which six (6) months shall have been spent in a pediatric intensive care or neonatal intensive care setting during the previous five (5) years.

      (3) Staffing.

      (a) The PPEC center shall employ nursing and ancillary staff that are necessary to provide the services essential to the center's operation.

      (b) There shall be an individual personnel record for each person employed by the center which includes the following:

      1. Resume with employee's training and experience;

      2. Evidence of current licensure or registration;

      3. Reports of all accidents occurring on duty; and

      4. Current certification in basic life support.

      (c) The following categories of personnel shall be available to the PPEC on an in-house or consultant basis:

      1. Developmentalist.

      2. Child life specialist.

      3. Occupational therapist.

      4. Physical therapist.

      5. Speech pathologist.

      6. Social worker.

 

      Section 11. In-service Training for Staff/Parents and Guardian(s). (1) Monthly staff development programs appropriate to the category of personnel shall be conducted to maintain quality patient care.

      (2) All staff development programs shall be documented.

      (3) All personnel shall be expected to maintain current certification in basic life support.

      (4) Each new employee shall participate in orientation to acquaint the employee with the philosophy, organization, program, practices, and goals of the PPEC facility.

      (5) A comprehensive orientation to acquaint the parent(s) and/or guardian(s) with the philosophy and services shall be provided at the time of the child's placement in the PPEC.

      (6) Staff development programs shall be provided to:

      (a) Facilitate the ability of the staff to function as a member of an interdisciplinary team which includes health professionals and the parent(s) and/or guardian(s).

      (b) Improve communication skills to facilitate a collaborative relationship between parent(s) and/or guardian(s) and professionals.

      (c) Increase understanding the effects childhood illness has on the child's development and the parent(s) and/or guardian(s).

      (d) Increase understanding and coping with the effects of childhood illnesses and shall cover a variety of topics including: issues of death and dying; awareness of services available at the hospital, school, community, state, and professional organizations, and fostering of advocacy skills.

      (e) Develop case management skills to assist the family in setting priorities and planning and implementing the child's care at home.

      (f) Provide training in the implementation of new technology.

      (g) Develop a comprehensive protocol for care which includes the medical, nutritional, developmental and psychosocial needs of medically/technologically dependent children.

      (h) Prepare for management of emergency situations.

 

      Section 12. Physical Environment. (1) The building shall be suitable for the purpose intended and should maintain a minimum of sixty (60) square feet of space per child, exclusive of kitchen, bathroom, storage areas, stairways, unfinished basements and attics.

      (2) The ventilation system shall be designed and balanced to provide the general pressure relationships shown in Table 1, Section 14 of this administrative regulation.

      (3) The lighting levels for the facility shall comply with the requirements in Table 2, Section 14 of this administrative regulation.

      (4) Plumbing approval. Prior to licensure and relicensure, all specifications shall be approved by the Kentucky Division of Plumbing, Department of Housing, Buildings and Construction.

      (5) Transportation. Emergency transportation to a hospital (with a pediatric unit) shall be achieved in ten (10) minutes or less.

      (6) Unless medically contraindicated, the facility shall be maintained as a temperature range of seventy-two (72) degrees to eighty (80) degrees Fahrenheit.

      (7) Accessibility. The PPEC shall meet requirements for making buildings and facilities accessible to and usable by the physically handicapped pursuant to KRS 198B.260 and administrative regulations promulgated thereunder.

      (8) Fire safety. The PPEC shall be approved by the Fire Marshal's office before licensure and relicensure is granted by the licensure agency.

      (9) Housekeeping and maintenance services.

      (a) Housekeeping. The center shall maintain a clean and safe facility free of unpleasant odors. Odors shall be eliminated at their source by prompt and thorough cleaning of commodes, urinals, bedpans and other sources.

      (b) Maintenance. The premises shall be well kept and in good repair. Requirements shall include:

      1. The center shall insure that the grounds are well kept and the exterior of the building, including the sidewalks, steps, porches, ramps, and fences are in good repair.

      2. The interior of the building including walls, ceilings, floors, windows, window coverings, doors, plumbing and electrical fixtures shall be in good repair.

      3. Garbage and trash shall be stored in areas separate from those used for the preparation and storage of food and shall be removed from the premises regularly. Containers shall be cleaned regularly.

      4. A pest control program shall be in operation in the centers pest control services shall be provided by maintenance personnel of the facility or by contract with a pest control company. The compounds shall be stored under lock.

      5. Sharp wastes, including needles, scalpels, razors or other sharp instruments used for patient care procedures shall be segregated from other wastes and aggregated in puncture resistant containers immediately after use. Needles and syringes shall not be recapped, cut, dismantled, or destroyed after use, but shall be placed intact directly into a puncture resistant container. The containers of sharp wastes shall either be incinerated, on site or off site, or rendered nonhazardous by a technology of equal or superior efficacy, which is approved by both the Cabinet for Human Resources and the Natural Resources and Environmental Protection Cabinet.

      6. The center shall establish a written policy for the handling and disposal of all infectious, pathological, and contaminated waste if the center generates them. Any incinerator used for the disposal of waste shall be in compliance with 401 KAR 59:020 or 401 KAR 61:010.

      a. Infectious waste shall be placed in double impervious plastic bags and each bag shall be two (2) mils in thickness. A bag, when full, shall not exceed twenty-five (25) pounds. All bags shall be securely closed and a tag, which reads "INFECTIOUS WASTE" and identifies the center from which the waste is being removed and shall be attached to the bag in a conspicuous manner.

      b. The following wastes shall be disposed of by incineration or, be autoclaved before disposal, or be carefully poured down a drain connected to a sanitary sewer: blood, blood specimens, used blood tubes, or blood products.

 

      Section 13. Emergency Procedures. (1) A copy of the current annual fire inspection report, shall be on file with the licensing agency.

      (2) There shall be a working telephone, which is neither locked nor a pay station, in the center.

      (3) Emergency telephone numbers shall be posted on or in the immediate vicinity of all telephones.

 

      Section 14. Appendix.

TABLE 1 - PRESSURE RELATIONSHIPS AND

VENTILATION FOR PPEC CENTERS

Area

Designation

Pressure

Relationship to Adjacent

Areas

Minimum Air

Changes of Out-door Air Per Hour

Minimum Total Air

Changes

Per Hour

Patient room

0

1

4

Patient area corridor

0

2

4

Treatment room

0

2

4

Physical therapy and hydrotherapy if applicable

N

2

-

Dining and recreation areas

0

2

4

Soiled workroom

N

2

4

Clean workroom

P

2

4

Toilet room

N

-

10

Bedpan room, if applicable

N

-

10

Bathroom

N

-

10

Janitor's closet

N

-

10

Linen and trash chute rooms

N

-

10

Food preparation center

0

2

10

Dishwashing area

N

-

10

Dietary day storage

0

-

2

Laundry, general

0

2

10

Soiled linen sorting and storage

N

-

10

Clean linen storage

P

2

2

P=Positive N=Negative O=Equal -=Optional

 

TABLE 2 - LIGHTING LEVELS FOR PPEC CENTERS

Area

Foot-candles*

Administrative and lobby areas, day

50

Administrative and lobby areas, night

20

Corridors and interior ramps

20

Corridor night lighting

3

Dining area and kitchen

30

Doorways

10

Exit stairways and landings

5

Janitor's closet

15

Nurses' station, general, day

50

Nurses' station, general, night

20

Nurses' desk, for charts and records

70

Nurses' medicine cabinet

100

Patient care unit (or room), general

10

Patient care room, reading

30

Recreation area (floor level)

50

Stairways other than exists

30

Toilet and bathing facilities

30

Utility room, general

20

Utility room, work counter

50

*Minimum on task at any time

      (16 Ky.R. 302; Am. 554; 755; eff. 10-18-89.)