H. B. 2909
(By Delegates Hatfield, Hrutkay,
Manuel and Martin)
[Introduced February 7, 2003; referred to the
Committee on Health and Human Resources then Finance.]
A BILL to amend article five-c, chapter sixteen of the code of West
Virginia, one thousand nine hundred thirty-one, as amended, by
adding thereto two new sections, designated sections twenty
and twenty-one, all relating to requiring nursing homes to
have quality assurance programs and plans; and specifying
requirements.
Be it enacted by the Legislature of West Virginia:
That article five-c, chapter sixteen of the code of West
Virginia, one thousand nine hundred thirty-one, as amended, be
amended by adding thereto two new sections, designated sections
twenty and twenty-one, all to read as follows:
ARTICLE 5C. NURSING HOMES.
§16-5C-20. Quality assurance program.
(a) By the first day of January, two thousand four, each
nursing home shall establish an effective quality assurance program that includes components described in this section and section
twenty-one of this article.
(b) The nursing home shall appoint a qualified individual to
manage quality assurance activities within the nursing home.
(c) The nursing home shall establish a quality assurance
committee that includes at least:
(1) A director of nursing;
(2) An administrator;
(3) A social worker;
(4) A medical director;
(5) A dietitian; and
(6) A geriatric nursing assistant of the nursing home.
(d) The quality assurance committee shall:
(1) Designate a chairperson to manage committee activities;
(2) Meet monthly to accomplish quality assurance activities;
(3) Assist in developing and approving the nursing home's
quality assurance plan;
(4) Submit the quality assurance plan to the director at the
time of licensure or at the time of license renewal;
(5) Submit any change in the quality assurance plan to the
director within thirty days of the change;
(6) Review and approve the nursing home's quality assurance
plan at least yearly; and
(7) Prepare monthly reports for any ombudsman, family council and residents' council operating at the nursing home.
(e) For the purposes of ensuring implementation and
effectiveness of the quality assurance program, the nursing home
shall make quality assurance records and documents available to the
director.
§16-5C-21. Quality assurance plan.
(a) The nursing home's quality assurance committee shall
develop and implement a quality assurance plan that includes
procedures for:
(1) Concurrent review;
(2) Ongoing monitoring;
(3) Patient complaints;
(4) Accidents and incidents; and
(5) Abuse and neglect.
(b) The quality assurance plan shall include:
(1) The procedures for conducting concurrent review of each
resident including:
(A) Criteria to determine any change in a resident's
condition;
(B) A method to document the concurrent review; and
(C) Identification of the licensed nurse or nurses conducting
the concurrent review;
(2) The procedures to evaluate clinical data for any resident
with a change in condition including at least:
(A) Medications;
(B) Laboratory values;
(C) Intake and output;
(D) Skin breakdown;
(E) Noted weights;
(F) Appetite;
(G) Injuries resulting from accidents or incidents; and
(H) Any other relevant parameters that may affect the
resident's physical or mental status;
(3) Procedures to take action when there is a change in the
resident's condition; and
(4) Procedure for referral of data to the quality assurance
committee, when appropriate.
(c) The quality assurance plan shall include:
(1) A description of the measurable criteria for ongoing
monitoring of all aspects of resident care including:
(A) Medication administration;
(B) Prevention of decubitus ulcers, dehydration and
malnutrition;
(C) Nutritional status and weight loss or weight gain;
(D) Accidents and injuries;
(E) Unexpected death; and
(F) Changes in physical or mental status;
(2) The methodology for collection of data;
(3) The methodology for evaluation and analysis of data to
determine trends and patterns;
(4) A description of the thresholds and performance parameters
that represent acceptable care for the measured criteria;
(5) Time frames for referral to the quality assurance
committee;
(6) A description of the plan for follow-up to determine
effectiveness of the recommendations; and
(7) A description of how the quality assurance activities will
be documented.
(d) The quality assurance plan shall include:
(1) A description of a complaint process that effectively
addresses resident or family concerns including:
(A) The designated person or persons and their phone numbers
to receive complaints or concerns;
(B) The method to be used to acknowledge complaints received;
and
(C) The time frames for investigating complaints dependent
upon the nature or seriousness of the complaint;
(2) A description of a logging system that will be used
including the:
(A) Name of the complainant;
(B) Date the complaint was received;
(C) Nature of the complaint; and
(D) Date that the complainant was notified of the disposition
or resolution of the complaint; and
(3) The procedures for:
(A) Notifying residents of their right to file a complaint
with the director;
(B) Informing residents, families or guardians of the
complaint process upon admission; and
(C) Posting the complaint process or making it available
without the need to request it.
(e) The quality assurance plan shall include:
(1) A definition of accident and injury that is appropriate to
the type of resident served by the nursing home;
(2) A description of the process for reporting accidents and
injuries including:
(A) Who shall report incidents;
(B) The time frame for reporting incidents; and
(C) The procedure for reporting incidents;
(3) A policy statement that includes a provision that
reporting incidents can be done without fear of reprisal;
(4) A description of how internal investigations of accidents
and injuries will be handled including:
(A) Assessment of any injury;
(B) Interview of the resident, staff and witness;
(C) Review of any relevant records including the resident's medical records, discharge summary and hospital records; and
(D) Time frames for conducting the investigation;
(5) A description of the process for notifying family or
guardian about the incident;
(6) A description of a process for the ongoing evaluation of
accidents and injuries to determine patterns and trends; and
(7) A description of how relevant information will be referred
to the quality assurance committee.
(f) The quality assurance plan shall include:
(1) The process for implementing the reporting requirements
contained in sections nine and eleven, article six, chapter nine of
this code;
(2) A description of the process for providing immediate
notification to the family, guardian or responsible party about the
incident;
(3) A description of the process for the ongoing evaluation of
validated incidents of abuse and neglect to determine patterns and
trends; and
(4) A description of how relevant information will be referred
to the quality assurance committee.
NOTE: The purpose of this bill is to
require nursing homes to
have quality assurance programs and quality assurance plans.
All sections in this bill are new; therefore, strike-throughs
and underscoring have been omitted.