NAC Chapter 449 is Nevada's comprehensive licensing and operational standards chapter for a broad range of medical facilities and related entities regulated by the Nevada Division of Public and Behavioral Health. It establishes licensure requirements, administrative standards, personnel qualifications, physical plant requirements, client rights, and enforcement procedures for facility types including psychiatric residential treatment facilities, substance use disorder treatment facilities, detoxification programs, opioid/narcotic treatment programs, halfway houses for persons recovering from alcohol or other substance use disorders, and recovery centers, among many others. Facility operators must comply with applicable sections governing their specific license type, including application, renewal, staffing, recordkeeping, medication management, dietary services, and safety requirements. Enforcement mechanisms include license denial, suspension, revocation, and administrative sanctions.
View official source[Rev. 4/13/2026 1:18:30 PM] [NAC-449 Revised Date: 8-24] CHAPTER 449 - MEDICAL FACILITIES AND OTHER RELATED ENTITIES GENERAL PROVISIONS 449.002 Definitions. 449.0022 “Administrator” defined. 449.0024 “Affiliated facility” defined. 449.0026 “Agent” defined. 449.0028 “Bureau” defined. 449.0029 “Centers for Medicare and Medicaid Services” defined. 449.00295 “Central Repository” defined. 449.003 “Deficiency” defined. 449.00305 “Division” defined. 449.0031 “Division of Welfare and Supportive Services” defined. 449.0032 “Emergency” defined. 449.0033 “Employment agency to provide nonmedical services” defined. 449.0034 “Facility” defined. 449.0042 “Holiday” defined. 449.0043 “Home for individual residential care” defined. 449.0044 “Immediate and serious threat” and “immediate jeopardy” defined. 449.0046 “Incident” defined. 449.0048 “License” defined. 449.0049 “Licensed dietitian” defined. 449.005 “Licensee” defined. 449.0052 “Medicaid” defined. 449.0054 “Medicare” defined. 449.0056 “Party” defined. 449.0058 “Person” defined. 449.006 “Recipient” defined. 449.0061 “Referral agency” defined. 449.0062 “Resident” defined. 449.0064 “Residential facility” defined. 449.0066 “Sanction” defined. 449.0068 “Services” defined. 449.007 “Survey” defined. 449.0072 “Treatment” defined. 449.008 Computation of time. 449.0085 Licensee prohibited from employing or contracting with unlicensed person to provide certain nutrition services. 449.009 Control by Division over medical records of medical facility or facility for dependent upon suspension of license or cessation of operation: Authorized actions to remove, store and protect records; facilities to pay cost of maintenance of records; notice before destruction of records. 449.010 Severability. 449.0105 Adoption of certain publications by reference; revision of publication after adoption. 449.0106 Adoption by reference of certain publications relating to personal protective equipment and prevention of infection; revision of publication after adoption. 449.01065 Requirements relating to personal protective equipment; exception for nursing pool. 449.0107 Posting of star rating by medical facility or facility for the dependent; exception. 449.0108 Notification of Division concerning accreditation of medical facility; administrative penalty. 449.0109 Program and policy for control of infection; designation and training of person responsible for infection control. GENERAL REQUIREMENTS FOR LICENSURE 449.011 Application for license. 449.0112 Investigation; prelicensure or precertification survey; inspection for fire safety; exceptions. 449.01125 Duties of Division if Central Repository unable to complete investigation of applicant; grounds for denial or revocation of license or delay of action concerning application. 449.0113 Duties of administrator or licensee if Central Repository unable to complete investigation of employee or independent contractor; grounds for termination; actions to ensure patient safety. 449.0114 Display of license; compliance with law; transfer of real property; change in administrator, ownership, location, services or maximum number of clients. 449.0115 Review of building plans for new construction or remodeling by certain applicants: Required documents; payment of fees and costs. 449.01153 Approval of building plans for construction or remodeling of certain facilities: Period of validity. 449.01156 On-site advisory inspection of facility: Written request; action by Division; fee. 449.0116 Renewal of license: Application; validity of existing license pending decision on application; inspection of facility; untimely filing or failure to file application. 449.0118 Denial, suspension or revocation of license: Grounds. 449.0119 Denial, suspension or revocation of license or endorsement: Appeals. CULTURAL COMPETENCY AND PREVENTION OF DISCRIMINATION 449.011901 Definitions. 449.011903 “Cultural competency training” defined. 449.011906 “Department” defined. 449.011909 “Director” defined. 449.011911 “Facility” defined. 449.011913 Types of prohibited discrimination. 449.011916 Policies and procedures for transfer, discharge and provision of services. 449.011919 Posting of notice relating to filing of complaints. 449.011921 Requirements for posting certain required information: Contents; size; placement. 449.011923 Provision to patient or resident of information concerning complaints. 449.011926 Policy on handling of complaints; log of complaints. 449.011929 Written permission required for presence of certain persons during physical examination where patient is unclothed. 449.011931 Cultural competency training for agent or employee who provides care to patient or resident. 449.011933 Submission of course or program for cultural competency training. 449.011936 Materials for course or program for cultural competency training. 449.011939 Approval or denial of course or program for cultural competency training; means for delivery of course or program. 449.011941 Assignment of course number to course or programs for cultural competency training. 449.011943 Policies concerning preferred names and pronouns; adaptation of records to reflect gender identities or expressions; method to obtain medically relevant information from patients or residents. 449.011946 Provision of certain statements, notices and information in appropriate languages and with reasonable accommodations. 449.011949 Designation of representative to ensure compliance. 449.011951 Facility to make certain documentation available to Division or Department. FEES 449.012 Definitions. 449.01205 “Agency to provide personal care services in the home” defined. 449.0121 “Ambulatory surgical center” defined. 449.01215 “Branch office” defined. 449.01219 “Community triage center” defined. 449.01225 “Facility for hospice care” defined. 449.01227 “Facility for refractive surgery” defined. 449.01228 “Facility for transitional living for released offenders” defined. 449.01229 “Facility for treatment with narcotics” defined. 449.0123 “Home health agency” defined. 449.01235 “Home office” defined. 449.0124 “Hospice care” defined. 449.01245 “Intermediate care facility for persons with an intellectual disability or persons with a developmental disability” defined. 449.0125 “Medication unit” defined. 449.01252 “Mobile unit” defined. 449.01255 “Nursing pool” defined. 449.01257 “Psychiatric residential treatment facility” defined. 449.01259 “Recovery center” defined. 449.0126 “Rural clinic” defined. 449.01265 “Rural hospital” defined. 449.013 License and renewal fees to operate ambulatory surgical center or home office of home health agency, branch office of home health agency, rural clinic, free standing birthing center, program of hospice care, independent center for emergency medical care, nursing pool, facility for treatment with narcotics, medication unit, referral agency, facility for refractive surgery, mobile unit, agency to provide personal care services in home, facility for the care of adults during day, community health worker pool and employment agency to provide nonmedical services; fee to support system for reporting of information on cancer and other neoplasms; expiration of application for license. 449.016 License and renewal fees to operate skilled nursing facility, hospital, rural hospital, intermediate care facility, residential facility for groups, facility for treatment of alcohol or other substance use disorders, facility for hospice care, home for individual residential care, facility for modified medical detoxification, community triage center, facility for treatment of irreversible renal disease, halfway house for persons recovering from alcohol or other substance use disorders, facility for transitional living for released offenders, psychiatric residential treatment facility and recovery center; expiration of application for license; fee to support system for reporting of information on cancer and other neoplasms; refund of certain fees. 449.0164 Fees for renewal of licenses for certain facilities: Payment in two equal installments. 449.0168 Fees for modification of certain licenses. 449.01685 Division authorized to charge and collect fee from licensee to recover costs of investigating complaint if complaint is substantiated. 449.0169 Department of Corrections to pay fee to Division for certain services. PROVISION OF HOSPICE CARE General Provisions 449.017 Definitions. 449.0171 “Bereavement services” defined. 449.0172 “Facility for hospice care” defined. 449.0173 “Governing body” defined. 449.0175 “Hospice care” defined. 449.0176 “Medical director” defined. 449.01765 “Palliative services” defined. 449.0177 “Patient” defined. 449.0178 “Terminally ill” defined. Licensing 449.0181 Compliance with regulations required for license to operate facility for hospice care. 449.0183 Report of change in ownership, address or staff of program of hospice care. Administration 449.0184 Governing body required; duties of governing body and administrator. Medical Services 449.0185 Requirements for program of hospice care. 449.0186 Requirements for plan of care. 449.0187 Requirements for operation of facility for hospice care. 449.01875 New construction or remodeling: Submission and approval of building plans; prerequisites for approval of facility for licensure. 449.0188 Continuity of service to patients required. FACILITIES FOR THE TREATMENT OF ALCOHOL OR OTHER SUBSTANCE USE DISORDERS General Provisions 449.019 Definitions. 449.022 “Administrator” defined. 449.025 “Alcohol or other substance use disorder treatment” defined. 449.030 “Case management services” defined. 449.031 “Client” defined. 449.034 “Detoxification” defined. 449.043 “Facility” defined. 449.044 “Facility for modified medical detoxification” defined. 449.046 “Governing body” defined. 449.060 “Medically managed intensive detoxification program” defined. 449.064 “Overall program” defined. 449.068 “Qualified social worker” defined. 449.069 “Residential program” defined. 449.072 “Social model detoxification program” defined. Licensing 449.079 Denial, revocation or suspension of license if facility not certified by Division; appeal. 449.081 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of licensing. Administration and Personnel 449.085 Governing body; bylaws. 449.088 Policies and procedures. 449.091 Transfer of client to another facility. 449.094 Money of clients. 449.098 Preparations for disasters; reporting of fire or disaster. 449.102 Inventory and return of client’s belongings. 449.105 Insurance. 449.108 General requirements for programs. 449.111 Administrator: Duties. 449.114 Employees: General requirements. 449.117 Employees: Proof of compliance with provisions concerning tuberculosis. Social Model Detoxification Programs 449.121 Certain facilities authorized to offer program. 449.1214 General requirements. 449.1218 Program of ongoing quality improvement. Operation of Facility 449.123 General sanitary requirements. 449.126 Laundry requirements. 449.129 Design, construction, equipment and maintenance. 449.132 Accommodations for clients. 449.135 Safety from fire. 449.141 Health services. 449.144 Medication. 449.147 Dietary services. 449.150 Records of clients. FACILITIES FOR MODIFIED MEDICAL DETOXIFICATION 449.15311 Definitions. 449.15313 “Administrator” defined. 449.15315 “Client” defined. 449.15317 “Facility” defined. 449.15319 “Overall program” defined. 449.15321 “Program” defined. 449.15323 Proof of certification required; revocation of license. 449.15325 Governing body; bylaws and policies. 449.15327 Policies and procedures for services and operation of facility. 449.15329 Transfer of client. 449.15331 Handling of money of client. 449.15333 Inventory of belongings of client. 449.15335 Liability insurance. 449.15337 Program: Requirements; review. 449.15339 Responsibilities and duties of administrator. 449.15341 Policies and procedures concerning employees. 449.15343 Nursing services. 449.15345 Health services. 449.15347 Pharmaceutical services. 449.15349 Medication and biologicals. 449.15351 Dietary services. 449.15353 Records of clients. 449.15355 Safety and sanitation; temperature. 449.15357 Laundry requirements. 449.15359 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of facility for licensure. 449.15361 Design, construction, equipment and maintenance. 449.15363 Accommodations for clients. 449.15365 Safety from fire. 449.15367 Preparations for disasters; reporting of fire or disaster. FACILITIES FOR TREATMENT WITH NARCOTICS; MEDICATION UNITS General Provisions 449.154 Definitions. 449.15415 “DEA” defined. 449.1542 “Facility for treatment with narcotics” defined. 449.1543 “Medical director” defined. 449.15435 “Medication unit” defined. 449.15438 “SAMHSA” defined. 449.1544 Division is state authority for certain federal regulations. Licensing 449.15445 License and federal certification required to operate facility or unit. 449.1545 Filing requirements; recommendation for certification. 449.15455 Investigation and prelicensure survey. 449.1547 Suspension, revocation or cancellation of license; provisional license; denial of application. Operation 449.1548 General operational requirements. 449.15485 Continuing review of operations; investigation of complaints. HALFWAY HOUSES FOR PERSONS RECOVERING FROM ALCOHOL OR OTHER SUBSTANCE USE DISORDERS 449.1549 Definitions. 449.154901 “Administrator” defined. 449.154903 “Client” defined. 449.154905 “Facility” defined. 449.15491 Administrator: Qualifications. 449.154911 Administrator: General duties. 449.154913 General operational guidelines. 449.154915 Policies and procedures: Establishment; maintenance of manual. 449.154917 Limitation on admissions. 449.154919 Health and sanitation. 449.154921 Laundry facilities. 449.154923 Kitchens; storage of food. 449.154925 Bedrooms; bedding. 449.154927 Use of certain areas as bedroom prohibited. 449.154929 Bathrooms and toilet facilities; toilet articles. 449.154931 Accommodations for residents with restricted mobility. 449.154933 First aid. 449.154935 Medication. 449.154937 Telephones; listing of facility’s telephone number. 449.154939 Notification to Bureau under certain circumstances. 449.154941 Rights of clients. 449.154943 Client files: Maintenance; contents; confidentiality. 449.154945 Safety from fire. FACILITIES FOR TRANSITIONAL LIVING FOR RELEASED OFFENDERS General Provisions 449.154951 Definitions. 449.154953 “Administrator” defined. 449.154955 “Facility” defined. 449.154957 “Resident” defined. 449.154959 “Supportive services” defined. Administration 449.154961 Administrator: Qualifications. 449.154963 Administrator: General duties. 449.154965 Operation of facility. 449.154967 Policies and procedures. 449.154969 Preparations for disasters and other emergencies. Operation 449.154971 Limitation on number of admissions. 449.154973 Prerequisites to provision of particular services. 449.154975 Sanitation, safety and comfort. 449.154977 Laundry facilities. 449.154979 Kitchens; preparation and storage of food. 449.154981 Bedrooms and bedding. 449.154983 Use of certain areas as bedroom prohibited. 449.154985 Bathrooms and toilet facilities; toiletries. 449.154987 First aid. 449.154989 Medication. 449.154991 Telephones; listing of facility’s telephone number. 449.154993 Notification of occurrence of certain incidents. 449.154995 Rights of residents. 449.154997 Files for residents. 449.154999 Safety from fire. HOMES FOR INDIVIDUAL RESIDENTIAL CARE 449.15511 Definitions. 449.15513 “Caregiver” defined. 449.15515 “Director” defined. 449.15517 “Home” defined. 449.15519 “Protective supervision” defined. 449.15521 Director: Qualifications. 449.15523 Director: Duties. 449.15525 Requirements for safety and sanitation of facility. 449.15527 Agreement between operator of home and resident concerning rates; maintenance of records of residents. 449.15529 On-site survey of home by Bureau. RESIDENTIAL FACILITIES FOR GROUPS General Provisions 449.156 Definitions. 449.1565 “Administer” defined. 449.157 “Administrator” defined. 449.1575 “Board” defined. 449.1585 “Caregiver” defined. 449.1591 “Category 1 resident” defined. 449.1595 “Category 2 resident” defined. 449.1597 “Dietary supplement” defined. 449.1599 “Discharge” defined. 449.160 “Division” defined. 449.161 “Grade” defined. 449.164 “Hospice care” defined. 449.169 “Medical professional” defined. 449.170 “Placard” defined. 449.172 “Residential facility” defined. 449.173 “Residential facility which provides care to persons with Alzheimer’s disease” defined. 449.175 “Severity and scope score” defined. 449.176 “Staff of a facility” defined. 449.178 “Transfer” defined. Licensing 449.179 Submission and approval of plan for new construction or remodeling; inspection; evidence of compliance. 449.180 Requirements for purchasing licensed facility. 449.190 License: Contents; validity; transferability; issuance of more than one type. 449.191 Denial, suspension or revocation of endorsement: Grounds. 449.1915 Suspension or revocation of license and endorsement if residential facility has been assigned grade of D on two or more consecutive surveys or resurveys, or both. Administration and Personnel 449.194 Responsibilities of administrator. 449.196 Qualifications and training of caregivers. 449.197 Medical services may be provided only by medical professional. 449.1985 Performance of certain tasks by caregiver. 449.199 Staffing requirements; limitation on number of residents; written schedule for each shift; direct supervision of certain employees. 449.200 Personnel files. 449.202 Rights of staff members during investigation of facility; duties of investigator. General Operational Requirements 449.204 System of financial accounting; insurance. 449.205 Advertising and promotional materials. 449.208 Restrictions on conducting other businesses or providing other services on premises. 449.209 Health and sanitation. 449.211 Automatic sprinkler systems. 449.213 Laundry and linen services. 449.216 Common areas; dining rooms. 449.217 Kitchens; storage of food; adequate supplies of food; permits; inspections. 449.2175 Service of food; seating; menus; special diets; nutritional requirements; dietary consultants. 449.218 Bedrooms: Floor space; windows and doors; privacy; storage space; bedding; personal furnishings; lighting. 449.220 Bedroom doors. 449.221 Use of certain areas in facility as bedroom prohibited. 449.222 Bathrooms and toilet facilities; toilet articles. 449.224 Housing for staff members. 449.226 Safety requirements for residents with restricted mobility or poor eyesight; water hazards; auditory systems for bathrooms and bedrooms; access by vehicles. 449.227 Accommodations for residents with restricted mobility. 449.229 Requirements and precautions regarding safety from fire. 449.231 First aid and cardiopulmonary resuscitation. 449.232 Telephones; emergency telephone numbers for each resident; listing of facility’s telephone number. 449.241 Limitations on use of volunteers; requirements concerning residents who volunteer to assist staff or perform other duties. 449.258 Written policies for facility; policy on visiting hours; residents’ mail; compliance with policies. 449.259 Supervision and treatment of residents generally. 449.260 Activities for residents. 449.262 Provision of dental, optical and hearing care and social services; report of suspected abuse, neglect, isolation or exploitation; restrictions on use of restraints, confinement or sedatives. 449.267 Money and property of residents. 449.268 Rights of residents; procedure for filing grievance, complaint or report of incident; investigation and response. Admitting, Transferring and Discharging Residents 449.2702 Written policy on admissions; eligibility for residency. 449.2704 Disclosure of information concerning rates and payment for services. 449.2706 Transfer of resident whose condition deteriorates. 449.2707 Transfer of resident: Effective date. 449.2708 Discharge of resident; notice of discharge; issuance of notice to quit to resident for improper or harmful behavior. Restrictions on Admitting or Retaining Residents With Certain Medical Needs or Conditions 449.271 Residents requiring gastrostomy care or suffering from staphylococcus infection or other serious infection or medical condition. 449.2712 Residents requiring use of oxygen. 449.2714 Residents requiring use of intermittent positive pressure breathing equipment. 449.2716 Residents having colostomy or ileostomy. 449.2718 Residents requiring manual removal of fecal impactions or use of enemas or suppositories. 449.272 Residents requiring use of indwelling catheter. 449.2722 Residents having unmanageable condition of bowel or bladder incontinence; residents having manageable condition of bowel or bladder incontinence. 449.2724 Residents having contractures. 449.2726 Residents having diabetes. 449.2728 Residents requiring regular intramuscular, subcutaneous or intradermal injections. 449.2732 Residents requiring protective supervision. 449.2734 Residents having tracheostomy or open wound requiring treatment by medical professional; residents having pressure or stasis ulcers. 449.2736 Procedure to exempt certain residents from restrictions. 449.2738 Review of medical condition of resident; relocation or transfer of resident having certain medical needs or conditions. Medical Services, Medical Records and Other Records Concerning Residents 449.274 Medical care of resident after illness, injury or accident; periodic physical examination of resident; rejection of medical care by resident; written records. 449.2742 Administration of medication: Responsibilities of administrator, caregivers and employees of facility. 449.2744 Administration of medication: Maintenance and contents of logs and records. 449.2746 Administration of medication: Restrictions concerning medication taken as needed by resident; written records. 449.2748 Medication: Storage; duties upon discharge, transfer and return of resident. 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information. Special Types of Services and Facilities 449.275 Residential facility which provides residents with hospice care: Responsibilities of staff; retention of resident with special medical needs. 449.2751 Residential facility which provides assisted living services: Application for endorsement; general requirements. 449.2754 Residential facility which provides care to persons with Alzheimer’s disease: Application for endorsement; general requirements. 449.2756 Residential facility which provides care to persons with Alzheimer’s disease: Standards for safety; personnel required; training for employees. 449.2758 Residential facility which provides care for elderly persons or persons with disabilities: Training for caregivers. 449.2762 Residential facility which offers or provides care for adults with intellectual disabilities or adults with developmental disabilities: Application for endorsement; training for caregivers. 449.2764 Residential facility which offers or provides care for persons with mental illnesses: Application for endorsement; training for employees. 449.2766 Residential facility which offers or provides care for persons with chronic illnesses and debilitating diseases: Application for endorsement; training for employees. 449.2768 Residential facility which provides care to persons with dementia: Training for employees. Deficiencies 449.27702 Determination of severity and scope of deficiency; assignment of grade. 449.27704 Placard: Issuance and display; failure to comply. 449.27706 Resurvey: Application and fee; failure to comply. BUSINESSES THAT PROVIDE REFERRALS TO GROUP HOUSING ARRANGEMENTS 449.27811 Definitions. 449.27813 “Client” defined. 449.27817 “Financial assessment” defined. 449.27818 “Group housing arrangement” defined. 449.27819 “Needs assessment” defined. 449.27823 License not required by certain persons to make referrals; application for licensure; referral through licensed referral agency. 449.27827 Requirements for employees. 449.27829 Responsibilities of referral agency. 449.27831 Contract for services; fees; maintenance of client records. HOSPITALS General Provisions 449.279 Definitions. 449.286 “Governing body” defined. 449.287 “Hospital” defined. 449.289 “Inpatient” defined. 449.297 “Outpatient” defined. 449.298 “Outpatient department” defined. 449.299 “Patient” defined. 449.300 “Restraint” defined. Licensing and Administration 449.307 Applicability of license; coverage against certain liabilities. 449.310 Limitation on number of patients; annual on-site inspection not required under certain circumstances. 449.312 Change in ownership, use or construction; correction of deficiencies. 449.313 Responsibilities and duties of governing body; bylaws; appointment and duties of chief executive officer; protocol for organ donations; annual operating budget. 449.314 Quality of care; scope of services. 449.3152 Quality improvement program. 449.3154 Construction, remodeling, maintenance and change of use: General requirements; prerequisites to approval of licensure. 449.3156 Compliance with certain guidelines for design and construction; correction of deficiencies. Policies and Procedures for Operation of Hospital 449.316 Physical environment: Safety and well-being of patients; plan for emergency preparedness; safety management. 449.317 Risk management. 449.318 Accreditation by national accrediting organization required; exceptions; submission of proof of accreditation to Division. 449.319 Requirements for personal needs of patients. 449.321 Requirement to be primarily engaged in providing certain services; determination of whether requirement is met; exemption for certain hospitals. 449.322 Housekeeping and laundry services. 449.325 Prevention, control and investigation of infections and communicable diseases. 449.327 Preparation, sterilization, storage and distribution of sterile supplies and medical and surgical equipment. 449.329 Admission of patients. 449.331 Provision of emergency services and medical care; transfer agreements with long-term care facilities; attestation of compliance. 449.332 Discharge planning. 449.337 Dietary services: General requirements. 449.338 Dietary services: Provision for needs of patients; facilities; standards; permits; records. 449.3385 Dietary services: Personnel. 449.339 Dietary services: Nutritional status of patients. 449.3395 Dietary services: Sanitary conditions; supplies. 449.340 Pharmaceutical services. 449.343 Orders for medication and biologicals. 449.344 Administration of medication; security. 449.346 Rehabilitative services. 449.349 Emergency services. 449.352 Social services. 449.358 Medical staff. 449.361 Nursing services. 449.3622 Appropriate care of patients. 449.3624 Assessment of patients. 449.3626 Rights of patients. 449.3628 Protection of patients; use of physical restraints. 449.363 Personnel policies concerning employment, licensing and certification; training of employees who provide care to victims of sexual assault or attempted sexual assault. 449.364 Obstetrical services: Administration; staffing and equipment. 449.3645 Obstetrical services: Labor rooms; delivery rooms; utility rooms; area for cleaning instruments. 449.365 Obstetrical services: Required services. 449.3655 Obstetrical services: Transfer or discharge of patient. 449.367 Obstetrical services: Nurseries. 449.370 Outpatient services. 449.371 Intensive care services. 449.373 Laboratory services; pathology services; blood and blood products. 449.3735 Transfusions of blood. 449.374 Nuclear medicine services. 449.375 Records for nuclear medicine services; authorization. 449.376 Radiological services. 449.377 Radiological therapeutic services. 449.379 Medical records. 449.382 Medical library. 449.385 Surgical services. 449.388 Anesthesia services. 449.389 Respiratory care services. 449.391 Dental services. 449.394 Psychiatric services. INTERMEDIARY SERVICE ORGANIZATIONS General Provisions 449.395 Definitions. 449.39501 “Certificate” defined. 449.39502 “Client” defined. 449.39503 “Intermediary service organization” defined. 449.39504 “Managing employer” defined. 449.39505 “Other responsible person” defined. 449.39506 “Personal assistance” defined. 449.39507 “Personal assistant” defined. 449.39508 “Guardian” interpreted. Certification 449.3951 Form of application; written verification for submission of fingerprints. 449.39511 Application for certificate and renewal: Fees. 449.39512 Application for certificate and renewal: Proof of insurance coverage. 449.39513 Applicability of certificate; specification of primary location; records. 449.39514 Issuance of provisional certificate. Authorized Activities and General Requirements for Operation 449.39515 Operation of intermediary service organization and agency to provide personal care services in the home. 449.39516 Duties and responsibilities. 449.39517 Personal assistants: Qualifications; maintenance and availability of personnel files. 449.39518 Personal assistants: Results of reports on criminal history. 449.395185 Personal assistants: Performance of certain tasks. 449.39519 Client to serve as managing employer and provide training to personal assistant; reporting of training to organization. 449.3952 Additional training to be provided by intermediary service organization. 449.39521 Visits and telephone interviews with clients. 449.39522 Written statement of services provided to clients. 449.39523 Discussion of services provided to clients. 449.39524 Rights of person with a disability receiving services. Administrative Review and Hearings 449.39525 Request for administrative review of complaint. 449.39526 Scheduling of administrative review. 449.39527 Conduct of administrative review. 449.39528 Issuance of written decision following administrative review. 449.39529 Request for hearing. 449.395295 Hearings: Scheduling; notice. 449.3953 Hearings: Representation; evidence; rights of parties. 449.39531 Resolution of complaint. 449.39532 Final decision of hearing officer; request for judicial review. 449.39533 Record of hearing. 449.39534 Provision of transcript of oral proceedings of hearing. Administrative Sanctions 449.39535 Definitions. 449.39536 “Ban on enrollment” defined. 449.39537 “Cluster” defined. 449.39538 “Compliance” defined. 449.39539 “De minimis violation” defined. 449.3954 “Major violation” defined. 449.39541 “Plan of correction” defined. 449.39542 “Resurvey” defined. 449.39543 “Severity and scope score” defined. 449.39544 “Subsequent violation” defined. 449.39545 Imposition of sanctions generally. 449.39546 Minimum sanction to be imposed. 449.39547 Available sanctions. 449.39548 Duration of sanctions. 449.39549 Notice of sanction; appointment of temporary manager; ban on enrollment or suspension of certificate authorized in certain circumstances. 449.3955 Imposition of one or more sanctions; reporting of violations; presumption of de minimis violation. 449.39551 Severity and scope of violations to be considered in determining sanctions to be imposed. 449.39552 Scope of violations: Survey of organization; sampling of clients; use of scope relating to one client authorized. 449.39553 Scope of violations: Use of scope; basis for assessment. 449.39554 Scope of violations: Criteria for evaluation. 449.39555 Severity of violations: Use of severity scale; basis for assessment; criteria for evaluation. 449.39556 Subsequent violation on resurvey: Rebuttable presumption; imposition of sanction. 449.39557 Determination of sanctions: Initial assessment. 449.39558 Determination of sanctions: Secondary factors to be considered. 449.39559 Determination of sanctions: Basis for selection; restrictions upon service and monetary penalties presumed to be most effective. 449.3956 Plan of correction: Development by intermediary service organization; authority of Division when plan is not acceptable; effect of failure to submit plan. 449.39561 Monetary penalties: Determination of initial penalty; daily penalties; maximum total penalties. COMMUNITY HEALTH WORKER POOLS 449.39565 Definitions. 449.39567 “Client” defined. 449.39569 “Continuing education” defined. 449.39571 “Representative of the client” defined. 449.39573 “Service plan” defined. 449.39575 “Services of a community health worker” defined. 449.39577 Location to which license applies; name of administrator to appear on license; liability coverage. 449.39579 Qualifications and duties of administrator; access to records in absence of administrator. 449.39581 Written policies and procedures. 449.39583 Qualifications of community health worker. 449.39585 Personnel files for community health workers. 449.39587 Training and evaluation of community health workers. 449.39589 Rights of clients: Duties of administrator; provision of written description to clients. 449.39591 Initial screening of client. AGENCIES TO PROVIDE PERSONAL CARE SERVICES IN THE HOME General Provisions 449.396 Definitions. 449.3961 “Activities of daily living” defined. 449.3962 “Agency” defined. 449.3963 “Attendant” defined. 449.3964 “Client” defined. 449.3965 “Personal care services” defined. 449.3966 “Representative of the client” defined. 449.3967 “Service plan” defined. 449.3968 “Work station” defined. Licensing 449.3972 Location to which license applies; agency to retain proof of liability coverage and compliance with certain statutory provisions. Administration and Personnel 449.3973 Qualifications and duties of administrator; appointment of designee to act in administrator’s absence. 449.39735 Training of employees: Provision or arranging for provision of training; costs; payment of salary or hourly wage; exceptions; documentation. 449.3974 Maintenance of policies and procedures concerning qualifications, responsibilities and conditions of employment for staff members. 449.3975 Attendants: Qualifications; annual training. 449.3976 Attendants: Maintenance of personnel file; evaluation of competency. 449.3977 Attendants: Required knowledge and training. 449.39775 Attendants: Performance of certain tasks. 449.3978 Attendants: Prohibition on provision of certain types of services to clients. Provision of Services 449.3979 Provision of written disclosure statement to client upon acceptance for services by agency. 449.398 Rights of clients: Duties of administrator; provision of written description to clients. 449.3981 Initial screening of client and development or acceptance of service plan; requirements before providing personal care to client. 449.3982 Supervisory home visits or telephone calls required to ensure quality of care provided; documentation of evaluation. FACILITIES FOR CARE OF ADULTS DURING THE DAY General Provisions 449.4061 Definitions. Licensing 449.4063 Design, construction, equipment and maintenance of facility: General requirements; prerequisites to approval for licensure. 449.4065 Consultation with representative of Division; notice of nonconformity. 449.4067 Operation in combination with other medical facility or facility for the dependent. 449.4069 Insurance. Operation of Facility 449.407 Advertising and promotional materials. 449.4071 Policies and procedures; accounting. 449.4072 Director and employees: Qualifications and duties; physical and mental health; personnel files. 449.40723 Supervision of clients; volunteers. 449.40725 Orientation and training of employees and volunteers. 449.4073 Files concerning employees. 449.4074 Requirements of facility; health and sanitation; medications; exits. 449.4075 Preparations for fires and other emergencies; reporting of fire or disaster. 449.4076 First aid. 449.4077 Policy for admissions; retention of signed copy. 449.4078 Requirements for admission; designation of physician. 449.4079 Required services. 449.408 Housekeeping and maintenance. 449.4081 Administration of medication; notification of accidents, injuries or illnesses; treatment with dignity; use of restraints or sedatives. 449.40815 Performance of certain tasks by employee. 449.4082 Service of food; dietary consultants. 449.40833 Summary of client’s care; referrals. 449.40835 Records. Medical and Ancillary Services 449.4084 Contract for provision by another person. 449.4085 Provision by facility authorized. 449.4086 Evaluation of programs and policies. 449.4087 Written assessments of clients. 449.4088 Plan of care; periodic assessment. 449.4089 Menus. PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES General Provisions 449.410 Definitions. 449.4105 “Administrator” defined. 449.411 “Psychiatric residential treatment facility” defined. 449.4115 “Resident” defined. Licensing 449.414 License required to operate facility. 449.4145 Application for accreditation required; recognition as accrediting organization by Board; failure of facility to attain or maintain accreditation. 449.416 Prelicensure investigation and site inspection. 449.417 Issuance of license. 449.419 Personnel: Written policies required; evidence of licensure or certification and tuberculosis testing required. 449.420 Compliance with state, federal and local laws, regulations and ordinances; failure to comply is ground for suspension or revocation of license. 449.421 Suspension, revocation or cancellation of license; provisional license. Administration and Operation 449.423 Written scope of services; policies and procedures; responsibilities and duties of administrator. 449.424 Quality improvement program. 449.426 Construction and maintenance of facility; plan for emergency preparedness; safety from fire and other disasters. 449.427 Limitation on number of residents. 449.428 Access of residents to their belongings; accommodations, equipment and supplies for residents; lighting and temperature levels. 449.429 Housekeeping services; cleaning and laundry requirements. 449.430 Prevention, control and investigation of infections and communicable diseases. 449.432 Administration of medication; security. 449.4325 Orders for medication and biologicals. 449.433 Reporting of problems concerning administration of drug to resident and misuses and losses of controlled substances; information concerning drugs must be available to professional members of staff. 449.435 Dietary services: General requirements. 449.436 Dietary services: Facilities; standards; permits. 449.438 Dietary services: Sanitary conditions required; supplies. 449.439 Dietary services: Therapeutic diets. 449.441 Dietary services: Personnel. Provision of Services 449.442 Policies and procedures for protection of rights of residents; duties of employee or independent contractor who believes resident has been abused or neglected. 449.445 Policies and procedures for admission of residents; provision of certain information to resident or person legally responsible for resident. 449.447 Records of residents. 449.448 Assessment and appropriate care of residents. 449.4495 Discharge planning. FACILITIES FOR REFRACTIVE SURGERY 449.450 “Facility” defined. 449.4504 Administrator: Appointment; duties; qualifications. 449.4505 Administrator of facility that performs intraocular lens implants: Duties. 449.4506 Staffing requirements; personnel files. 449.4508 Maintenance of patient records. 449.451 Written policies and procedures. 449.4512 Program of quality improvement. 449.4514 Rights of patients; informed consent. 449.4516 Equipment and supplies. 449.4518 Liability for use of leased equipment. 449.4522 Sanitation and hygiene; space and storage. 449.4524 Medical care of patients. 449.4526 Application for indemnification for certain damages; claims against surety bond or substitute thereof. FACILITIES FOR TREATMENT OF IRREVERSIBLE RENAL DISEASE General Provisions 449.501 Definitions. 449.502 “Advanced practice registered nurse” defined. 449.504 “Charge nurse” defined. 449.5045 “Competency” defined. 449.505 “Dialysis” defined. 449.5053 “Dialysis technician” defined. 449.5055 “Direct supervision” defined. 449.5065 “End-stage renal disease” defined. 449.507 “Facility” defined. 449.508 “Hemodialysis” defined. 449.510 “Immediate supervision” defined. 449.511 “Intermediate level disinfection” defined. 449.513 “Licensed practical nurse” defined. 449.516 “Product water” defined. 449.517 “Supervision” defined. 449.519 “Training” defined. Construction; Health and Safety 449.520 New construction or remodeling: Notification; increase in number of stations for which facility is licensed. 449.5205 New construction or remodeling: Submission of plans and specifications; minor changes; inspection. 449.522 Construction, space and design; physical environment; restrictions for treatment of patients with hepatitis B. 449.5225 Safety and comfort of patients during construction; imposition of more stringent design and space requirements. 449.523 Safety requirements. 449.5235 Maintenance and repair of equipment. 449.525 Water treatment system: General requirements. 449.5255 Water treatment system: Chemical testing of product water; records. 449.526 Water treatment system: Microbiological testing of product water. 449.5265 Reuse of hemodialyzer; transport of used dialyzer. 449.528 Adoption of more stringent requirements for treatment of water and reuse of hemodialyzers. 449.5285 Sanitation: Precautions regarding blood and bodily fluids. 449.529 Sanitation: Control of infections; nonsmoking policy. 449.5295 Sanitation: Provision of sanitary environment; walls, floors and ceilings; blood spills. 449.531 Sanitation: Disinfection of dialysis machines; culturing dialysate; cleaning of machines and equipment; handling of waste. 449.5315 Hepatitis B: Vaccinations for certain staff members; postvaccination screening; adoption of related provisions. 449.532 Hepatitis B: Vaccinations for certain patients. 449.5325 Hepatitis B surface antigen: Screening of patients; additional serologic screening. 449.534 Hepatitis B surface antigen: Treatment of patients who test positive. 449.5345 Tuberculosis: Screening of staff and patients. Provision of Services 449.540 Program of quality assurance; recordation of accidents and incidents; reporting of certain events. 449.5405 Rights of patients. 449.541 Interdisciplinary teams; plans for care of patients. 449.5415 Preparations for emergencies and disasters. 449.543 Pharmaceutical services. 449.5435 Nursing services; physicians and other staff. 449.544 Nutrition services. 449.5445 Social services. 449.546 Patient care: Advanced practice registered nurses and physician assistants; medical emergencies. 449.5465 Patient care: Licensed practical nurses and dialysis technicians. 449.547 Self-dialysis: Provision of training and certain services. 449.5475 Continuous ambulatory peritoneal dialysis. 449.549 Continuous cycling peritoneal dialysis. 449.5495 Patient services by contract; laboratory. Administration and Personnel 449.550 Governing body. 449.5505 Medical director. 449.552 Physicians. 449.5525 Orientation program for new employees; continuing education. 449.553 Medical staff: Generally. 449.5535 Nurses. 449.555 Dietitians. 449.5555 Social workers. 449.556 Staff responsible for operating water treatment system. 449.5565 Staff that repairs or maintains equipment used to provide care to patients. Clinical Records 449.558 Preparation and maintenance. 449.5585 Additional requirements. 449.559 Medical history and physical examination. 449.5595 Transient patients. 449.561 Discharge or transfer of patients; removal of records. 449.5615 Cessation of operation of facility. Dialysis Technicians 449.570 General qualifications; identification to be worn during training; provision of care; requirements to act as preceptor. 449.5705 Qualification of technician determined to be qualified before July 1, 2001. 449.571 Program of training: Curriculum; duties of instructor; written examinations. 449.5715 Program of training: Qualifications of instructors. 449.573 Program of training: Certain persons authorized to provide instruction and serve as preceptor. 449.5735 Program of training: Required hours. 449.574 Committee to review program of training. 449.5745 Written list concerning knowledge and skills. 449.576 Peritoneal dialysis: Additional activities required. 449.5765 Cannulation or administration of normal saline or heparin: Additional activities required. 449.577 Cannulation or administration of normal saline, heparin or lidocaine: Verification and documentation of competency required. 449.5775 Documentation of successful completion of program of training; employment by another facility. 449.579 Patient care: Technicians must demonstrate certain knowledge and competency. 449.5795 Prohibited acts. PROVISION OF CERTAIN SPECIAL SERVICES Open-Heart Surgery 449.612 Definitions. 449.612011 “Approval” defined. 449.612012 “Approved hospital” defined. 449.612014 “Cardiac surgery” defined. 449.612017 “Open-heart surgery” defined. 449.61202 Prerequisites to initial provision of service. 449.61204 Form and contents of application for approval to provide service. 449.61206 Notification of applicant upon review of application; site inspection required. 449.61208 Composition and duties of site inspection team. 449.6121 Hospital to pay costs of inspection. 449.61212 Approval or denial of application; period of validity of approval; cessation of performance of surgeries. 449.61214 Amount of surgery required following approval. 449.61216 Provision of patient with preoperative instruction. 449.61218 Surgical team: Composition; privileges and qualifications of members; participation of qualified nurses. 449.6122 Qualifications of anesthesiologist. 449.61222 Qualifications of nurse in charge of service. 449.61224 Perfusion team: Use required; qualifications; approval of members by surgeon of record. 449.61226 Operating rooms: General requirements. 449.61228 Operating rooms: Equipment and staff. 449.6123 Intensive care facility: General requirements. 449.61232 Intensive care facility: Staff. 449.61234 Intensive care facility: Equipment and supplies. 449.61236 Orientation and continuing education of personnel. 449.61238 Maintenance of blood bank. 449.6124 Maintenance of cardiac catheterization laboratory. 449.61242 Maintenance of medical laboratory. 449.61244 Maintenance of facilities to perform contrast studies and equipment to review films of operations. 449.61246 Maintenance of registry to record results for each patient. 449.61248 Maintenance of program to follow recovery of patient. 449.6125 Annual review and inspection of hospital. 449.61252 Annual inspection of hospital: Assessment of rate of mortality. 449.61254 Further review or on-site inspection for failure to comply with provisions or for excessive rate of mortality; notice; plan for compliance. 449.61256 Denial, suspension or revocation of approval: Grounds; hearing. Transplantation of Organs 449.6126 Definitions. 449.61262 Application for approval to provide services. 449.61264 Evaluation of application for approval. 449.61266 Duties of hospital providing services. 449.61268 Revocation of approval. 449.6127 Notice of intent to deny application or revoke approval; hearing. INDEPENDENT CENTERS FOR EMERGENCY MEDICAL CARE Licensing 449.61302 Limitations on issuance of license. 449.61306 Denial of application for license or renewal of license. 449.61308 Compliance with regulations; ground for suspension or revocation of license. Administration and Personnel 449.6132 Requirement of governing body; adoption of written rules. 449.61322 Exception to requirements of governing body. 449.61324 Standards of care; policy for authentication. 449.61326 Program to review quality of care; contents of program. 449.61328 Integration into local emergency medical system. 449.6133 Appointment and responsibilities of administrator. 449.61332 Employment and duties of medical director. 449.61334 Standards and procedures for selection, treatment and retention of medical staff and members of allied health professions. 449.61336 Rules for organization of medical staff. 449.61338 Employment and duties of chief nurse; size of on-duty nursing staff; limitation on scope of practice by person who is not registered nurse; oversight of nursing staff. Facilities 449.6135 Design, construction, equipment and maintenance: General requirements; prerequisites to approval for licensure. 449.61352 Contents of center: Emergency entrance; reception and waiting areas; treatment and examination rooms; space for storage and maintenance of medical records and supplies. 449.61354 Contents of treatment rooms; accessibility to person in wheelchair. Medical Services and Medical Records 449.6137 Requirement for minimum level of care in certain situations. 449.61372 Criteria for denial of care, transfer or discharge of patient; compliance with state and federal laws. 449.61374 Laboratory services and reports; procedures for storage and administration of tissue specimens, blood and blood products; agreements with outside blood banks; review of blood transfusions and reactions. 449.61376 Program for control of infection. 449.61378 Radiological services: Availability; interpretation and reporting of films; storage and retention. 449.6138 Distribution and administration of drugs and controlled substances. 449.61382 Medical records: Maintenance; access; authorized release; completion after discharge. 449.61384 Contents of medical records. FREESTANDING BIRTHING CENTERS 449.61387 Definitions. 449.613875 “Birth assistant” defined. 449.61388 “Certified nurse-midwife” defined. 449.613885 “Clinical provider” defined. 449.61389 Proof and maintenance of accreditation; maintenance of documents relating to issuance or renewal of accreditation; specification of capacity in application for license. 449.613895 Design, construction, equipment and maintenance. 449.6139 Submission of plans for new construction or remodeling; prerequisites to approval of facility for licensure; exception. 449.613905 Supply of oxygen; policies and procedures for administration and storage of oxygen. 449.61391 Policies and procedures for control of infection: Manufacturer’s guidelines; training and evaluation of employees; notification to employees upon revision; supply of personal protective equipment. 449.613915 Compliance with certain laws, regulations, codes and ordinances; participation in National Healthcare Safety Network; provision of records to Division. 449.61392 Adoption of publication by reference; revision of publication after adoption; compliance with adopted standards. 449.613925 Qualifications of clinical provider; director to maintain personnel file and ensure licensure, certification or registration of employees; staff requirements for delivery and care. 449.61393 Birth assistants: Qualifications. 449.613935 Birth assistants: Supervision; delegation of tasks; personnel files; prohibited tasks. 449.61394 Program of supervised training: Supervision; instruction; policies and procedures. 449.613945 Establishment of criteria and protocols concerning pregnancy; requirements for birth at birthing center; exception. 449.61395 Information to be provided to patient; access of patient to medical record; adoption of procedure for complaint. 449.613953 Exclusions from term “surgery.” 449.613956 Duties of director relating to drugs and laboratory testing supplies; use of prescribed drug by patient. 449.61396 Death of patient; notification of Division; provision of counseling. INTERMEDIATE CARE FACILITIES General Provisions 449.614 Definitions. 449.617 “Administrator” defined. 449.623 “Facility” defined. 449.629 “Intermediate care facility as a distinct part of a health and care facility furnishing more than one level of care” defined. 449.632 “Intermediate care facility for persons with an intellectual disability or persons with a developmental disability” defined. 449.635 “Licensee” defined. 449.638 “Long-term care facility” defined. 449.644 “Mixed facility” defined. 449.647 “New facility” defined. 449.650 “Nursing home” defined. 449.653 “Patient in an intermediate care facility I” defined. 449.656 “Patient in an intermediate care facility II” defined. 449.657 “Person with a developmental disability” defined. 449.658 “Person with an intellectual disability” defined. 449.659 “Resident” defined. Licensing 449.668 Provisional licenses. Administration and Personnel 449.671 Financing; liability insurance. 449.674 Administrator: Qualifications. 449.677 Employees: General requirements. 449.680 Maintenance of evidence of screenings for communicable diseases. 449.681 Employees of facility which provides care to persons with dementia: Continuing education. Construction and Operation: Generally 449.685 Design, construction, equipment and maintenance: General requirements; prerequisites to approval of facility for licensure. 449.692 Sanitary requirements. 449.695 Laundry requirements. 449.698 Fire inspections; hazardous conditions; operation of other business. 449.701 Preparations for emergencies; reporting of fire or disaster. 449.704 Written policies and procedures for facility; admission agreements; transfer agreements. 449.707 Money of residents. 449.710 Inventory of residents’ belongings. 449.713 Program requirements. 449.716 Dietary services. 449.719 Health services. 449.722 Pharmaceutical services. 449.725 Records. 449.728 Supervision by physician; volunteers; advertising. Construction and Operation: Facilities for Persons With an Intellectual Disability or Persons With a Developmental Disability 449.732 Definitions. 449.7322 “Facility” defined. 449.7324 “New facility” defined. 449.7326 Standards for construction, remodeling or change in use of facility; fire alarms; emergency radio system; submission and approval of building plans. 449.7328 Elevators. 449.733 Electrical systems. 449.7332 Mechanical systems. 449.7334 Doors, windows, ceilings, walls and floors. 449.7336 Entrances and lobbies; miscellaneous space. 449.7338 Dining and storage space. 449.7342 Facilities for employees and volunteers. 449.7344 Areas for engineering and maintenance. 449.7346 Janitors’ closets. 449.7348 Linen service. 449.735 Area for medical records. 449.7352 Nursing units. 449.7354 Service areas. 449.7356 Processing of waste. 449.736 Personnel. 449.737 Plan of care. 449.740 Corporal punishment; restraints. 449.743 Records. COMMUNITY TRIAGE CENTERS 449.74311 Definitions. 449.74313 “Administrator” defined. 449.74315 “Facility” defined. 449.74317 “Governing body” defined. 449.74321 “Patient” defined. 449.74322 “Person with mental illness” defined. 449.74323 “Program” defined. 449.74325 “Psychologist” defined. 449.74327 Governing body; bylaws and policies. 449.74329 Policies and procedures for services and operation of facility. 449.74331 Transfer of patient. 449.74333 Handling of money of patient. 449.74335 Inventory of belongings of patient. 449.74337 Liability insurance. 449.74339 General requirements for programs and services. 449.74341 Responsibilities and duties of administrator. 449.74343 Policies and procedures concerning employees. 449.74345 Nursing services. 449.74347 Health services. 449.74349 Mental health services. 449.74351 Pharmaceutical services. 449.74353 Medication and biologicals. 449.74355 Records of patients. 449.74357 Laundry requirements. 449.74359 Dietary services. 449.74361 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of facility for licensure. 449.74363 Design, construction, equipment and maintenance of facility. 449.74365 Entrances, lobbies and offices; storage space. 449.74367 Patients’ rooms; toilet and bathing facilities. 449.74369 Service areas; miscellaneous requirements. 449.74371 Safety and sanitation. 449.74373 Preparations for disasters; reporting of fire or disaster. FACILITIES FOR SKILLED NURSING General Provisions 449.744 “Facility for skilled nursing” defined. Licensing and Administration of Facility 449.74411 Applicability of license; limitation on number of patients; coverage against certain liabilities. 449.74413 Change in ownership, use or construction of facility. 449.74415 Responsibilities of governing body. 449.74417 Administrator of facility. 449.74419 Committee for quality assurance. 449.74421 Procedures for emergency or disaster. Admission, Transfer and Discharge of Patient 449.74423 Certain conditions for admission prohibited. 449.74425 Admission of patient with mental illness or an intellectual disability. 449.74427 Agreement with hospital for transfer of patients. 449.74429 Transfer or discharge of patient. 449.74431 Summary of discharge. Assessment of Patients and Plan of Care 449.74433 Comprehensive assessment of needs of patient. 449.74435 Quarterly assessment of patient. 449.74437 Conduct of assessments. 449.74439 Comprehensive plan of care. Medical Records 449.74441 Maintenance. 449.74443 Inspection. Rights of Patients 449.74445 Generally. 449.74447 Communications with other persons; examination of records by advocate. 449.74449 Notice to patients of rights, services and charges. 449.74451 Charges to be consistent with notice of charges. 449.74453 Notice to patients of programs available for assistance in payment of services. 449.74457 Policies and procedures for advance directives by patient; information to be furnished regarding physicians. 449.74459 Examination by patient of survey of facility and plan of correction. 449.74461 Finances of patient: System for maintenance and accounting. 449.74463 Finances of patient: Authorization to withhold money. 449.74465 Sending and receiving mail. 449.74467 Performance of services for facility by patient. Quality of Care 449.74469 Standards of care. 449.74471 Administration of drugs. 449.74473 Program for control of infections. 449.74475 Vision and hearing. 449.74477 Pressure sores. 449.74479 Urinary problems. 449.74481 Range of motion. 449.74483 Mental or psychosocial behavior. 449.74485 Nasogastric tubes. 449.74487 Nutritional health; hydration. 449.74489 Physical or chemical restraint of patients. 449.74491 Prohibition of certain practices regarding patients; investigation of certain violations and injuries to patients; unfit employees. 449.74493 Notification of changes or condition of patient. 449.74495 Development of program of activities. 449.74497 Daily activities of patient. 449.74499 Participation in activities. Staff and Attending Physicians 449.74511 Personnel policies; personnel records. 449.74513 Medical director. 449.74515 Physicians. 449.74517 Nursing staff. 449.74519 Nursing assistants and nursing assistant trainees. 449.74521 Other health care professionals. 449.74522 Employees of facility which provides care to persons with dementia. Provision of Services 449.74523 Social services. 449.74525 Dietary services. 449.74527 Specialized rehabilitative services. 449.74529 Dental services. 449.74531 Pharmaceutical services. 449.74533 Laboratory services. 449.74535 Radiological and other diagnostic services. 449.74537 Special services. Physical Environment 449.74539 General requirements. 449.74543 Design, construction, equipment and maintenance: General requirements; prerequisites to approval of facility for licensure. 449.74549 Patients’ rooms. NURSING POOLS General Provisions 449.747 Definitions. Licensing 449.7471 License required. 449.7473 Location to which license applies; persons named in license; restrictions on use of license. 449.7474 Duties of licensee or applicant for license. Administration and Personnel 449.7475 Administrator: Qualifications and duties. 449.7476 Director of professional services: Qualifications and duties. 449.7477 Personnel policies: Maintenance and availability. 449.7478 Requirements for contracts to provide nursing services. 449.7479 Referral of patients when services not available; provision of services; bonding of staff. 449.748 Duties of registered nurse; provision of nursing care by practical nurse or nursing assistant. 449.7481 Annual evaluation of nursing pool by licensee. HOME HEALTH AGENCIES General Provisions 449.749 Definitions. 449.750 Adoption of publication by reference; revision of publication after adoption. Licensing and Inspection 449.752 License required. 449.758 Applicability of license; coverage against certain liabilities. 449.761 Periodic inspections. 449.767 Action to enjoin operation without license. 449.768 Applicant or licensee to maintain home office in Nevada. Administration and Personnel 449.782 Personnel policies. 449.788 Licensure, registration or certification of certain personnel. 449.793 Periodic review of patient and clinical records by appointed committee; minutes of meetings. 449.7935 Compliance with certain federal requirements; exception; provision of data to Division; application of certain provisions to physician assistants and advanced practice registered nurses. Medical Services and Medical Records 449.794 Clinical records: Maintenance. 449.797 Clinical records; contents. 449.800 Orders of a physician, physician assistant or advanced practice registered nurse. COMMUNITY-BASED LIVING ARRANGEMENT SERVICES General Provisions 449.801 Definitions. 449.802 “Certificate” defined. 449.804 “Community-based living arrangement services” or “services” defined. 449.805 “Facility” defined. 449.807 “Individual support team” defined. 449.808 “Individualized plan” defined. 449.810 “Mental illness” defined. 449.811 “Provider” defined. 449.813 “Provisional license” defined. 449.814 “Quality assurance review” defined. 449.816 “Resident” defined. Issuance and Renewal of Provisional Licenses and Licenses 449.817 Provisional license or license required to provide services; exception. 449.818 Contents of application for provisional license; fee; bond. 449.819 Review of application for provisional license; actions upon determination that application is incomplete. 449.820 Training required of applicant for provisional license; inspection of facility; issuance and validity of provisional license. 449.822 Grounds for denial of application for provisional license; notice of denial. 449.823 Quality assurance review; extension or revocation of provisional license; issuance of license. 449.825 Renewal of license; fee. Operation of Provider 449.826 Duties of provider. 449.828 Policies and procedures of governmental or organizational provider. 449.829 Initial and periodic investigations of employee, independent contractor or adult present during provision of services; termination of employment, contract or authority to be present for conviction of certain crimes; period in which to correct information regarding conviction. 449.831 Required certifications and courses for employee or independent contractor who provides services. 449.832 Arrangements for services from specially trained persons; determination of need for such services. 449.834 Financial plan; financial records; financial report. 449.835 Assessment of need for services; maintenance of findings of assessment; establishment of individual support team and permanent individualized plan; acceptance of person before assessment in urgent situation. 449.837 Contract for provision of services. 449.8385 Training for providers and employees; exception. 449.840 Record regarding recipient of services: Contents; maintenance; availability for review by recipient or guardian. 449.841 Record regarding recipient of services: Retention; availability for review by representatives of Department of Health and Human Services. 449.8415 Logs and records of medication; administration of over-the-counter medications and dietary supplements. 449.843 Rights of recipient of services. 449.844 Facilities: Ownership or lease by operator; limitation on number of residents; compliance with certain state and local requirements. 449.846 Facilities: Occupancy, size, furnishings and use of bedrooms; use of certain rooms or bedrooms prohibited. 449.847 Facilities: Common areas; dining areas; kitchens; storage of food. 449.849 Facilities: Maintenance of premises. 449.850 Facilities: Fire safety. 449.852 Facilities: Policy concerning visitation; presence of minor child of provider or employee prohibited; visitation by child of resident. Quality Assurance Reviews and Discipline 449.853 Quality assurance review; report and correction of violation. 449.855 Authorized actions of Division upon determination of deficiencies; plans of correction; grounds for sanctions; authorized sanctions. 449.856 Grounds for revocation of provisional license or license. 449.858 Notice of intent to revoke provisional license or license. 449.859 Immediate termination of provision of services. 449.861 Appeal. EMPLOYMENT AGENCIES TO PROVIDE NONMEDICAL SERVICES 449.870 Definitions. 449.871 “Attendant” defined. 449.873 “Client” defined. 449.874 “Employment agency” defined. 449.876 “Nonmedical services” defined. 449.877 Designation of primary place of business on license; operation of multiple work stations; licensee’s name to appear on face of license; liability coverage required. 449.879 Qualifications and duties of administrator. 449.880 Qualifications of attendant; required training. 449.882 Duties of employment agency. CARA PLANS OF CARE 449.939 Definitions. 449.941 “CARA Plan of Care” defined. 449.942 “Infant” defined. 449.944 “Medical facility” defined. 449.945 “Provider of health care” defined. 449.947 Establishment and contents of plan; use of form; provision of copy to parent or guardian and Division. 449.948 Duties of Division; confidentiality and protection of plans and related information. FINANCIAL REPORTING 449.951 Definitions. 449.953 Annual fee for insurers: Amount; notice; administrative fine for failure to pay. 449.957 Hospitals to file certain reports; certification; exception; extension. 449.960 Hospitals to submit quarterly financial and utilization report; certification; extension. 449.962 Facility for intermediate care or facility for skilled nursing to submit quarterly financial and utilization report; certification; extension. 449.9625 Institution to submit quarterly financial and utilization report; certification; extension; exception. 449.963 Information concerning treated patients: Submission; limitation on disclosure. 449.966 Notice of insufficiency of submitted information. 449.969 Administrative fine for failing to meet deadlines. MOBILE UNITS 449.970 Definitions. 449.9701 “Independent facility” defined. 449.97012 “Mobile unit” defined. 449.97014 “Parent facility” defined. 449.97016 “Service site” defined. 449.97018 “Staging area” defined. 449.9702 Applicability of provisions. 449.97022 Licensure. 449.97024 Application for licensure. 449.97026 Design, construction, equipment, maintenance and parking. 449.97028 Staging areas; disposal of biohazards and waste. 449.9703 Compliance with certain statutes and regulations. 449.97032 Compliance with regulations relating to evaluation of quality of services. 449.97034 Written policies for operation of unit; agreement with hospital or medical facility for transfer of patients during emergencies. 449.97036 Rights of patients. 449.97038 Maintenance of schedule and records; supplies and equipment; diagnostic radiological services; laboratory services. 449.9704 Occupancy; fire safety; exits; use and maintenance of equipment; telecommunications device. 449.97042 Restrictions on operation; office of independent facility; operation pursuant to contract. SURGICAL CENTERS FOR AMBULATORY PATIENTS General Provisions 449.971 Definitions. 449.9715 “Allied health profession” defined. 449.972 “Ambulatory surgical center” defined. 449.9721 “Biohazardous waste” defined. 449.9722 “Biologic indicator test” defined. 449.9724 “Cleaning” defined. 449.9725 “Division” defined. 449.973 “Governing body” defined. 449.9731 “High-level disinfection” defined. 449.9732 “Implantable device” defined. 449.9733 “Invasive procedure” defined. 449.9735 “Licensee” defined. 449.9736 “Low-level disinfection” defined. 449.9738 “Multidose vial” defined. 449.974 “Patient” defined. 449.9741 “Physician” defined. 449.9742 “Registered nurse” defined. 449.97422 “Reprocess” defined. 449.97426 “Single-dose vial” defined. 449.97428 “Sterilization” defined. 449.9743 “Surgery” defined. Licensing 449.9745 Center required to provide proof of national accreditation; submission of reports to Division; application by accrediting organization for recognition by State Board of Health. 449.9755 Investigation of applicant and inspection of facility. 449.978 Effect of expiration of license. 449.9785 Conformance with regulations required. Administration 449.979 Governing body required. 449.9795 Duties of governing body. 449.980 Responsibilities of governing body. 449.9801 Procedures for granting privileges to members of medical staff. 449.9805 Establishment of policy for authentication. 449.981 Appointment and responsibilities of administrator. 449.9811 Program for review of surgical procedures and patient outcomes. 449.9812 Program for quality assurance. 449.9813 Committee for quality assurance. 449.9815 Maintenance. 449.982 Sanitation and housekeeping. 449.983 Protection from fire and other disasters. 449.9832 Establishment of policies for provision of services and care by persons under contract with or who are otherwise not employed by center. 449.9835 Exemption from requirements for governing body and administrator. 449.9837 Restrictions on operation of ambulatory surgical center; maintenance of records. 449.9843 Compliance with certain standards, laws, ordinances and codes; submission and approval of building plans; prerequisites to approval of center for licensure. 449.9844 Class designations: Authorized procedures; operating room dimensions. Program for the Prevention and Control of Infections and Communicable Diseases 449.98451 Adoption of guidelines by governing body for establishment of program. 449.98452 General requirements of program. 449.98453 Program required to include policies and procedures for prevention of exposure to blood-borne and other potentially infectious pathogens. 449.98454 Program required to include policies and procedures for single-dose vials and multidose vials. 449.98455 Sterilization and disinfection of surgical instruments, items and equipment; training required for employees and contractors responsible for sterilization or disinfection. 449.98456 Center required to designate employee or enter into contract for overseeing and managing program; qualifications and duties of employee or contractor. 449.98457 Mandatory training and evaluation of employees and other persons. Personnel 449.9855 Policies and requirements for personnel. 449.9865 Medical staff. 449.988 Nursing staff. 449.9883 Requirements for employment of certain persons to engage in practice of surgical technology; documentation. Medical Records, Services and Facilities 449.9885 Medical records: Maintenance. 449.989 Medical records: Contents. 449.990 Medication and treatment. 449.9902 Emergency equipment and supplies. 449.9905 Pharmacist employed by or contracted with center; records, storage and administration of drugs; center required to obtain license to operate pharmacy. 449.991 Laboratory services. 449.992 Pathological services. 449.9925 Blood and derivatives of blood: Procurement, storage, transfusion and administration; policies and procedures; reporting of adverse reaction. 449.993 Diagnostic radiological services. 449.9935 Operating and recovery rooms; endoscopy suite; revision of certain standards adopted by reference. 449.9937 Extended recovery units. 449.994 Records required before surgery; report of surgery. 449.9945 Administration and record of anesthesia. 449.9947 Register of surgeries performed in operating rooms. 449.9955 Informing patient of rights, services and cost. 449.996 Transfer of patients. 449.9965 Prohibited locations for construction of center. 449.997 Conversion of hazardous building into center prohibited. RECOVERY CENTERS General Provisions 449.99702 “Recovery center” defined. Licensing and Inspection 449.99704 License required to operate. 449.99706 Requirements to operate. 449.99708 Prelicensure investigation and inspection. 449.9971 Issuance and expiration of license. 449.99712 Suspension, revocation or cancellation of license; provisional license. Administration 449.99714 Governing body; quality improvement and risk management programs; review of programs. 449.99716 Appointment, qualifications and responsibilities of administrator. Construction and Operation 449.99718 Design, construction, equipment and maintenance. 449.9972 General requirements. 449.99722 Patients’ rooms. 449.99724 Limitation on number of patients; insurance. 449.99726 Preparations for emergencies; reporting of fire or disaster. 449.99728 Administration of prescription medications. 449.9973 Control of infections. 449.99732 Meals; hydration; sanitation. Admission, Care, Transfer and Discharge of Patients 449.99734 Responsibilities for admission and care of patient. 449.99736 Assessment of needs of patient. 449.99738 Plan of care; compliance with professional standards. 449.9974 Provision of service or treatment. 449.99742 Summary of discharge. 449.99744 Agreement with hospital for transfer of patients. Records of Patients 449.99746 Contents, maintenance and confidentiality of medical records. 449.99748 Inspection of records relating to patient. Personnel and Staffing 449.99749 Personnel policies and records. 449.99752 Staffing. 449.99754 Employment of health care professionals. Medical Services 449.99756 Specialized rehabilitative services. 449.99758 Pharmaceutical services; labeling and storage of drugs and biologicals; licensure of pharmacy; chart order signed by prescribing practitioner. 449.9976 Laboratory services. 449.99762 Radiological and other diagnostic services. RECEIVERS 449.9981 List of interested and qualified persons. 449.99811 Experience. 449.99812 Authority. 449.99813 Compensation and payment of bond. 449.99814 Operation of facility. ADMINISTRATIVE SANCTIONS General Provisions 449.9982 Definitions. 449.99821 “Ban on admissions” defined. 449.99822 “Cluster” defined. 449.99823 “Compliance” and “substantially correct the deficiency” defined. 449.99824 “Costs” defined. 449.99825 “De minimis deficiency” defined. 449.998253 “Division of Health Care Financing and Policy” defined. 449.998255 “Facility” defined. 449.99826 “Immediate family” defined. 449.99827 “Initial deficiency” defined. 449.99828 “Major deficiency” defined. 449.99829 “Medicaid facility” defined. 449.9983 “Medicare facility” defined. 449.99832 “Monitor” defined. 449.99833 “New admission” defined. 449.99834 “Particular kinds of care, treatment or services” defined. 449.99835 “Plan of correction” defined. 449.99836 “Provider agreement” defined. 449.99837 “Repeated deficiency” defined. 449.99838 “Resurvey” defined. 449.99839 “Severity and scope score” defined. 449.9984 “Subsequent deficiency” defined. 449.99841 “Temporary management” defined. 449.99843 Purposes of administrative sanctions. 449.99844 Interpretation of provisions in accordance with federal standards. Imposition: Generally 449.9985 Authority of Division and Bureau. 449.99851 Requirement for imposition; optional imposition. 449.99852 Requirement for imposition; multiple sanctions. 449.99853 Imposition of one or more sanctions; criteria for imposition of particular sanction. 449.99854 Imposition in lieu of or in addition to recommendation to terminate provider agreement; duration of sanctions. 449.99855 Imposition in emergencies: Authority; notice. 449.99856 Deficiencies: Basis for imposition of sanctions; reporting; presumption of de minimis deficiency; confidentiality. 449.99857 Classifications of severity and scope of deficiencies: Use. 449.99858 Scope of violations: Evaluation of representative sample of recipients; size of sample. 449.99859 Scope of deficiencies: Use of scope scale; basis for assessment. 449.9986 Scope of deficiencies: Criteria for evaluation. 449.99861 Severity of deficiencies: Use of severity scale; basis for assessment; criteria for evaluation. 449.99862 Presumption when same deficiency found on resurvey; imposition of sanction for subsequent deficiency. 449.99863 Available sanctions. 449.99864 Determination of appropriate sanction: Procedure. 449.99865 Determination of appropriate sanction: Initial assessment. 449.99866 Determination of appropriate sanction: Consideration of secondary factors. 449.99867 Determination of appropriate sanction: Basis for selection; presumption. Plan of Abatement 449.99868 Notification of immediate and serious threat to health and safety; submission and contents of plan. Plan of Correction 449.9987 Development and submission of plan; authority of Bureau when plan is not acceptable; effect of failure to submit plan; confidentiality. Limitation on Occupancy of Residential Facility 449.99875 Purpose and scope of limitation; imposition in addition to partial ban on admissions. 449.99876 Criteria for imposition. 449.99877 Duration and termination of limitation. 449.99878 Notice of limitation: General requirements; effect of noncompliance. Ban on Admissions 449.9988 Purpose and scope of ban. 449.99881 Criteria for imposition. 449.99882 Duration and termination of ban. 449.99883 Notice of ban: General requirements; effect of noncompliance. Monitoring of Facility 449.99885 Authority of Bureau. Monetary Penalties 449.99895 Imposition by Bureau; purpose; applicable criteria. 449.99896 Criteria for imposition; imposition of initial and daily penalties. 449.99897 Imposition of initial penalty pending hearing or appeal; stay of payment of penalties pending appeal. 449.99898 Procedure for imposition; interest on total penalty assessed. 449.99899 Determination of amount of penalties. 449.998995 Use of initial monetary penalty to correct deficiency. 449.999 Limitation on principal amount of total daily penalty. 449.99901 Daily penalty: Computation according to number of recipients. 449.99902 Increase in penalty for repeated deficiencies or false compliance. 449.99903 Presumption regarding deficiencies identified on resurvey. 449.99904 Reduction of penalty. 449.99905 Daily penalty: Effective beginning date. 449.99906 Daily penalty: Date and period of computation; notice to facility. 449.99907 Termination of daily penalties; failure of Medicaid facility to remove immediate and serious threat after appointment of temporary management. 449.99908 Time for payment of penalties. 449.99909 Assessment of interest on unpaid balance of penalty. 449.9991 Recovery of costs for collection of penalty. 449.99911 Failure to pay penalty: Suspension of license of facility. 449.99912 Disposition of money collected. Temporary Management 449.99915 Appointment of temporary manager when there is immediate and serious threat: Notice; effect of failure to accept manager and to remove threat. 449.99916 Appointment of temporary manager when there is no immediate and serious threat: Notice. 449.99917 Temporary manager: Qualifications. 449.99918 Temporary manager: Authority. 449.99919 Effect of failure to agree to appointment of or to relinquish authority to temporary manager. 449.9992 Events requiring termination of management; initiation of judicial proceedings. 449.99921 Payment of costs and expenses. Closure of Facility and Transfer of Residents 449.99925 Authority of Bureau. 449.99926 Requirements for notification. 449.99927 Appointment of temporary manager. 449.99928 Bureau to supervise or appoint temporary manager to supervise transfer; imposition of other appropriate sanctions. 449.99929 Determination of appropriate placement of residents. 449.9993 Rights of appeal for transferred residents. Facilities Participating in Medicaid 449.99935 Authorized recommendations in addition to available sanctions. 449.99936 Withholding of monetary penalties from payments owed to facility. 449.99937 Denial of payments for new admissions generally. 449.99938 Denial of payments for new admissions who have certain specified diagnoses or special care needs. 449.99939 Suspension of payments for services furnished to Medicaid recipient on or after date of deficiency. OUTPATIENT FACILITIES: PERMIT FOR SERVICES OF GENERAL ANESTHESIA, CONSCIOUS SEDATION AND DEEP SEDATION General Provisions 449.9994 Definitions. 449.99941 “Bureau” defined. 449.999413 “Division” defined. 449.999415 “Inspection” defined. 449.999417 “Outpatient facility” defined. 449.999419 “Treatment” defined. Permitting 449.99942 Application; general requirements; proof of national accreditation; fee; period for validity; application required for each location. 449.999421 Inspection by Division of applicant and outpatient facility; prerequisite of satisfactory fire inspection. 449.999422 Term of permit; circumstances under which permit deemed invalid. 449.999423 Renewal of permit: Application; additional inspection by Division authorized; fees; untimely filing or failure to file application. 449.999424 Outpatient facility required to provide proof of national accreditation; submission of reports to Division; application by accrediting organization for recognition by State Board of Health; maintenance of list by Division of approved accrediting organizations. 449.999425 Display of permit; maintenance of outpatient facility in compliance with law; notification of transfer of real property; notification of change of ownership, location or services provided. 449.999426 Additional grounds for denial, suspension or revocation of permit. Program for the Prevention and Control of Infections and Communicable Diseases 449.99943 Definitions. 449.999431 “Biologic indicator test” defined. 449.999432 “Cleaning” defined. 449.999433 “High-level disinfection” defined. 449.999434 “Implantable device” defined. 449.999435 “Invasive procedure” defined. 449.999436 “Low-level disinfection” defined. 449.999437 “Multidose vial” defined. 449.999438 “Reprocess” defined. 449.999439 “Single-dose vial” defined. 449.99944 “Sterilization” defined. 449.999441 Adoption of guidelines by holder of permit for establishment of program. 449.999442 General requirements of program. 449.999443 Program required to include policies and procedures for prevention of exposure to blood-borne and other potentially infectious pathogens. 449.999444 Program required to include policies and procedures for single-dose vials and multidose vials. 449.999445 Sterilization and disinfection of surgical instruments, items and equipment; training required for employees and contractors responsible for sterilization or disinfection. 449.999446 Outpatient facility required to designate employee or enter into contract for overseeing and managing program; qualifications and duties of employee or contractor. 449.999447 Mandatory training and evaluation of employees and other persons. 449.999448 Establishment of additional policies and guidelines by holder of permit to ensure health and safety of patients; professional standards of practice; requirement of tuberculosis test for employees and persons under contract with outpatient facility. Administrative Sanctions 449.99945 Definitions. 449.999451 “Cluster” defined. 449.999452 “De minimis deficiency” defined. 449.999453 “Deficiency” defined. 449.999454 “Immediate and serious threat” and “immediate jeopardy” defined. 449.999455 “Incident” defined. 449.999456 “Initial deficiency” defined. 449.999457 “Severity and scope score” defined. 449.999458 Purpose of sanctions. 449.999459 Grounds for denial, suspension or revocation of permit. 449.99946 Appeal of denial, suspension or revocation of permit or other sanction. 449.999461 Imposition of sanctions: Authority of Division and Bureau. 449.999462 Imposition of sanctions: Requirement for imposition; optional imposition; multiple sanctions; use of severity and scope factors for particular sanction. 449.999463 Imposition of sanctions in emergencies: Notice; authority; exception to notice requirement. 449.999464 Deficiencies: Basis for imposition of sanctions; reporting; presumption of de minimis deficiency. 449.999465 Scope of violations: Evaluation of representative sample of recipients; sample size. 449.999466 Scope of deficiencies: Use of scope scale; basis for assessment. 449.999467 Scope of deficiencies: Criteria for evaluation. 449.999468 Severity of deficiencies: Use of severity scale; basis for assessment; criteria for evaluation. 449.999469 Presumption when same deficiency found on subsequent inspection; imposition of sanction for subsequent deficiency. 449.99947 Available sanctions. 449.999471 Determination of appropriate sanction: Procedure. 449.999472 Determination of appropriate sanction: Initial assessment. 449.999473 Determination of appropriate sanction: Consideration of secondary factors. 449.999474 Determination of appropriate sanction: Basis for selection; presumption for monetary penalties. 449.999475 Plan of correction: Development and submission of plan; authority of Bureau when plan is not acceptable; effect of failure to submit plan. 449.999476 Monetary penalties: Criteria for imposition; imposition of initial and daily penalties; exception for de minimis deficiency. 449.999477 Monetary penalties: Imposition of initial penalty pending hearing or appeal; stay of payment of penalties pending appeal. 449.999478 Monetary penalties: Procedure for imposition; interest on total penalty assessed. 449.999479 Monetary penalties: Determination of amount of penalties. 449.99948 Monetary penalties: Increase in penalty for repeated deficiencies or falsely alleged compliance. 449.999481 Monetary penalties: Presumption regarding deficiencies identified on subsequent inspection. 449.999482 Monetary penalties: Reduction of penalty. 449.999483 Monetary penalties: Effective beginning date. 449.999484 Monetary penalties: Date and period of computation; notice to outpatient facility. 449.999485 Monetary penalties: Termination of daily penalties. 449.999486 Monetary penalties: Time for payment. 449.999487 Recovery of expenses incurred by Bureau or Division for implementing and enforcing administrative penalties, bringing actions for enforcement and collecting monetary penalties. 449.999488 Failure to pay monetary penalty: Suspension of permit. 449.999489 Disposition of money collected. STAR RATINGS OF CERTAIN HEALTH CARE FACILITIES 449.99984 Definitions. 449.999842 “Deficiency” defined. 449.999844 “Facility” defined. 449.999845 “Unit” defined. 449.999846 Criteria for assignment of ratings; issuance of placard with rating. 449.999848 Follow-up inspections and appeals. REVISER’S NOTE. Ch. 444, Stats. 2021, which removed provisions from NRS relating to licensing and regulation of peer support recovery organizations, contains the following provision not included in NRS: “Sec. 34.5. Any regulations adopted by the State Board of Health pursuant to NRS 449.0302 governing peer support recovery organizations [ NAC 449.15488 to 449.154894 , inclusive] are void. The Legislative Counsel shall remove those regulations from the Nevada Administrative Code as soon as practicable after January 1, 2022.” GENERAL PROVISIONS NAC 449.002 Definitions. ( NRS 439.200 , 449.03005 , 449.0302 ) As used in NAC 449.002 to 449.99939 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.0022 to 449.0072 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R131-99 & R132-99, 11-29-99; R051-02, 7-24-2002; R179-09, 7-22-2010; R090-12, 12-20-2012; R120-16, 9-21-2017; R133-15, 12-19-17; R109-18, 1-30-2019) NAC 449.0022 “Administrator” defined. ( NRS 449.0302 ) “Administrator” means the person responsible for the day-to-day management of a facility. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0024 “Affiliated facility” defined. ( NRS 449.0302 ) “Affiliated facility” means a facility that owns, directly or indirectly, an equity interest of 5 percent or more in the capital, the stock, the profits or the assets of another facility or is, as a subcontractor, agent or otherwise, responsible for the management or control of that facility. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0026 “Agent” defined. ( NRS 449.0302 ) “Agent” means a person having actual or apparent authority to act on behalf of a licensee. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0028 “Bureau” defined. ( NRS 449.0302 ) “Bureau” means the Bureau of Health Care Quality and Compliance of the Division. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R179-09, 7-22-2010) NAC 449.0029 “Centers for Medicare and Medicaid Services” defined. ( NRS 449.0302 ) “Centers for Medicare and Medicaid Services” means the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. (Added to NAC by Bd. of Health by R051-02, eff. 7-24-2002) NAC 449.00295 “Central Repository” defined. ( NRS 449.0302 ) “Central Repository” means the Central Repository for Nevada Records of Criminal History. (Added to NAC by Bd. of Health by R111-12, eff. 3-28-2014) NAC 449.003 “Deficiency” defined. ( NRS 449.0302 ) 1. “Deficiency” means noncompliance with any federal or state statute or of the rules or regulations of the Division or the Centers for Medicare and Medicaid Services or conditions and standards of or requirements for participation in the Medicare or Medicaid program pertaining to a facility. 2. The term includes an incident concerning a facility where there are no extenuating circumstances or where the facility has made an inappropriate response to a complaint, including the failure to: (a) Prevent an incident from occurring, if the incident could have been avoided; (b) Identify an incident; (c) Take action to correct an incident before the identification of the incident by the Bureau; or (d) Implement a contingency plan if permanent action to correct an incident has not been undertaken. 3. In determining whether an incident is a deficiency, the right of the recipient to refuse treatment, where applicable, shall be deemed an extenuating circumstance. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.00305 “Division” defined. ( NRS 449.0302 ) “Division” means the Division of Public and Behavioral Health of the Department of Health and Human Services. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R094-06 & R098-06, 7-14-2006)—(Substituted in revision for NAC 449.0038) NAC 449.0031 “Division of Welfare and Supportive Services” defined. ( NRS 449.0302 ) “Division of Welfare and Supportive Services” means the Division of Welfare and Supportive Services of the Department of Health and Human Services. (Added to NAC by Bd. of Health, eff. 8-1-91)—(Substituted in revision for NAC 449.0074) NAC 449.0032 “Emergency” defined. ( NRS 449.0302 ) “Emergency” means a major deficiency that places one or more recipients in immediate jeopardy. The term includes, without limitation, any fire, flood, contagious infection, loss of utilities or inappropriate transfer of residents. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0033 “Employment agency to provide nonmedical services” defined. ( NRS 439.200 , 449.03005 ) “Employment agency to provide nonmedical services” means an employment agency that contracts with persons to provide “nonmedical services related to personal care to elderly persons or persons with disabilities,” as that term is defined in NRS 449.01517 . (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.0034 “Facility” defined. ( NRS 449.0302 ) Except as otherwise defined in NAC 449.011911 , “facility” means a medical facility, facility for the dependent, an employment agency that contracts with persons in this State to provide certain nonmedical services described in subsection 1 of NRS 449.03005 , a facility which is otherwise required by regulations adopted by the Board pursuant to NRS 449.0303 to be licensed or a referral agency. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R131-99 & R132-99, 11-29-99; R016-20, 11-2-2020) NAC 449.0042 “Holiday” defined. ( NRS 449.0302 ) “Holiday” means a day on which the offices of State Government are closed. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0043 “Home for individual residential care” defined. ( NRS 449.0302 ) “Home for individual residential care” has the meaning ascribed to it in NRS 449.0105 . (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.0044 “Immediate and serious threat” and “immediate jeopardy” defined. ( NRS 449.0302 ) “Immediate and serious threat” or “immediate jeopardy” means a situation in which corrective action within 48 hours is necessary because the failure by a facility to comply with a requirement for licensure, certification or participation in Medicare or Medicaid has caused, or if uncorrected is likely to cause, serious injury or harm, or even death, to a recipient. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0046 “Incident” defined. ( NRS 449.0302 ) “Incident” means an action, practice or situation that appears to be inconsistent with a federal or state statute, rule or regulation of the Division or the Centers for Medicare and Medicaid Services or conditions and standards of or requirement for participation in Medicare or Medicaid. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.0048 “License” defined. ( NRS 449.0302 ) “License” means all or part of any permit, certificate, approval, registration, charter or similar grant of permission to operate issued to a facility by the Division. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0049 “Licensed dietitian” defined. ( NRS 449.0302 ) “Licensed dietitian” has the meaning ascribed to it in NRS 640E.040 . (Added to NAC by Bd. of Health by R090-12, eff. 12-20-2012) NAC 449.005 “Licensee” defined. ( NRS 449.0302 ) “Licensee” means any person, corporation, partnership, voluntary association or other public or private entity, including any governmental body, licensed to operate a facility. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0052 “Medicaid” defined. ( NRS 449.0302 ) “Medicaid” means the program established pursuant to Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., to provide assistance for part or all of the cost of medical care rendered on behalf of indigent persons. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0054 “Medicare” defined. ( NRS 449.0302 ) “Medicare” means the program of health insurance for aged and disabled persons established pursuant to Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395 et seq. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0056 “Party” defined. ( NRS 449.0302 ) “Party” means each person or agency as defined in NRS 233B.035 . (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0058 “Person” defined. ( NRS 449.0302 ) “Person” means a natural person, trust, estate, partnership, corporation, professional association, governmental body or any other entity, public or private. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.006 “Recipient” defined. ( NRS 449.0302 ) “Recipient” means a person receiving care, services or treatment from a facility. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0061 “Referral agency” defined. ( NRS 449.0302 , 449.0305 ) “Referral agency” means a business that provides referrals to residential facilities for groups which is subject to regulation pursuant to NRS 449.0305 , including, without limitation, any business entity that engages in the process of referring clients for compensation to residential facilities for groups. (Added to NAC by Bd. of Health by R132-99, eff. 11-29-99) NAC 449.0062 “Resident” defined. ( NRS 449.0302 ) “Resident” means a person who resides in a residential facility. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0064 “Residential facility” defined. ( NRS 449.0302 ) “Residential facility” means a facility operated 24 hours per day in which one or more persons receiving care, treatment or services ordinarily remain for 24 hours a day. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0066 “Sanction” defined. ( NRS 449.0302 ) “Sanction” means a corrective measure or penalty that is imposed by the Bureau upon a facility. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0068 “Services” defined. ( NRS 449.0302 ) “Services” means medical or personal care, including necessary preparation of food, laundry and housekeeping in the case of a residential facility and items such as medical diagnosis and treatment, drugs and biologicals, supplies, appliances, equipment, medical-social services and use of a facility. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.007 “Survey” defined. ( NRS 449.0302 ) 1. “Survey” means a regularly scheduled inspection of a facility conducted by employees of the Bureau to verify the facility’s compliance with the regulations of the Division, the Centers for Medicare and Medicaid Services, eligibility for participation in the Medicare or Medicaid programs and eligibility for licensure. 2. The term includes a follow-up inspection to recertify a facility or evaluate compliance with a plan of correction or an inspection made in response to a complaint. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.0072 “Treatment” defined. ( NRS 449.0302 ) “Treatment” means any medication, drug, test or procedure conducted or administered to diagnose or remedy a physical or mental illness or condition. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.008 Computation of time. ( NRS 449.0302 ) For the purposes of any computation of time required by NAC 449.002 to 449.99939 , inclusive: 1. Any prescribed period of more than 5 days includes Saturdays, Sundays and holidays. 2. Any prescribed period of 5 days or less does not include Saturdays, Sundays or holidays. 3. If the date on which any action required to be performed falls on a Saturday, Sunday or holiday, the time is extended until the next day that is not a Saturday, Sunday or holiday. 4. The day of any act or event or on which notice is received is not included in the computation. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.0085 Licensee prohibited from employing or contracting with unlicensed person to provide certain nutrition services. ( NRS 449.0302 ) A licensee shall not employ or contract with a person to provide medical nutrition therapy or nutrition services unless the person is licensed pursuant to chapter 640E of NRS or exempt from such licensure. (Added to NAC by Bd. of Health by R090-12, eff. 12-20-2012) NAC 449.009 Control by Division over medical records of medical facility or facility for dependent upon suspension of license or cessation of operation: Authorized actions to remove, store and protect records; facilities to pay cost of maintenance of records; notice before destruction of records. ( NRS 449.171 ) 1. If the Division takes control of the medical records of a medical facility or a facility for the dependent pursuant to NRS 449.171 , the Division: (a) May remove any or all of the medical records and store them in a manner that ensures the safety of the medical records. (b) May contract with a person or governmental entity to ensure the safety of the medical records. (c) Shall determine the costs for maintaining the medical records and require the medical facility or facility for the dependent, as applicable, to pay those costs. The costs must be assessed beginning on the date on which the Division obtains control of the medical records and ending on the date on which the medical records are destroyed or returned to the facility pursuant to subsection 3. The medical facility or facility for the dependent, as applicable, shall pay the costs within 30 days after receipt of notice of the amount owed. 2. If the Division contracts with a person or governmental entity pursuant to paragraph (b) of subsection 1, the Division shall ensure that the person or governmental entity complies with the provisions of subsection 2 of NRS 449.171 . 3. The Division may: (a) Unless a longer period is required by federal law, destroy a medical record upon expiration of the period of retention required by NRS 629.051 ; or (b) Return a medical record to the medical facility or facility for the dependent, as applicable, if the license of the facility is reinstated or the facility restores its operation. 4. If the Division determines that a medical record in the control of the Division will be destroyed in accordance with subsection 3, the Division shall, for a period of not less than 30 days, post on an Internet website maintained by the Division and in other locations as determined by the Division a notice informing the patients of the medical facility or facility for the dependent, as applicable, how to obtain a medical record before it is destroyed. 5. If a medical facility or facility for the dependent fails to pay the amount owed pursuant to paragraph (c) of subsection 1, the Division may suspend or revoke the license of the medical facility or facility for the dependent pursuant to NAC 449.0118 . (Added to NAC by Bd. of Health by R114-10, eff. 12-20-2012) NAC 449.010 Severability. ( NRS 449.0302 ) If any of the provisions of NAC 449.002 to 449.99939 , inclusive, or any application thereof to any person, thing or circumstance is held invalid, it is intended that such invalidity not affect the remaining provisions, or their application, that can be given effect without the invalid provision or application. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 17, eff. 3-27-76] NAC 449.0105 Adoption of certain publications by reference; revision of publication after adoption. ( NRS 439.200 , 449.0302 ) 1. The State Board of Health hereby adopts by reference: (a) NFPA 101: Life Safety Code , in the form most recently published by the National Fire Protection Association, unless the Board gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the code may be obtained from the National Fire Protection Association at 11 Tracy Drive, Avon, Massachusetts 02322, at the Internet address http://www.nfpa.org or by telephone at (800) 344-3555, for the price of $151.50. (b) NFPA 99: Health Care Facilities Code , in the form most recently published by the National Fire Protection Association, unless the Board gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the standard may be obtained from the National Fire Protection Association at 11 Tracy Drive, Avon, Massachusetts 02322, at the Internet address http://www.nfpa.org or by telephone at (800) 344-3555, for the price of $111.00. (c) Guidelines for Design and Construction of Hospitals , in the form most recently published by the Facility Guidelines Institute, unless the Board gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the guidelines may be obtained from the Facility Guidelines Institute at the Internet address https://shop.fgiguidelines.org or by telephone at (800) 798-9296, for the price of $235. (d) Guidelines for Design and Construction of Residential Health, Care, and Support Facilities , in the form most recently published by the Facility Guidelines Institute, unless the Board gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the guidelines may be obtained from the Facility Guidelines Institute at the Internet address https://shop.fgiguidelines.org or by telephone at (800) 798-9296, for the price of $235. (e) Guidelines for Design and Construction of Outpatient Facilities , in the form most recently published by the Facility Guidelines Institute, unless the Board gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the guidelines may be obtained from the Facility Guidelines Institute at the Internet address https://shop.fgiguidelines.org or by telephone at (800) 798-9296, for the price of $235. 2. The State Board of Health will review each revision of the publications adopted by reference pursuant to subsection 1 to ensure its suitability for this State. If the Board determines that a revision is not suitable for this State, the Board will hold a public hearing to review its determination within 12 months after the date of the publication of the revision and give notice of that hearing. If, after the hearing, the Board does not revise its determination, the Board will give notice within 30 days after the hearing that the revision is not suitable for this State. If the Board does not give such notice, the revision becomes part of the publication adopted by reference pursuant to subsection 1. (Added to NAC by Bd. of Health by R066-04, R067-04, R068-04, R069-04, R073-04, R076-04 & R077-04, eff. 8-4-2004; A by R121-16, 9-21-2017; R122-16, 9-21-2017; R048-22, 12-29-2022) NAC 449.0106 Adoption by reference of certain publications relating to personal protective equipment and prevention of infection; revision of publication after adoption. ( NRS 439.200 , 439.0302) 1. The following publications are hereby adopted by reference: (a) “Part II.E.: Personal Protective Equipment (PPE) for Healthcare Personnel” of 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings , as updated in May 2022, published by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services and available at no cost on the Internet at http://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf , or, if that Internet website ceases to exist, from the Division. (b) “Optimizing Personal Protective Equipment (PPE) Supplies,” available at no cost on the Internet website of the Centers for Disease Control and Prevention of the United States Department of Health and Human Services at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html , or, if that Internet website ceases to exist, from the Division. (c) “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,” available at no cost on the Internet website of the Centers for Disease Control and Prevention of the United States Department of Health and Human Services at http://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html , or, if that Internet website ceases to exist, from the Division. 2. If any publication adopted by reference in subsection 1 is revised, the Division shall review the revision to determine its suitability for this State. If the Division determines that the revision is not suitable for this State, the Division shall hold a public hearing to review its determination and give notice of that hearing within 90 days after the date of the publication of the revision. If, after the hearing, the Division does not revise its determination, the Division shall give notice that the revision is not suitable for this State within 90 days after the hearing. If the Division does not give such notice, the revision becomes part of the publication adopted by reference pursuant to subsection 1. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) NAC 449.01065 Requirements relating to personal protective equipment; exception for nursing pool. ( NRS 439.200 , 439.0302) 1. A medical facility, facility for the dependent or other facility required by the regulations adopted by the Board pursuant to NRS 449.0303 to be licensed shall ensure that each person on the premises of the facility uses personal protective equipment in accordance with the publications adopted by reference in NAC 449.0106 . The facility shall maintain: (a) Not less than a 30-day supply of personal protective equipment at all times; or (b) If the facility is unable to comply with the requirements of paragraph (a) due to a shortage in personal protective equipment, documentation of attempts by and the inability of the facility to obtain personal protective equipment. 2. Except as otherwise provided in subsection 3, a medical facility, facility for the dependent or other facility required by the regulations adopted by the Board pursuant to NRS 449.0303 to be licensed shall: (a) Enter into a contract with a supplier of personal protective equipment which ensures that the facility has a supply of personal protective equipment sufficient to comply with the requirements of subsection 1; and (b) Track the amount of personal protective equipment that the facility has available, the rate at which personal protective equipment is used in the facility and orders for personal protective equipment in a manner sufficient to ensure compliance with the requirements of subsection 1. 3. The requirements of subsection 2 do not apply to a nursing pool that receives sufficient personal protective equipment from its clients to meet the requirements of subsection 1. Such a nursing pool shall maintain documentation demonstrating that it meets the requirements of this subsection. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) NAC 449.0107 Posting of star rating by medical facility or facility for the dependent; exception. ( NRS 439.200 , 449.0302 , 449.1825 ) 1. Information posted by a medical facility or facility for the dependent to satisfy the requirements of subsection 2 of NRS 449.1825 must, in addition to meeting the requirements of that subsection: (a) Be posted on a sign that is not less than 8.5 inches in height and 11 inches in width, with margins not greater than 1 inch on any side; (b) Be written using a single typeface in not less than 20-point type; and (c) State the name of the facility and identify the star rating assigned by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services as the “Centers for Medicare and Medicaid Services Star Rating.” 2. The requirements of subsection 2 of NRS 449.1825 apply to each entrance to a building where activity is conducted for which a license as a medical facility or facility for the dependent is required. 3. A medical facility or facility for the dependent is not required to post a star rating assigned by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services pursuant to subsection 2 of NRS 449.1825 if the facility did not receive such a rating, including, without limitation, if the facility received an asterisk instead of a star rating. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.0108 Notification of Division concerning accreditation of medical facility; administrative penalty. ( NRS 439.200 , 449.0302 , 449.165 ) 1. If a medical facility receives notice from a national accrediting organization that the national accrediting organization has accredited the medical facility, the medical facility shall submit to the Division in the manner prescribed by the Division a copy of the notice not later than 7 calendar days after receiving the notice. 2. If a medical facility loses the accreditation of a national accrediting organization, the medical facility shall notify the Division not later than 7 calendar days after receiving notice of the loss of accreditation. 3. The Division may impose an administrative penalty in an amount not to exceed $1,000 for a failure to comply with the requirements of this section. The Bureau shall not impose any administrative sanction pursuant to NAC 449.9982 to 449.99939 , inclusive, for such a deficiency. 4. As used in this section, “national accrediting organization” has the meaning ascribed to it in 42 C.F.R. § 488.1. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) NAC 449.0109 Program and policy for control of infection; designation and training of person responsible for infection control. ( NRS 439.200 , 449.0302 ) 1. A facility for the dependent shall: (a) Develop and carry out an infection control program to prevent and control infections within the facility; (b) Review the infection control program, including, without limitation, the infection control policy adopted pursuant to subsection 2, at least annually to ensure that the program meets current evidence-based standards for infection control plans and the safety needs of residents, staff and visitors; and (c) Develop and carry out a comprehensive plan for emergency preparedness. 2. To carry out the infection control program developed pursuant to paragraph (a) of subsection 1, the facility shall adopt an infection control policy. The policy must include, without limitation, current infection control guidelines developed by a nationally recognized infection control organization that are appropriate for the scope of service of the facility. Such nationally recognized organizations include, without limitation, the Association for Professionals in Infection Control and Epidemiology, Inc., the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, the World Health Organization or the Society for Healthcare Epidemiology of America, or a successor in interest to any of those organizations. 3. The program to prevent and control infections within the facility for the dependent developed pursuant to paragraph (a) of subsection 1 must provide for the designation of: (a) A primary person who is responsible for infection control; and (b) A secondary person who is responsible for infection control when the primary person is absent to ensure that someone is responsible for infection control at all times. 4. The persons designated pursuant to subsection 3 as responsible for infection control shall complete not less than 15 hours of training concerning the control and prevention of infections provided by the Association for Professionals in Infection Control and Epidemiology, Inc., the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, the World Health Organization or the Society for Healthcare Epidemiology of America, or a successor in interest to any of those organizations, not later than 3 months after being designated and annually thereafter. 5. Training completed pursuant to subsection 4 may be in any format, including, without limitation, an online course provided for compensation or free of charge. A certificate of completion for the training must be maintained in the personnel file of each person designated pursuant to subsection 3 for 3 years immediately following the completion of the training. 6. The plan for emergency preparedness developed pursuant to paragraph (c) of subsection 1 must address internal and external emergencies and local and widespread emergencies. Such emergencies must include, without limitation, emerging infectious diseases. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) GENERAL REQUIREMENTS FOR LICENSURE NAC 449.011 Application for license. ( NRS 439.200 , 449.0302 , 449.040 ) An application for a license that is filed with the Division pursuant to NRS 449.040 : 1. Must be complete and include proof of the identity of the applicant that is acceptable to the Division. 2. In accordance with NRS 449.050 , must be accompanied by the appropriate application fee specified in NAC 449.002 to 449.99939 , inclusive. 3. In establishing that the applicant is of reputable and responsible character as required by NRS 449.040 , must include personal references and information concerning the applicant’s financial status and business activities and associations in and out of this State during the immediately preceding 3-year period. If the applicant is a firm, association, organization, partnership, business trust, corporation or company, such references and information must be provided with respect to the members thereof and the person in charge of the facility or program for which application is made. 4. In addition to the information required by NRS 449.040 and any other information specifically required for a particular license, must include: (a) Full, complete and accurate information regarding the ownership of the facility or program and all changes to that ownership that occur while the application is pending. The information must include the name of: (1) Each natural person who is an owner of the facility or program; (2) Each person who has a direct or indirect ownership interest in the facility or program of 10 percent or more and who is the owner, in whole or in part, of any mortgage, deed of trust, note or other obligation secured in whole or in part by the facility or program or any of the property or assets of the facility or program; (3) If the applicant is a corporation, each officer and director; and (4) If the applicant is a partnership, each partner. (b) The address of the applicant’s principal office. (c) Evidence satisfactory to the Division that the facility or program meets all applicable federal, state and local laws and complies with all safety, health, building and fire codes. If there are any differences between the state and local codes, the more restrictive standards apply. (d) If required by NRS 439A.100 , a copy of a letter of approval issued by the Director of the Department of Health and Human Services. (e) A copy of the certificate of occupancy, a copy of the applicant’s business license and a copy of any special use permits obtained in connection with the operation of the facility or program. (f) A copy of any property lease or rental agreements concerning the facility or program. (g) If the applicant is a corporation, a copy of its bylaws and articles of incorporation. 5. If the application is for a facility for the care of adults during the day, must include the maximum number of clients allowed to occupy the facility at one time. 6. If the application is for an ambulatory surgical center, must identify the class designation for the ambulatory surgical center designated pursuant to NAC 449.9844 . As used in this subsection, “ambulatory surgical center” has the meaning ascribed to it in NAC 449.972 . (Added to NAC by Bd. of Health by R044-97, eff. 10-30-97; A by R078-12, 12-20-2012; R022-14, 6-26-2015; R048-22, 12-29-2022) NAC 449.0112 Investigation; prelicensure or precertification survey; inspection for fire safety; exceptions. ( NRS 439.200 , 449.0302 ) 1. Upon receipt of a properly completed application, proof of the identity of the applicant that is acceptable to the Division and the appropriate fee, the Division shall conduct an investigation concerning the premises, facilities, qualifications of personnel, methods of operation and policies of the applicant and perform a prelicensure survey or precertification survey, as applicable, of: (a) The applicant; and (b) The facility, program plan and management plan, as appropriate. 2. Except as otherwise provided in this subsection, before issuing a license or certificate, as applicable, the Division must receive a satisfactory report of inspection of the facility from the State Fire Marshal or the local fire department. The Division is not required to receive such a report before issuing a license or certificate, as applicable, to: (a) A provider of community-based living arrangement services; (b) An agency to provide personal care services in the home; (c) An intermediary service organization; (d) An agency to provide nursing in the home; (e) A nursing pool; (f) A business described in NRS 449.0305 ; (g) An employment agency described in NRS 449.03005 ; or (h) A program of hospice care. (Added to NAC by Bd. of Health by R044-97, eff. 10-30-97; A by R078-12, 12-20-2012; R048-22, 12-29-2022) NAC 449.01125 Duties of Division if Central Repository unable to complete investigation of applicant; grounds for denial or revocation of license or delay of action concerning application. ( NRS 449.0302 ) 1. If the Central Repository notifies the Division that it is unable to complete an investigation pursuant to NRS 449.122 because: (a) Additional information is required, the Division shall send a notice to the applicant or licensee directing the applicant or licensee to provide the Division and the Central Repository with the information or proof that the information cannot be obtained within 30 days after the date on which the notice was sent by the Division. (b) Criminal charges against the applicant or licensee are pending, the Division shall notify the applicant or licensee that he or she is required to: (1) Notify the Division of the date of each court proceeding relating to the charges; and (2) Provide the Central Repository with any information relating to the final disposition of the charges as soon as the information is available. 2. The Division may deny an application for a license of an applicant or revoke the license of a licensee who fails to comply with the provisions of this section. 3. The Division may delay taking any action concerning an application until the Central Repository completes its investigation. (Added to NAC by Bd. of Health by R111-12, eff. 3-28-2014) NAC 449.0113 Duties of administrator or licensee if Central Repository unable to complete investigation of employee or independent contractor; grounds for termination; actions to ensure patient safety. ( NRS 449.0302 ) 1. If the Central Repository notifies the administrator of, or the person licensed to operate, a facility, hospital, agency, program or home that it is unable to complete an investigation pursuant to NRS 449.123 because: (a) Additional information is required, the administrator of, or the person licensed to operate, the facility, hospital, agency, program or home shall, within 10 working days after receiving the notice from the Central Repository, send a notice to the employee, employee of a temporary employment service or independent contractor directing the employee, employee of a temporary employment service or independent contractor to provide the administrator of, or the person licensed to operate, the facility, hospital, agency, program or home and the Central Repository with the information or proof that the information cannot be obtained within 30 days after the date on which the notice was sent by the administrator of, or the person licensed to operate, the facility, hospital, agency, program or home. (b) Criminal charges against the employee, employee of a temporary employment service or independent contractor are pending, the administrator of, or the person licensed to operate, the facility, hospital, agency, program or home shall notify the employee, employee of a temporary employment service or independent contractor that he or she is required to: (1) Notify the administrator of, or the person licensed to operate, the facility, hospital, agency, program or home of the date of each court proceeding relating to the charges; and (2) Provide the Central Repository with any information relating to the final disposition of the charges as soon as the information is available. 2. The administrator of, or the person licensed to operate, the facility, hospital, agency, program or home shall terminate the employment of an employee or the contract with an independent contractor or notify the temporary employment service that its employee is prohibited from providing services for the facility, hospital, agency, program or home upon determining that the employee, employee of a temporary employment service or independent contractor has willfully failed to comply with the provisions of this section. 3. Pending the completion of an investigation of an employee, employee of a temporary employment service or independent contractor of a facility, hospital, agency, program or home for which the Central Repository has provided notice pursuant to subsection 1 that it is unable to complete the investigation for a reason stated in subsection 1, and during any period in which an employee, employee of a temporary employment service or independent contractor has to correct information provided by the Central Repository pursuant to NRS 449.125 , the administrator of, or the person licensed to operate, a facility, hospital, agency, program or home shall take actions to ensure the safety of its patients, residents or clients, including: (a) Prohibiting the employee, employee of a temporary employment service or independent contractor from working at the facility, hospital, agency, program or home by placing the employee, employee of a temporary employment service or independent contractor on leave; (b) Requiring the employee, employee of a temporary employment service or independent contractor to be under the direct supervision and observation of an employee of the facility, hospital, agency, program or home while caring for any patient, client or resident of the facility, hospital, agency, program or home; (c) Conducting an investigation into the circumstances of the record of criminal history to determine and carry out any measures that the facility, hospital, agency, program or home identifies as necessary to ensure the safety of its patients, residents or clients if the employee, employee of a temporary employment service or independent contractor cares for patients, residents or clients; or (d) Taking any combination of the actions set forth in paragraph (a), (b) or (c). 4. As used in this section, “facility, hospital, agency, program or home” has the meaning ascribed to it in NRS 449.119 and includes an intermediary service organization for the purpose of carrying out this section and NAC 449.01125 . (Added to NAC by Bd. of Health by R111-12, eff. 3-28-2014) NAC 449.0114 Display of license; compliance with law; transfer of real property; change in administrator, ownership, location, services or maximum number of clients. ( NRS 449.0302 , 449.050 ) 1. Upon receipt of a license, the licensee shall display the license at a conspicuous location within the facility. 2. During the term of the license, the licensee shall continuously maintain the facility in conformance with the provisions of NAC 449.002 to 449.99939 , inclusive, and chapter 449 of NRS. 3. If there is a transfer of the real property on which the facility is located, but no change in the operator of the facility, the licensee shall, within 10 days, notify the Division of the transfer in writing and provide the Division with a copy of any lease agreement relating to the transfer. 4. If there is a change in the administrator of the facility, the licensee shall notify the Division of the change within 10 days. The notification must provide evidence that the new administrator is currently licensed pursuant to chapter 654 of NRS and the regulations adopted pursuant thereto. If the licensee fails to notify the Division and submit an application for a new license within 10 days after the change, the licensee shall pay to the Division a fee in an amount equal to 150 percent of the fee required for a new application set forth in subsection 1 of NAC 449.0168 . 5. A licensee shall notify the Division immediately of any change in: (a) The ownership of the facility; (b) The location of the facility; (c) The services provided at the facility; and (d) If the facility is a facility for the care of adults during the day, the maximum number of clients allowed to occupy the facility at one time. (Added to NAC by Bd. of Health by R044-97, eff. 10-30-97; A by R122-05, 11-17-2005; R022-14, 6-26-2015) NAC 449.0115 Review of building plans for new construction or remodeling by certain applicants: Required documents; payment of fees and costs. ( NRS 439.150 , 439.200 , 449.0302 ) 1. An applicant for a license or the renewal of a license to operate a medical facility or facility for the dependent who wishes or is required to have building plans for new construction or remodeling reviewed by the Division must: (a) Submit to the Division or have on file a current application for a license or renewal of a license; (b) Pay to the Division any fees required for the issuance or renewal of a license pursuant to NAC 449.013 or 449.016 ; and (c) Submit two complete sets of building plans for new construction or remodeling prepared by a registered architect, registered residential designer or licensed general contractor to the entity designated to review such plans by the Division. 2. All costs incurred for the review of building plans and any changes or revisions made to the plans must be borne by the applicant and paid directly to the designee of the Division conducting the review of the plans. 3. The costs required to be paid pursuant to subsection 2 are not refundable and are in addition to the fees charged for the issuance or renewal of the license pursuant to NAC 449.013 or 449.016 . (Added to NAC by Bd. of Health, eff. 11-1-95; A by R035-97, 10-30-97; R129-99, 11-29-99, eff. 1-1-2000; R076-01, 10-18-2001; R067-04, R070-04 & R072-04, 8-4-2004; R076-04, 8-5-2004; R122-05, 11-17-2005; R051-06, 7-14-2006) NAC 449.01153 Approval of building plans for construction or remodeling of certain facilities: Period of validity. ( NRS 449.0302 ) If the Division approves building plans for the construction or remodeling of a facility for modified medical detoxification, a facility for skilled nursing, a facility for the care of adults during the day, a facility for the treatment of persons with alcohol or other substance use disorders, a hospital, a mobile unit, a residential facility for groups or a surgical center for ambulatory patients, the approval is valid for 42 months after it is issued, unless there has been: 1. A modification of the building plans; 2. A change in the ownership of the facility; or 3. A change in the intended use of the facility. (Added to NAC by Bd. of Health by R065-04, eff. 8-4-2004) NAC 449.01156 On-site advisory inspection of facility: Written request; action by Division; fee. ( NRS 439.150 , 439.200 , 449.0302 ) 1. A licensee or an applicant for the issuance or renewal of a license whose building plans for the construction of a facility have been reviewed pursuant to NAC 449.0115 may submit a written request to the Division for an on-site advisory inspection to be conducted by the Division after at least 80 percent of the construction of the facility is completed. The written request must include, without limitation, the anticipated date on which 80 percent of the construction of the facility will be completed. 2. If the Division receives a request submitted pursuant to subsection 1, the Division shall determine its ability to grant the request and shall issue a notice of that determination to the licensee or applicant who submitted the request. 3. If the Division grants a request submitted pursuant to subsection 1, the licensee or applicant who submitted the request shall, before the Division conducts the on-site inspection, submit to the Division a fee of: (a) Five hundred dollars, if the project is valued at not more than $500,000; (b) One thousand dollars, if the project is valued at more than $500,000 but not more than $1,000,000; or (c) Two thousand dollars, if the project is valued at more than $1,000,000. (Added to NAC by Bd. of Health by R065-04, eff. 8-4-2004) NAC 449.0116 Renewal of license: Application; validity of existing license pending decision on application; inspection of facility; untimely filing or failure to file application. ( NRS 439.150 , 439.200 , 449.0302 , 449.050 , 449.089 ) 1. Except as otherwise provided in subsection 2, a licensee who wishes to renew his or her license must submit a complete application for renewal to the Division on or before November 15 of the calendar year in which the license expires. The existing license shall be deemed valid until the submitted application for renewal is evaluated and a final determination is made by the Division concerning whether to renew the license. The Division may require an inspection of the facility to ensure that it meets the requirements of NAC 449.002 to 449.99939 , inclusive, before deciding whether to renew a license. 2. A licensee who, without good cause, files an application for the renewal of his or her license after the date set forth in subsection 1 but on or before December 31 of the calendar year in which the license expires and who wishes to renew the license must pay: (a) The fee required for the renewal of the license pursuant to NAC 449.013 or 449.016 , as appropriate; and (b) An additional charge equal to one-half the amount of the fee required for the renewal of the license pursuant to NAC 449.013 or 449.016 , as appropriate. 3. A licensee who fails to file an application for the renewal of his or her license before the license expires is not eligible to renew the license and, if he or she wishes to be licensed, must submit an application for a new license. (Added to NAC by Bd. of Health by R044-97, eff. 10-30-97; A by R065-04, 8-4-2004) NAC 449.0118 Denial, suspension or revocation of license: Grounds. ( NRS 449.0302 ) In addition to the grounds set forth in NRS 449.160 and any other grounds specifically applicable to a particular license, the Division may deny an application for a license or may suspend or revoke a license upon any of the following grounds: 1. The failure or refusal of an applicant or licensee to comply with any of the provisions of chapter 449 of NRS or the regulations adopted by the State Board of Health. 2. The failure or refusal of an applicant or licensee to comply with a reasonable order from the Division to remove a resident from a facility or program. 3. Operating a facility or program without a license, if a license is required before operating. 4. Accepting for care, at any given time, more residents than the number specified in the license. 5. The failure or refusal of a licensee to return an adequate plan of correction to the Division within 10 days after the receipt by the licensee of a statement of deficiencies. 6. The failure or refusal to cooperate fully with an investigation or inspection by the Bureau. 7. Misappropriation of the property of a resident of a facility. 8. Abuse, neglect or exploitation of an infirm person, a person with an intellectual disability or a person with a disability, or of a person who is 60 years of age or older. 9. The failure of a medical facility or facility for the dependent to pay the costs for the maintenance of the medical records of the facility required pursuant to paragraph (c) of subsection 1 of NAC 449.009 . (Added to NAC by Bd. of Health by R044-97, eff. 10-30-97; A by R114-10, 12-20-2012) NAC 449.0119 Denial, suspension or revocation of license or endorsement: Appeals. ( NRS 449.0302 , 449.170 ) An applicant or licensee who is aggrieved by an action of the Division relating to the denial, suspension or revocation of a license or an endorsement may appeal pursuant to the procedures set forth in NAC 439.300 to 439.395 , inclusive. (Added to NAC by Bd. of Health by R044-97, eff. 10-30-97; A by R119-10, 1-13-2011) CULTURAL COMPETENCY AND PREVENTION OF DISCRIMINATION NAC 449.011901 Definitions. ( NRS 449.0302 ) As used in NAC 449.011901 to 449.011951 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.011903 to 449.011911 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011903 “Cultural competency training” defined. ( NRS 449.0302 ) “Cultural competency training” means the training required by NAC 449.011931 . (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011906 “Department” defined. ( NRS 449.0302 ) “Department” means the Department of Health and Human Services. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011909 “Director” defined. ( NRS 449.0302 ) “Director” means the Director of the Department. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011911 “Facility” defined. ( NRS 449.0302 ) “Facility” means a medical facility, facility for the dependent or facility which is otherwise required by regulations adopted by the Board pursuant to NRS 449.0303 to be licensed. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011913 Types of prohibited discrimination. ( NRS 449.0302 , 449.101 ) Pursuant to paragraph (e) of subsection 1 of NRS 449.0302 and paragraph (a) of subsection 2 of NRS 449.101 , the specific types of prohibited discrimination include, without limitation: 1. Discrimination that results in a person not being treated with dignity and which is based wholly or partially on the actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or human immunodeficiency virus status of the patient or resident or any person with whom the patient or resident associates. 2. Indirect discrimination that may or may not be intentional and which results in the application of policies that are applied uniformly and in a nondiscriminatory manner by the facility. 3. Discrimination which is based wholly or partially on the person associating with other persons who: (a) Are actually or perceived to be of a different race, color, religion, national origin, ancestry, age, gender, sexual orientation, gender identity or expression or human immunodeficiency virus status of the person; or (b) Actually or are perceived to have a physical or mental disability. 4. Harassment or bullying of any kind of a person because of his or her actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or human immunodeficiency virus status. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011916 Policies and procedures for transfer, discharge and provision of services. ( NRS 449.0302 ) A facility shall adopt and maintain policies and procedures for the transfer and discharge of, and the provision of services to, patients or residents in the facility which do not discriminate against a patient or resident based on the source of payment for the services provided. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011919 Posting of notice relating to filing of complaints. ( NRS 449.0302 ) In addition to the statement prescribed by paragraph (b) of subsection 2 of NRS 449.101 , a facility shall post prominently in the facility and include on any Internet website to market the facility: 1. Notice that a patient or resident who has experienced prohibited discrimination may file a complaint with the Division; and 2. The contact information for the Division. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011921 Requirements for posting certain required information: Contents; size; placement. ( NRS 449.0302 ) 1. The statement required to be posted pursuant to paragraph (b) of subsection 2 of NRS 449.101 and the notice and information required to be posted pursuant to subsection 3 of NRS 449.101 or NAC 449.011919 , as applicable, must: (a) State the name of the facility; and (b) When posted in the facility: (1) Be not less than 8.5 inches in height and 11 inches in width, with margins not greater than 0.5 inches on any side; and (2) Be written using a single typeface in not less than 22-point type. 2. When posting prominently the statement required to be posted pursuant to paragraph (b) of subsection 2 of NRS 449.101 and the notice and information required to be posted pursuant to subsection 3 of NRS 449.101 or NAC 449.011919 , as applicable, the facility shall post the statement or notice and information in each: (a) Public entrance of the facility; (b) Waiting room of the facility; and (c) Public dining room of the facility. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011923 Provision to patient or resident of information concerning complaints. ( NRS 449.0302 ) 1. Upon admission of a patient or resident, the facility shall: (a) Provide the patient or resident with a written copy of the statement required pursuant to paragraph (b) of subsection 2 of NRS 449.101 and the notice and information required pursuant to subsection 3 of NRS 449.101 or NAC 449.011919 , as applicable. (b) Provide the patient or resident with a written notice that a patient or resident who has experienced prohibited discrimination may file a complaint with the facility. The written notice provided by the facility must include, without limitation: (1) The contact information for the Division; (2) A clear statement that such a complaint with the facility: (I) May be filed in addition to the complaint that may be filed with the Division pursuant to subsection 3 of NRS 449.101 or NAC 449.011919 , as applicable; and (II) Is not required to be filed for the patient or resident to file a complaint with the Division pursuant to subsection 3 of NRS 449.101 or 449.011919, as applicable; and (3) The procedure that the facility uses to address such complaints with the facility and the timeframe for how long it will take the facility to address such complaints with the facility. 2. As used in this section, “prohibited discrimination” means the discrimination described in NAC 449.011913 and in subsection 1 of NRS 449.101 . (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011926 Policy on handling of complaints; log of complaints. ( NRS 449.0302 ) A facility shall: 1. Develop and adopt a written policy on how a complaint with the facility that is filed pursuant to paragraph (b) of subsection 1 of NAC 449.011923 is documented, investigated and resolved; and 2. Maintain a log that lists: (a) All complaints with the facility that are filed pursuant to paragraph (b) of subsection 1 of NAC 449.011923 ; (b) The actions taken by the facility to investigate and resolve the complaint; and (c) If no action was taken, an explanation as to why no action was taken. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011929 Written permission required for presence of certain persons during physical examination where patient is unclothed. ( NRS 449.0302 ) To provide express permission pursuant to subsection 2 of NRS 449.102 , a patient or resident or the authorized representative of the patient or resident must provide permission in writing. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011931 Cultural competency training for agent or employee who provides care to patient or resident. ( NRS 449.0302 , 449.103 ) 1. Pursuant to subsection 1 of NRS 449.103 , within 30 business days after the course or program is assigned a course number by the Division pursuant to NAC 449.011941 or within 30 business days of any agent or employee being contracted or hired, whichever is later, and at least once each year thereafter, a facility shall conduct training relating specifically to cultural competency for any agent or employee of the facility who provides care to a patient or resident of the facility so that the agent or employee may: (a) More effectively treat patients or care for residents, as applicable; and (b) Better understand patients or residents who have different cultural backgrounds, including, without limitation, patients or residents who fall within one or more of the categories in paragraphs (a) to (f), inclusive, of subsection 1 of NRS 449.103 . 2. The facility shall provide the training required by subsection 1 through a course or program that is approved by the Director of the Department or his or her designee pursuant to NAC 449.011939 and is assigned a course number by the Division pursuant to NAC 449.011941 . 3. The facility shall keep documentation in the personnel file of any agent or employee of the facility of the completion of the cultural competency training required pursuant to subsection 1. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011933 Submission of course or program for cultural competency training. ( NRS 449.0302 , 449.103 ) 1. Within 90 days after a facility is licensed to operate, the facility must submit to the Department on a form prescribed by the Department the course or program which the facility will use to provide cultural competency training. The facility may: (a) Develop or operate the course or program; or (b) Contract with a third party to develop and operate the course or program. 2. The course or program submitted by the facility pursuant to subsection 1 must address patients or residents who have different cultural backgrounds from that of the agent or employee of the facility, including, without limitation, patients or residents who fall within one or more of the categories in paragraphs (a) to (f), inclusive, of subsection 1 of NRS 449.103 . 3. When a facility submits a course or program pursuant to subsection 1, the facility must also provide to the Department the following information for the instructor of the course or program: (a) The application of the instructor who will teach the course or program; (b) Three letters of recommendation for the instructor, including, without limitation, at least one letter of recommendation in which the recommender has knowledge of the methods the instructor uses in teaching a cultural competency course or program; and (c) The resume of the instructor of the course or program that includes, without limitation, the education, training and experience the instructor has in providing cultural competency training. 4. Except as otherwise provided in subsection 5, when a facility submits a course or program pursuant to subsection 1, the facility must also provide to the Department: (a) The syllabus of the course or program; (b) The following information: (1) The name of the facility; (2) The address of the facility; (3) The electronic mail address of the facility; (4) The license number of the facility; and (5) The name and contact information of a person who represents the facility and who can discuss the course or program submitted by the facility pursuant to subsection 1; (c) If the facility contracts with a third party who develops and operates the course or program, the following information: (1) The name of the third party; (2) The address of the third party; (3) The electronic mail address of the third party; and (4) The name and contact information of a person who represents the third party and who can discuss the course or program submitted by the facility pursuant to subsection 1; (d) Evidence that the subjects covered by the course or program include, without limitation, the course materials required by NAC 449.011936 ; (e) A sample sign-in sheet for the course or program that contains: (1) The dates of the course or program; and (2) A place for a participant of the course or program to print and sign his or her name; (f) A sample evaluation form that a participant of the course or program may complete at the end of the course or program which evaluates: (1) The content of the course or program; (2) The instructor of the course or program; and (3) The manner in which the course or program is presented to the participant; and (g) A sample document that a participant of the course or program may complete at the end of the course or program in which the participant can perform a self-evaluation. 5. A facility may submit a course or program pursuant to subsection 1 without submitting the information required in subsection 4 if the course or program: (a) Is provided by: (1) A nationally recognized organization, as determined by the Director of the Department; (2) A federal, state or local government agency; or (3) A university or college that is accredited in the District of Columbia or any state or territory of the United States; and (b) Provides proof of completion upon the participant of the course or program completing the course or program that the Director or his or her designee determines to be satisfactory. 6. When a facility submits pursuant to subsection 1 a course or program that is described in subsection 5, the facility must also provide to the Department: (a) The name of the course or program; (b) The name of the organization, agency, university or college providing the course or program; (c) If the course or program is provided online, the URL of the course or program; (d) If the course or program is provided through a training system, access to the training system; (e) If the course or program is not provided online or through a training system, the syllabus of the course or program; (f) The following information: (1) The name of the facility; (2) The address of the facility; (3) The electronic mail address of the facility; (4) The license number of the facility; and (5) The name and contact information of a person who represents the facility and who can discuss the course or program submitted by the facility pursuant to subsection 1; and (g) Any other information the Department requests to assist the Director or his or her designee in determining whether or not to approve the course or program pursuant to NAC 449.011939 . 7. As used in this section, “URL” means the Uniform Resource Locator associated with an Internet website. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011936 Materials for course or program for cultural competency training. ( NRS 449.0302 , 449.103 ) 1. A course or program subject to the requirements of subsection 4 of NAC 449.011933 must include, without limitation, the following course materials: (a) An overview of cultural competency; (b) An overview of implicit bias and indirect discrimination; (c) The common assumptions and myths concerning stereotypes and examples of such assumptions and myths; (d) An overview of social determinants of health; (e) An overview of best practices when interacting with persons who fall within one or more of the categories in paragraphs (a) to (f), inclusive, of subsection 1 of NRS 449.103 ; (f) An overview of gender, race and ethnicity; (g) An overview of religion; (h) An overview of sexual orientation and gender identities or expressions; (i) An overview of mental and physical disabilities; (j) Examples of barriers to providing care; (k) Examples of language and behaviors that are discriminatory; and (l) Examples of a welcoming and safe environment. 2. The course materials included in a course or program, including, without limitation, the course materials required by subsection 1, must include, without limitation: (a) Evidence-based, peer-reviewed sources; (b) Source materials that are used in universities or colleges that are accredited in the District of Columbia or any state or territory of the United States; (c) Source materials that are from nationally recognized organizations, as determined by the Director of the Department; (d) Source materials that are published or used by federal, state or local government agencies; or (e) Other source materials that are deemed appropriate by the Department. 3. The Department must: (a) Publish a copy of the requirements set forth in subsections 1 and 2 on its Internet website; and (b) Provide a copy of the requirements set forth in subsections 1 and 2 to a facility upon request by the facility. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011939 Approval or denial of course or program for cultural competency training; means for delivery of course or program. ( NRS 449.0302 , 449.103 ) 1. The Department shall review the course or program information submitted pursuant to NAC 449.011933 and, if applicable, NAC 449.011936 within 60 days after receipt. During this review process, the Department may have the course or program reviewed by a person who is an expert on cultural competency or a committee of persons who are experts on cultural competency. 2. If the information that is provided to the Department meets the requirements set forth in NAC 449.011933 and 449.011936 , if applicable, the Director or his or her designee may approve the course or program. If the information that is provided to the Department does not meet the requirements set forth in NAC 449.011933 and 449.011936 , if applicable, the Director or his or her designee shall not approve the course or program. 3. Within 5 business days after completing the review of the information pursuant to subsection 1, the Director or his or her designee shall: (a) Notify the facility that submitted the information whether the course or program is approved or not approved pursuant to subsection 2; and (b) If the Director or his or her designee does not approve the course or program, inform the facility of any additional information that the facility needs to submit for the course or program to be approved. 4. The facility shall submit the additional information that the facility needs to submit pursuant to paragraph (b) of subsection 3 within 45 days after being notified that the course or program is not approved pursuant to paragraph (a) of subsection 3. Upon receiving the additional information, the Director or his or her designee may approve the course or program. If the additional information is not received or fails to include all of the information that the Director or his or her designee informed the facility that it needed to submit, the Director or his or her designee shall not approve the course or program. 5. Any course or program approved pursuant to this section may be provided: (a) Online; (b) Through a training system; or (c) In person. 6. If the Director or his or her designee approves the course or program, the Director or his or her designee shall notify the Division of the approval of the course or program not later than 7 business days after such approval. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011941 Assignment of course number to course or programs for cultural competency training. ( NRS 449.0302 , 449.103 ) 1. Not later than 7 business days after receiving the notice of approval of the course or program pursuant to subsection 6 of NAC 449.011939 , the Division shall assign a course number to the approved course or program. 2. Not later than 7 business days after assigning the course number pursuant to subsection 1, the Division shall notify the facility whose course or program is approved pursuant to NAC 449.011939 of the course number assigned pursuant to subsection 1. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011943 Policies concerning preferred names and pronouns; adaptation of records to reflect gender identities or expressions; method to obtain medically relevant information from patients or residents. ( NRS 449.0302 , 449.104 ) 1. A facility shall: (a) Develop policies to ensure that a patient or resident is addressed by his or her preferred name and pronoun and in accordance with his or her gender identity or expression; and (b) Adapt electronic records and any paper records the facility has to reflect the gender identities or expressions of patients or residents with diverse gender identities or expressions, including, without limitation: (1) If the facility is a medical facility, adapting health records to meet the medical needs of patients or residents with diverse sexual orientations and gender identities or expressions, including, without limitation, integrating information concerning sexual orientation and gender identity or expression into electronic systems for maintaining health records; and (2) If the facility is a facility for the dependent or other residential facility, adapting electronic records and any paper records the facility has to include the preferred name and pronoun and gender identity or expression of a resident. 2. If a patient or resident chooses to provide the following information, the health records adapted pursuant to subparagraph (1) of paragraph (b) of subsection 1 must include, without limitation: (a) The preferred name and pronoun of the patient or resident; (b) The gender identity or expression of the patient or resident; (c) The gender identity or expression of the patient or resident that was assigned at the birth of the patient or resident; (d) The sexual orientation of the patient or resident; and (e) If the gender identity or expression of the patient or resident is different than the gender identity or expression of the patient or resident that was assigned at the birth of the patient or resident: (1) A history of the gender transition and current anatomy of the patient or resident; and (2) An organ inventory for the patient or resident which includes, without limitation, the organs: (I) Present or expected to be present at the birth of the patient or resident; (II) Hormonally enhanced or developed in the patient or resident; and (III) Surgically removed, enhanced, altered or constructed in the patient or resident. 3. A medical facility that has adapted health records pursuant to subparagraph (1) of paragraph (b) of subsection 1 shall develop a method to lead patients or residents through a series of questions to help obtain thorough and medically relevant information regarding the patients or residents to accurately reflect the diverse gender identities or expressions of patients or residents with diverse gender identities or expression to be used in providing care to the patient or resident, including, without limitation, when interacting with insurance providers. A patient or resident may decline to answer any such questions. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011946 Provision of certain statements, notices and information in appropriate languages and with reasonable accommodations. ( NRS 449.0302 ) 1. Except as otherwise provided in subsection 2, the statements, notices and information required by NAC 449.011901 to 449.011951 , inclusive, and NRS 449.101 to 449.104 , inclusive, must be in English and, as appropriate for a facility, in any other language the Department determines is appropriate based on the demographic characteristics of this State. In addition to the notices and information provided in English and any other language the Department determines is appropriate based on the demographic characteristics of this State, a facility may provide the statements, notices and information in any other language the facility may desire. 2. A facility must make reasonable accommodations in providing the statements, notices and information described in subsection 1 for patients or residents who: (a) Are unable to read; (b) Are blind or visually impaired; (c) Have communication impairments; or (d) Do not read or speak English or any other language in which the statements, notices and information are written pursuant to subsection 1. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011949 Designation of representative to ensure compliance. ( NRS 449.0302 ) A facility shall designate a representative of the facility who shall be responsible for ensuring that the facility is in compliance with NAC 449.011901 to 449.011951 , inclusive, and NRS 449.101 to 449.104 , inclusive. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) NAC 449.011951 Facility to make certain documentation available to Division or Department. ( NRS 449.0302 ) Upon request from the Division or Department, a facility shall make available to the Division or Department documentation for the Division or Department to determine if the facility is complying with NAC 449.011901 to 449.011951 , inclusive, and NRS 449.101 to 449.104 , inclusive. If the Division or Department obtains personally identifiable information of a patient or resident through such a request, the Division or Department shall maintain the confidentiality of such information. (Added to NAC by Bd. of Health by R016-20, eff. 11-2-2020) FEES NAC 449.012 Definitions. ( NRS 439.150 , 439.200 , 449.0302 , 449.0303 , 449.050 ) As used in NAC 449.012 to 449.0169 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.01205 to 449.01265 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97; A by R229-97, 4-15-98; R052-02 & R063-02, 7-24-2002; R065-04, 8-4-2004; R051-06 & R095-06, 7-14-2006; R182-07, 1-30-2008; R046-14, 10-24-2014; R121-16, 9-21-2017; R048-22, 12-29-2022) NAC 449.01205 “Agency to provide personal care services in the home” defined. ( NRS 449.0302 ) “Agency to provide personal care services in the home” has the meaning ascribed to it in NRS 449.0021 . (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.0121 “Ambulatory surgical center” defined. ( NRS 449.0302 ) “Ambulatory surgical center” has the meaning ascribed to it in NAC 449.972 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97) NAC 449.01215 “Branch office” defined. ( NRS 449.0302 ) “Branch office” has the meaning ascribed to it in NAC 449.749 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97) NAC 449.01219 “Community triage center” defined. ( NRS 449.0302 ) “Community triage center” has the meaning ascribed to it in NRS 449.0031 . (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.01225 “Facility for hospice care” defined. ( NRS 449.0302 ) “Facility for hospice care” has the meaning ascribed to it in NAC 449.0172 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97; A by R123-99, 11-29-99) NAC 449.01227 “Facility for refractive surgery” defined. ( NRS 449.0302 ) “Facility for refractive surgery” has the meaning ascribed to it in NRS 449.00387 . (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002; A by R042-06, 7-14-2006) NAC 449.01228 “Facility for transitional living for released offenders” defined. ( NRS 449.0302 ) “Facility for transitional living for released offenders” has the meaning ascribed to it in NRS 449.0055 . (Added to NAC by Bd. of Health by R095-06, eff. 7-14-2006) NAC 449.01229 “Facility for treatment with narcotics” defined. ( NRS 449.0302 , 449.0303 ) “Facility for treatment with narcotics” has the meaning ascribed to it in NAC 449.1542 . (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98)—(Substituted in revision for NAC 449.0122) NAC 449.0123 “Home health agency” defined. ( NRS 449.0302 ) “Home health agency” has the meaning ascribed to it in NAC 449.749 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97) NAC 449.01235 “Home office” defined. ( NRS 449.0302 ) “Home office” has the meaning ascribed to it in NAC 449.749 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97) NAC 449.0124 “Hospice care” defined. ( NRS 449.0302 ) “Hospice care” has the meaning ascribed to it in NAC 449.0175 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97) NAC 449.01245 “Intermediate care facility for persons with an intellectual disability or persons with a developmental disability” defined. ( NRS 449.0302 ) “Intermediate care facility for persons with an intellectual disability or persons with a developmental disability” has the meaning ascribed to it in NAC 449.632 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97) NAC 449.0125 “Medication unit” defined. ( NRS 449.0302 , 449.0303 ) “Medication unit” has the meaning ascribed to it in NAC 449.15435 . (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98) NAC 449.01252 “Mobile unit” defined. ( NRS 449.0302 ) “Mobile unit” has the meaning ascribed to it in NRS 449.01515 . (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.01255 “Nursing pool” defined. ( NRS 449.0302 ) “Nursing pool” has the meaning ascribed to it in NRS 449.0153 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97) NAC 449.01257 “Psychiatric residential treatment facility” defined. ( NRS 439.150 , 449.0302 , 449.050 ) “Psychiatric residential treatment facility” has the meaning ascribed to it in NAC 449.411 . (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.01259 “Recovery center” defined. ( NRS 439.200 , 449.0302 , 449.0303 ) “Recovery center” has the meaning ascribed to it in NAC 449.99702 . (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.0126 “Rural clinic” defined. ( NRS 449.0302 ) “Rural clinic” has the meaning ascribed to it in NRS 449.0175 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97) NAC 449.01265 “Rural hospital” defined. ( NRS 449.0302 ) “Rural hospital” has the meaning ascribed to it in NRS 449.0177 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97) NAC 449.013 License and renewal fees to operate ambulatory surgical center or home office of home health agency, branch office of home health agency, rural clinic, free standing birthing center, program of hospice care, independent center for emergency medical care, nursing pool, facility for treatment with narcotics, medication unit, referral agency, facility for refractive surgery, mobile unit, agency to provide personal care services in home, facility for the care of adults during day, community health worker pool and employment agency to provide nonmedical services; fee to support system for reporting of information on cancer and other neoplasms; expiration of application for license. ( NRS 439.150 , 439.200 , 449.03005 , 449.0302 , 449.0303 , 449.0305 , 449.050 , 457.240 ) 1. Except as otherwise provided in NAC 449.0168 , an applicant for a license to operate any of the following facilities, programs of hospice care or agencies must pay to the Division of Public and Behavioral Health the following nonrefundable fees: (a) An ambulatory surgical center $9,784 (b) A home office of a home health agency 5,168 (c) A branch office of a home health agency 5,358 (d) A rural clinic 4,058 (e) A freestanding birthing center 1,564 (f) A program of hospice care 7,054 (g) An independent center for emergency medical care 4,060 (h) A nursing pool 4,602 (i) A facility for treatment with narcotics 5,046 (j) A medication unit 1,200 (k) A referral agency 2,708 (l) A facility for refractive surgery 6,700 (m) A mobile unit 2,090 (n) An agency to provide personal care services in the home 1,374 (o) A facility for the care of adults during the day allowed to be occupied by not more than 50 clients at one time . 1,164 (p) A facility for the care of adults during the day allowed to be occupied by more than 50 clients at one time ... 1,753 (q) A community health worker pool 1,000 (r) An employment agency to provide nonmedical services 1,400 2. An applicant for the renewal of such a license must pay to the Division of Public and Behavioral Health the following nonrefundable fees: (a) An ambulatory surgical center $4,892 (b) A home office of a home health agency 2,584 (c) A branch office of a home health agency 2,679 (d) A rural clinic 2,029 (e) A freestanding birthing center 782 (f) A program of hospice care 3,527 (g) An independent center for emergency medical care 2,030 (h) A nursing pool 2,301 (i) A facility for treatment with narcotics 2,523 (j) A medication unit 600 (k) A referral agency 1,354 (l) A facility for refractive surgery 3,350 (m) A mobile unit 1,045 (n) An agency to provide personal care services in the home 687 (o) A facility for the care of adults during the day allowed to be occupied by not more than 50 clients at one time 814 (p) A facility for the care of adults during the day allowed to be occupied by more than 50 clients at one time 1,227 (q) A community health worker pool 500 (r) An employment agency to provide nonmedical services 700 3. Upon the issuance or renewal of a license to operate an ambulatory surgical center, program of hospice care, agency to provide personal care services in the home or rural clinic, the licensee shall pay to the Division a nonrefundable fee equal to 6 percent of the renewal fee set forth in subsection 2. The Division shall use the fees collected pursuant to this subsection during the immediately following fiscal year to support the system for the reporting of information on cancer and other neoplasms. 4. An application for a license is valid for 1 year after the date on which the application is submitted. If an applicant does not meet the requirements for licensure imposed by chapter 449 of NRS or the regulations adopted pursuant thereto within 1 year after the date on which the applicant submits his or her application, the applicant must submit a new application and pay the required fee to be considered for licensure. [Bd. of Health, Health Facility Fees Art. 1, eff. 1-20-77]—(NAC A 7-22-87; 1-31-90; 9-1-93; 11-1-95; 10-3-96; R035-97 & R044-97, 10-30-97; R229-97, 4-15-98; R105-98, 9-23-98; R132-99, 11-29-99; R123-01, 12-17-2001, eff. 1-1-2002; R052-02 & R063-02, 7-24-2002; R050-02, 10-22-2002; R074-03, 10-22-2003; R065-04, 8-4-2004; R042-06 & R095-06, 7-14-2006; R182-07, 1-30-2008; R060-10, 1-13-2011; R022-14, 6-26-2015; R120-16, 9-21-2017; R133-15, 12-19-17; R109-18, 1-30-2019; R062-21, 9-28-2022; R010-22 & R048-22, 12-29-2022) NAC 449.016 License and renewal fees to operate skilled nursing facility, hospital, rural hospital, intermediate care facility, residential facility for groups, facility for treatment of alcohol or other substance use disorders, facility for hospice care, home for individual residential care, facility for modified medical detoxification, community triage center, facility for treatment of irreversible renal disease, halfway house for persons recovering from alcohol or other substance use disorders, facility for transitional living for released offenders, psychiatric residential treatment facility and recovery center; expiration of application for license; fee to support system for reporting of information on cancer and other neoplasms; refund of certain fees. ( NRS 439.150 , 439.200 , 449.0302 , 449.050 , 457.240 ) 1. Except as otherwise provided in NAC 449.0168 , an applicant for a license to operate any of the following facilities must pay to the Division the following nonrefundable fees: Fee per facility Fee per bed in the facility (a) A skilled nursing facility........................................................... $2,252 $108 (b) A hospital, other than a rural hospital....................................... 14,606 110 (c) A rural hospital.......................................................................... 9,530 62 (d) An intermediate care facility for persons with an intellectual disability or persons with a developmental disability.......................... 2,018 280 (e) An intermediate care facility, other than an intermediate care facility for persons with an intellectual disability or persons with a developmental disability....................................................................... 946 72 (f) Except as otherwise provided in subsection 3, a residential facility for groups................................................................................. 2,386 200 (g) A facility for the treatment of alcohol or other substance use disorders............................................................................................... 782 190 (h) A facility for hospice care......................................................... 3,988 352 (i) A home for individual residential care....................................... 1,764 184 (j) A facility for modified medical detoxification.......................... 9,960 494 (k) A community triage center........................................................ 782 136 (l) A facility for the treatment of irreversible renal disease........... 4,178 120 (m) A halfway house for persons recovering from alcohol or other substance use disorders......................................................................... 2,800 368 (n) A facility for transitional living for released offenders............ 3,990 146 (o) A psychiatric residential treatment facility............................... 9,530 62 (p) A recovery center...................................................................... 946 72 2. An applicant for the renewal of such a license must pay to the Division the following nonrefundable fees: Fee per facility Fee per bed in the facility (a) A skilled nursing facility........................................................... $1,126 $54 (b) A hospital, other than a rural hospital....................................... 7,303 55 (c) A rural hospital.......................................................................... 4,765 31 (d) An intermediate care facility for persons with an intellectual disability or persons with a developmental disability.......................... 1,009 140 (e) An intermediate care facility, other than an intermediate care facility for persons with an intellectual disability or persons with a developmental disability....................................................................... 473 46 (f) Except as otherwise provided in subsection 3, a residential facility for groups................................................................................. 1,193 100 (g) A facility for the treatment of alcohol or other substance use disorders............................................................................................... 391 95 (h) A facility for hospice care......................................................... 1,994 176 (i) A home for individual residential care....................................... 500 92 (j) A facility for modified medical detoxification.......................... 4,980 247 (k) A community triage center........................................................ 391 68 (l) A facility for the treatment of irreversible renal disease........... 2,089 60 (m) A halfway house for persons recovering from alcohol or other substance use disorders......................................................................... 1,400 184 (n) A facility for transitional living for released offenders............ 1,995 73 (o) A psychiatric residential treatment facility............................... 4,765 31 (p) A recovery center...................................................................... 473 46 3. An applicant for a license or for the renewal of a license for a residential facility for groups shall pay a fee of $35 for each bed in the facility if the facility is paid less than $1,000 per month for services provided to each bed in the facility. 4. An application for a license is valid for 1 year after the date on which the application is submitted. If an applicant does not meet the requirements for licensure imposed by chapter 449 of NRS or the regulations adopted pursuant thereto within 1 year after the date on which he or she submits his or her application, the applicant must submit a new application and pay the required fee to be considered for licensure. 5. Upon the issuance or renewal of a license to operate a facility for the treatment of irreversible renal disease, facility for hospice care, hospital, facility for intermediate care or facility for skilled nursing, the licensee shall pay to the Division a nonrefundable fee equal to 6 percent of the renewal fee set forth in subsection 2. The Division shall use the fees collected pursuant to this subsection during the immediately following fiscal year to support the system for the reporting of information on cancer and other neoplasms. 6. Pursuant to NRS 449.050 , if an application for a license to operate a facility for transitional living for released offenders or the renewal of such a license is denied, any amount of a fee paid pursuant to paragraph (n) of subsection 1 or paragraph (n) of subsection 2 that exceeds the expenses and costs incurred by the Division must be refunded to the applicant. [Bd. of Health, Health Facility Fees Art. 2, eff. 1-20-77]—(NAC A 7-22-87; 8-31-89; 9-1-93; 11-1-95; R035-97 & R044-97, 10-30-97; R105-98, 9-23-98; R123-99 & R131-99, 11-29-99; R129-99, 11-29-99, eff. 1-1-2000; R110-01, 11-21-2001; R050-02, 10-22-2002; R074-03, 10-22-2003; R065-04, 8-4-2004; R051-06, 7-14-2006; R060-10, 1-13-2011; R046-14, 10-24-2014; R121-16, 9-21-2017; R010-22, 12-29-2022) NAC 449.0164 Fees for renewal of licenses for certain facilities: Payment in two equal installments. ( NRS 439.150 , 439.200 , 449.0302 , 449.050 ) An applicant for the renewal of a license for a residential facility for groups, a halfway house for persons recovering from alcohol or other substance use disorders, a home for individual residential care or a facility for transitional living for released offenders may pay the fee required for the renewal of his or her license in two equal installments if: 1. On or before November 1 of the calendar year in which the license expires, the applicant submits a complete application for the renewal of the license which includes, without limitation: (a) The first installment payment which is equal to one-half the amount of the fee required for the renewal of the license pursuant to NAC 449.013 or 449.016 , as appropriate; (b) An additional fee of $100 for the administrative costs of billing and collecting such payments; and (c) A signed payment agreement and a confession of judgment for the total amount of the second installment payment which may be filed with a court of competent jurisdiction if the applicant fails to make the second installment payment in accordance with the agreement; 2. On or before April 15 of the calendar year for which the license is renewed, he or she submits the second installment payment for the remainder of the fee required for the renewal of the license pursuant to NAC 449.013 or 449.016 , as appropriate; and 3. The applicant has not failed to make a payment in accordance with any other similar agreement. (Added to NAC by Bd. of Health by R065-04, eff. 8-4-2004; A by R095-06, 7-14-2006) NAC 449.0168 Fees for modification of certain licenses. ( NRS 439.150 , 439.200 , 449.0302 , 449.0305 , 449.050 ) 1. Except as otherwise provided in subsection 2, a holder of a license to operate a medical facility, facility for the dependent, program of hospice care or referral agency who wishes or is required pursuant to NAC 449.190 , 449.307 , 449.7473 or 449.758 to modify his or her license to reflect: (a) A change in the name of the facility, program or agency; (b) A change of the administrator of the facility, program or agency; (c) A change in the number of beds in the facility; (d) A change in the type of facility licensed or the addition of another type of facility to be licensed; (e) A change in the category of residents who may reside at the facility; (f) A change in the designation of a staging area for a mobile unit or, if the mobile unit is operated by an independent facility, a change in the address of the independent facility; or (g) A change in any of the services provided by an agency to provide nursing in the home, Ê must submit an application for a new license to the Division and pay to the Division a fee of $250. 2. An applicant who applies for a license pursuant to paragraph (c) of subsection 1 because of an increase in the number of beds in the facility must pay to the Division: (a) A fee of $250; and (b) A fee for each additional bed as follows: (1) If the facility is an intermediate care facility for persons with an intellectual disability or persons with a developmental disability $280 (2) If the facility is a residential facility for groups 184 (3) If the facility is a facility for the treatment of alcohol or other substance use disorders 190 (4) If the facility is a facility for hospice care 352 (5) If the facility is a home for individual residential care 266 (6) If the facility is a facility for modified medical detoxification 494 (7) If the facility is a hospital, other than a rural hospital 110 (8) If the facility is a rural hospital 62 (9) If the facility is a skilled nursing facility 108 (10) If the facility is an intermediate care facility, other than an intermediate care facility for persons with an intellectual disability or persons with a developmental disability 92 (11) If the facility is a facility for the treatment of irreversible renal disease 120 (12) If the facility is a halfway house for persons recovering from alcohol or other substance use disorders 368 (13) If the facility is a facility for transitional living for released offenders 146 3. If the address of the home office of a home health agency has not changed, a holder of a license to operate a branch office of the home health agency who wishes or is required pursuant to NAC 449.758 to modify his or her license to reflect a change in the address of the branch office of the home health agency must: (a) Submit an application for a new license to the Division; and (b) Pay to the Division a fee of $250. 4. A fee paid pursuant to this section is nonrefundable. 5. As used in this section: (a) “Administrator” means the person who is responsible for the daily management of a medical facility, facility for the dependent or program of hospice care. (b) “Independent facility” has the meaning ascribed to it in NAC 449.9701 . (c) “Staging area” has the meaning ascribed to it in NAC 449.97018 . (Added to NAC by Bd. of Health by R035-97, eff. 10-30-97; A by R053-99, 9-27-99; R132-99, 11-29-99; R110-01, 11-21-2001; R063-02, 7-24-2002; R050-02, 10-22-2002; R074-03, 10-22-2003; R123-05, 11-17-2005; R060-10, 1-13-2011; R048-22, 12-29-2022) NAC 449.01685 Division authorized to charge and collect fee from licensee to recover costs of investigating complaint if complaint is substantiated. ( NRS 439.150 , 439.200 , 449.0302 ) 1. The Division may charge and collect a fee from any licensee who is involved in a complaint submitted to the Division to recover the costs of investigating the complaint after the investigation is completed and the complaint is substantiated. The fee will be based upon the hourly rate established for each surveyor of health facilities as determined by the budget of the Division. 2. As used in this section, “substantiated” means supported or established by evidence or proof. (Added to NAC by Bd. of Health by R155-10, eff. 12-16-2010; A by R048-22, 12-29-2022) NAC 449.0169 Department of Corrections to pay fee to Division for certain services. ( NRS 449.0302 ) 1. To the extent that money is appropriated for this purpose, each institution of the Department of Corrections shall pay a fee of $3,266 each year to the Division for the purpose of enabling the Division to carry out its duties set forth in NRS 209.382 , 444.330 and 446.885 . 2. As used in this section, “institution” has the meaning ascribed to it in NRS 209.071 . (Added to NAC by Bd. of Health by R060-10, 1-13-2011, eff. 7-1-2011) PROVISION OF HOSPICE CARE General Provisions NAC 449.017 Definitions. ( NRS 439.200 , 449.0302 ) As used in NAC 449.017 to 449.0188 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.0171 to 449.0178 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health, eff. 7-20-90; A by R041-06, 7-14-2006; R048-22, 12-29-2022) NAC 449.0171 “Bereavement services” defined. ( NRS 449.0302 ) “Bereavement services” means social and emotional support offered to the family of a patient in a program of hospice care for at least 1 year following the death of the patient. (Added to NAC by Bd. of Health, eff. 7-20-90) NAC 449.0172 “Facility for hospice care” defined. ( NRS 449.0302 ) “Facility for hospice care” has the meaning ascribed to it in NRS 449.0033 . (Added to NAC by Bd. of Health, eff. 7-20-90; A by R123-99, 11-29-99) NAC 449.0173 “Governing body” defined. ( NRS 449.0302 ) “Governing body” means the person or group of persons responsible for carrying out and monitoring the administration of a program of hospice care or for the operation of a facility for hospice care. (Added to NAC by Bd. of Health, eff. 7-20-90; A by R123-99, 11-29-99) NAC 449.0175 “Hospice care” defined. ( NRS 449.0302 ) “Hospice care” has the meaning ascribed to it in NRS 449.0115 . (Added to NAC by Bd. of Health, eff. 7-20-90) NAC 449.0176 “Medical director” defined. ( NRS 449.0302 ) “Medical director” means the physician who is responsible for acting as a medical resource to an interdisciplinary team which provides hospice care. (Added to NAC by Bd. of Health, eff. 7-20-90) NAC 449.01765 “Palliative services” defined. ( NRS 449.0302 ) “Palliative services” has the meaning ascribed to it in NRS 449.0156 . (Added to NAC by Bd. of Health by R041-06, eff. 7-14-2006) NAC 449.0177 “Patient” defined. ( NRS 449.0302 ) “Patient” means a person who is terminally ill and who is receiving hospice care. (Added to NAC by Bd. of Health, eff. 7-20-90) NAC 449.0178 “Terminally ill” defined. ( NRS 449.0302 ) “Terminally ill” has the meaning ascribed to it in NRS 449.0195 . (Added to NAC by Bd. of Health, eff. 7-20-90; A by R041-06, 7-14-2006) Licensing NAC 449.0181 Compliance with regulations required for license to operate facility for hospice care. ( NRS 449.0302 ) The Division shall not issue a license to operate a facility for hospice care unless the program of hospice care which it provides complies with the requirements of NAC 449.017 to 449.0188 , inclusive. (Added to NAC by Bd. of Health, eff. 7-20-90; A by R123-99, 11-29-99) NAC 449.0183 Report of change in ownership, address or staff of program of hospice care. ( NRS 449.0302 ) An applicant for a license to administer a program of hospice care or a person licensed to administer such a program shall immediately advise the Division of any change in: 1. The ownership of the program; 2. The address of the principal office of the program; or 3. The membership of the staff which prevents the program from providing adequate hospice care to each patient. (Added to NAC by Bd. of Health, eff. 7-20-90) Administration NAC 449.0184 Governing body required; duties of governing body and administrator. ( NRS 449.0302 ) Every facility which provides a program of hospice care must have a governing body which shall: 1. Appoint an administrator of the program of hospice care. The administrator shall be available on a daily basis for consultation with members of the interdisciplinary team of the program of hospice care. 2. Ensure that all services provided by the program of hospice care are consistent with accepted standards of practice for the care of the patients. (Added to NAC by Bd. of Health, eff. 7-20-90) Medical Services NAC 449.0185 Requirements for program of hospice care. ( NRS 449.0302 ) A program of hospice care must comply with the following requirements: 1. A qualified person must be available when required to evaluate the dietary patterns of each patient and plan diets to meet the individual nutritional needs of each patient. 2. Each patient must be advised regarding the availability of pastoral care. 3. Bereavement services must be available to each member of a patient’s family after the patient dies to provide appropriate counseling. 4. Nursing care must be provided by a registered nurse or under the supervision of a registered nurse. 5. A social worker must provide social services to each patient in the program under the direction of the interdisciplinary team. 6. The services of: (a) A physical therapist; (b) An occupational therapist; and (c) A speech-language pathologist, Ê must be provided when such services are prescribed for a patient by his or her physician. 7. Home health aide and homemaker services must be available to each patient and provided at intervals which meet the needs of each patient. A registered nurse must: (a) Supervise the persons providing such services; and (b) Prepare written instructions for the persons providing such services which identify the duties they are to perform. 8. Arrangements must be made to provide any medical supplies and appliances which are required by a patient, including any drug or biological needed for palliative services. (Added to NAC by Bd. of Health, eff. 7-20-90; A by R041-06, 7-14-2006) NAC 449.0186 Requirements for plan of care. ( NRS 449.0302 ) 1. The medical director of a program of hospice care shall cause a written plan of care to be established for each patient in the program. Any person who furnishes care for the patient shall adhere to the plan. 2. A plan of care must: (a) Be established by the physician of the patient or by the medical director of the program of hospice care, and the interdisciplinary team which provides the hospice care; (b) Include an assessment of the needs of the patient and identify the services required by the patient, which must include the management of discomfort and relief of symptoms of the patient; (c) State the scope and frequency of each service to be provided to the patient and members of his or her family; and (d) Be reviewed and updated at intervals that are specified in the plan by the person who established the plan. The review must be documented in writing. (Added to NAC by Bd. of Health, eff. 7-20-90) NAC 449.0187 Requirements for operation of facility for hospice care. ( NRS 439.200 , 449.0302 ) A facility for hospice care must comply with the following requirements: 1. A program of hospice care must be provided for each inpatient pursuant to a written plan of care established pursuant to NAC 449.0186 . 2. Nursing services must be provided 24 hours per day in accordance with the plan of care for each patient. 3. Medication must be dispensed to each patient according to the instructions of the patient’s physician or the medical director. 4. Treatment must be administered to a patient pursuant to the instructions of the physician of the patient or the plan of care for the patient. 5. Each patient must be maintained in a clean and well-groomed manner. 6. Each patient must be protected from accidents, injuries and infections. 7. At least one registered nurse must be on duty for each work shift, providing direct care to patients. 8. A written plan of the procedures to be followed during a local disaster, a widespread disaster or a disaster which occurs within the facility for hospice care must be adopted. The plan must: (a) Provide procedures designed to protect each patient and to care for any casualty which may arise from such a disaster; (b) Be reviewed and the procedures set forth therein rehearsed by all members of the staff at least once in each quarter of the year; and (c) Be approved by the Division. 9. A private room with an adjoining bath must be provided for each patient. 10. An anteroom, a room adjoining the room of each patient or a private area must be provided and furnished with a bed and chairs for use by the members of the patient’s family. 11. A facility for hospice care must comply with the provisions of 42 C.F.R. § 418.110(d). (Added to NAC by Bd. of Health, eff. 7-20-90; A by R123-99, 11-29-99; R048-22, 12-29-2022) NAC 449.01875 New construction or remodeling: Submission and approval of building plans; prerequisites for approval of facility for licensure. ( NRS 439.200 , 439.0302) 1. Except as otherwise provided in subsection 2, before any construction of a new facility for hospice care or remodeling of an existing facility for hospice care commences, the facility must submit two complete sets of the building plans for the construction or remodeling, as applicable, to: (a) The entity designated by the Division to review such plans in the manner prescribed by NAC 449.0115 , regardless of whether the facility is applying for a license or the renewal of a license. The review by that entity is only advisory, and approval by that entity does not constitute the approval of the construction or remodeling by the Bureau. (b) The Division. The facility shall not commence the construction or remodeling, as applicable, until the plans have been approved by the Division. 2. The provisions of subsection 1 do not apply to the remodeling of an existing facility for hospice care if the remodeling is limited to refurbishing an area within the facility including, without limitation, painting the area, replacing flooring in the area, repairing windows in the area or replacing window and wall coverings in the area. 3. The Division shall not issue a license to operate a newly constructed facility for hospice care until the Bureau has approved the construction. The Bureau shall not approve the construction without conducting a survey at the site of the facility. Such a survey must occur after the construction has been completed. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) NAC 449.0188 Continuity of service to patients required. ( NRS 449.0302 ) A person licensed to administer a program of hospice care or to operate a facility for hospice care shall maintain the continuity of service provided to each patient pursuant to NAC 449.017 to 449.0188 , inclusive, during the term of his or her license. (Added to NAC by Bd. of Health, eff. 7-20-90; A by R044-97, 10-30-97; R123-99, 11-29-99) FACILITIES FOR THE TREATMENT OF ALCOHOL OR OTHER SUBSTANCE USE DISORDERS General Provisions NAC 449.019 Definitions. ( NRS 449.0302 ) As used in NAC 449.019 to 449.150 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.022 to 449.072 , inclusive, have the meanings ascribed to them in those sections. (Supplied in codification; A by Bd. of Health by R077-01, 10-18-2001; R016-20, 11-2-2020) NAC 449.022 “Administrator” defined. ( NRS 449.0302 ) “Administrator” means the person who is appointed by the governing body of a facility who has primary responsibility for the operations of the overall program of the facility. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.4, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001) NAC 449.025 “Alcohol or other substance use disorder treatment” defined. ( NRS 449.0302 ) “Alcohol or other substance use disorder treatment” means a program concerned with substance use disorder treatment directed towards achieving the mental and physical restoration of persons with alcohol or other substance use disorders. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.9, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001) NAC 449.030 “Case management services” defined. ( NRS 449.0302 ) “Case management services” means a multistep process by which clients may receive assistance in accessing services, including, without limitation, services concerning health, mental health, education, vocation, employment, legal issues, child care, housing and aftercare for recovery from alcohol or other substance use disorders. (Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001) NAC 449.031 “Client” defined. ( NRS 449.0302 ) “Client” means a resident or patient of a facility. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.8, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001) NAC 449.034 “Detoxification” defined. ( NRS 449.0302 ) “Detoxification” means the process of eliminating the toxic effects of alcohol and drugs from the body. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.1.3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001) NAC 449.043 “Facility” defined. ( NRS 449.0302 ) “Facility” means a facility for the treatment of alcohol or other substance use disorders as defined in NRS 449.00455 . [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.1, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001) NAC 449.044 “Facility for modified medical detoxification” defined. ( NRS 449.0302 ) “Facility for modified medical detoxification” has the meaning ascribed to it in NRS 449.00385 . (Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001) NAC 449.046 “Governing body” defined. ( NRS 449.0302 ) “Governing body” means a body that has the ultimate authority for the administration of the overall program at a facility pursuant to NAC 449.085 . (Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001) NAC 449.060 “Medically managed intensive detoxification program” defined. ( NRS 449.0302 ) “Medically managed intensive detoxification program” means a program which provides 24-hour medical monitoring of treatment and detoxification services in a licensed hospital pursuant to NAC 449.279 to 449.394 , inclusive, and which has life support systems in place. (Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001) NAC 449.064 “Overall program” defined. ( NRS 449.0302 ) “Overall program” means all aspects of alcohol or other substance use disorder treatment, including general fiscal management, fund-raising projects and the general long-term goals of a facility which are defined in writing. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.10, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001) NAC 449.068 “Qualified social worker” defined. ( NRS 449.0302 ) “Qualified social worker” means a person who is licensed by the Board of Examiners for Social Workers to practice as a social worker. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 1 § 1.11, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001)—(Substituted in revision for NAC 449.073) NAC 449.069 “Residential program” defined. ( NRS 449.0302 ) “Residential program” means a treatment program for alcohol or other substance use disorders which takes place in a 24-hour residential setting and which encompasses organized services staffed by designated treatment personnel who provide a planned regimen of client care. (Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001) NAC 449.072 “Social model detoxification program” defined. ( NRS 449.0302 ) “Social model detoxification program” means a treatment program that concentrates on providing psychosocial services and nonmedical detoxification. (Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001) Licensing NAC 449.079 Denial, revocation or suspension of license if facility not certified by Division; appeal. ( NRS 449.0302 ) 1. If a facility is not certified by the Division pursuant to paragraph (d) of subsection 1 of NRS 458.025 , the Division shall deny an application for a license or suspend or revoke the license of the facility. 2. An applicant or licensee who wishes to appeal an action of the Division relating to the denial, suspension or revocation of a license may appeal the action pursuant to the procedures set forth in NAC 439.300 to 439.395 , inclusive. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 2 §§ 2.7-2.12, eff. 3-27-76; A and renumbered as §§ 2.7-2.11, 12-27-77]—(NAC A by R035-97 & R044-97, 10-30-97; R077-01, 10-18-2001) NAC 449.081 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of licensing. ( NRS 449.0302 ) 1. Building plans for new construction or remodeling must be submitted to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 . Before the construction or remodeling may begin, the plans for the construction or remodeling must be approved by the Division. 2. The Division shall not approve the licensing of a facility until all construction has been completed and a survey is conducted at the site. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 16, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R076-01 & R077-01, 10-18-2001; R073-04, 8-4-2004) Administration and Personnel NAC 449.085 Governing body; bylaws. ( NRS 449.0302 ) 1. Every facility must have a governing body which has the ultimate authority for the administration of the overall program. 2. The governing body shall adopt written bylaws and policies that define the powers and duties of the governing body, its committees, the administrator and any advisory group. 3. The bylaws and policies must: (a) Identify the overall goals. (b) Include an organizational chart. (c) Define the major lines of authority and areas of responsibility within the treatment program. (d) Define the membership of the governing body, the types of membership, the method of selection or appointment of members, offices or committees and their terms of office. (e) Define the frequency of meetings of the governing body and attendance requirements. 4. The duties of the governing body include, but are not limited to, the following items: (a) Appointment of a qualified administrator with authority and responsibilities appropriate to the requirements of the program; (b) Adoption, review and revision of the governing body’s bylaws and policies; (c) Adoption of controls designed to achieve and maintain maximum standards of service; and (d) Review and approval of an annual budget to carry out the objectives of the program. 5. New facilities must show sufficient resources to operate for 120 days. 6. The governing body shall retain the ultimate responsibility for the overall program and its objectives. 7. The governing body shall meet at least semiannually. Minutes must be kept of the meetings, including the date of the meeting, those in attendance, topics discussed, decisions made and actions taken, target dates for the implementation of recommendations and all program reports. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R044-97, 10-30-97; R077-01, 10-18-2001) NAC 449.088 Policies and procedures. ( NRS 449.0302 ) 1. A facility must have written policies and procedures available to members of the staff, clients and the public which govern the operation of the facility and services provided by the facility. 2. The policies must: (a) Ensure that only those persons are accepted as clients whose needs can be met by the facility directly or in cooperation with community resources or other providers of treatment with which it is affiliated. (b) Ensure that a client whose physical or mental condition has changed to such an extent that the client can no longer be adequately served by the facility will be transferred promptly to an appropriate facility. (c) Set forth the rights of clients and members of the staff and provide for the registration and disposition of complaints without threat of discharge or reprisal against any employee or client. (d) Ensure that the admission agreement between the administrator and the client does not permit the administrator or his or her designee a power of attorney. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001) NAC 449.091 Transfer of client to another facility. ( NRS 449.0302 ) 1. Except in the case of an emergency, the transfer of a client to another facility must not be effected until the client, attending physician, if any, and responsible agency are notified in advance. 2. If a client is transferred to another facility, information required for appropriate continuation of care must be released to the receiving facility in compliance with the standards set forth in 42 C.F.R. Part 2, which are hereby adopted by reference. A copy of the standards may be obtained from the Division, free of charge, upon request. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001) NAC 449.094 Money of clients. ( NRS 449.0302 ) 1. If a facility handles a client’s money, a written ledger account of all deposits, disbursements or other transactions must be maintained. A record must be made available to the client at least quarterly. 2. A client’s money must be given to the client within 24 hours of his or her exit from the facility. 3. Large sums of money must be maintained in a financial institution in the community where the facility is located in a separate trustee account apart from the facility’s operational accounts and must be clearly designated. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001) NAC 449.098 Preparations for disasters; reporting of fire or disaster. ( NRS 449.0302 ) 1. Each facility shall develop a written plan for disasters which outlines procedures for members of the staff and clients to follow in case of fire or another emergency and which provides for meeting the needs of clients if the facility must be evacuated or is destroyed. 2. A simple floor plan showing the routes for evacuating must be posted in prominent locations on each floor of each facility. 3. Each facility shall conduct a disaster drill at least annually, and a written record of each drill must be retained in the facility for not less than 12 months after the drill is conducted. 4. The facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001; R073-04, 8-4-2004) NAC 449.102 Inventory and return of client’s belongings. ( NRS 449.0302 ) If a facility holds or stores a client’s belongings, there must be an inventory of the belongings on admission, made a part of the client’s record, and updated as needed. These belongings must be returned to the client upon his or her exit. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001) NAC 449.105 Insurance. ( NRS 449.0302 ) Liability insurance in a sufficient amount to protect clients, members of the staff, volunteers, and visitors, must be maintained. A certificate of insurance must be furnished to the Division. The certificate must include provision for 30 days notice to the Division of cancellation or the nonrenewal of the policies. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 3, eff. 3-27-76; A 3-30-77] NAC 449.108 General requirements for programs. ( NRS 449.0302 ) 1. A residential program must be certified by the Division pursuant to NAC 458.108 and must comply with any applicable regulations adopted pursuant to paragraph (d) of subsection 1 of NRS 458.025 . 2. At the time of admission into a residential program, there must be documentation indicating that the client has been informed of: (a) The general nature and goal of the program; (b) The rules governing client conduct and the infractions that can lead to disciplinary action or discharge from the program; (c) The treatment costs, if any, to be borne by the client; (d) The client’s rights and responsibilities; and (e) Confidentiality laws, rules and regulations. 3. The program must be periodically evaluated to ensure compliance with any applicable regulations adopted pursuant to paragraph (d) of subsection 1 of NRS 458.025 . 4. The facility must provide access to medical, dental, psychological and rehabilitative services to meet the needs of all its clients, to the extent possible, with assistance from available community resources. 5. If a facility provides services through outside sources, written arrangements must be made ensuring that the services are supplied directly by, or under the supervision of, qualified persons. 6. The facility must provide case management services as needed by the client either directly or by written agreement with a qualified social worker, a registered nurse or a counselor certified or licensed by the Board of Examiners for Alcohol, Drug and Gambling Counselors. 7. A plan for case management services must be recorded in the client’s record and must be periodically evaluated in conjunction with the client’s treatment plan. 8. Each facility shall review the program at least annually. Areas reviewed must include, but need not be limited to, appropriateness of admissions, lengths of stay, discharge planning, use of services, and utilization of the components of the program and outside services. Written reports of the reviews must be evaluated by the governing body, administrator and such committees as they designate. Documentation of the evaluation process must be maintained at the facility. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 4, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001; R073-04, 8-4-2004; R098-06, 7-14-2006) NAC 449.111 Administrator: Duties. ( NRS 449.0302 ) 1. The administrator is responsible to the governing body for the operation of the facility in accordance with established policy. 2. The administrator shall: (a) Organize the administrative functions of the program, delegate duties and establish a formal means of accountability on the part of subordinates. (b) Ensure that a written manual defining program policies and procedures is prepared, regularly revised and updated. The manual must: (1) Contain all of the required written policies, procedures, definitions, lists and other documentation required by NAC 449.019 to 449.150 , inclusive. (2) Be available to members of the staff at all times at designated and convenient locations. (c) Appoint a person of majority age to act for him or her during any absence. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 5, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001; R016-20, 11-2-2020) NAC 449.114 Employees: General requirements. ( NRS 449.0302 ) 1. A facility must have on duty, all hours of each day, members of the staff sufficient in number and qualifications to carry out policies, responsibilities and program continuity. 2. Each member of the counseling staff must be: (a) A registered intern; (b) Certified or licensed by the Board of Examiners for Alcohol, Drug and Gambling Counselors; or (c) A licensed mental health professional who has experience with alcohol and drug counseling. 3. The administrator or his or her appointee must be present and responsible for the operations of the facility during normal hours. 4. A facility must have written policies and procedures for the recruitment, selection, promotion and termination of members of the staff. 5. The facility must have written policies and procedures covering wages and salaries, working hours, employee benefits, vacation and sick leave, rules of conduct, and training and the development of the staff. 6. The facility must provide an orientation session to new employees. Documentation of the sessions must be maintained in the employee’s personnel record. 7. There must be written policies and procedures governing disciplinary actions which clearly define the mechanism for suspension or dismissal of members of the staff as well as the procedures for appeal. 8. Written job descriptions must be maintained for all positions. A description must include: (a) The title of the job; (b) The tasks and responsibilities of the job; (c) The skills, education and experience necessary for the job; (d) The relationship of the job to other jobs within the program; and (e) The working conditions, location, shift, materials and equipment to be used on the job. Ê The job description must accurately reflect the actual job situation and must be reviewed annually or whenever a change in the job or qualifications occurs. Job descriptions must be available on request to all members of the staff. 9. A personnel record must be maintained for each employee. The record must contain: (a) The employment application; (b) Letters of recommendation; (c) Reference investigation records; (d) Verification of training, experience and, if applicable, certification; (e) Documentation of attendance at the orientation session for new employees; (f) Job performance evaluations; (g) Incident reports; and (h) Disciplinary actions taken. 10. Personnel records must be maintained in a secure manner and must be available only to those persons authorized in written policies and procedures. An employee must have access to his or her own records upon request. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 6, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001; R098-06, 7-14-2006) NAC 449.117 Employees: Proof of compliance with provisions concerning tuberculosis. ( NRS 449.0302 ) All persons employed in a facility must have documentation showing that they are in compliance with any applicable provisions of chapter 441A of NAC concerning tuberculosis. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 12, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001) Social Model Detoxification Programs NAC 449.121 Certain facilities authorized to offer program. ( NRS 449.0302 ) A social model detoxification program may be offered to clients in: 1. Residential programs that offer detoxification services; 2. A licensed facility for modified medical detoxification pursuant to NAC 449.15311 to 449.15367 , inclusive; or 3. A medically managed intensive detoxification program. (Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001; A by R016-20, 11-2-2020) NAC 449.1214 General requirements. ( NRS 449.0302 ) 1. A facility that offers a social model detoxification program: (a) Must have a physician, nurse practitioner, registered nurse or physician assistant conduct a physical assessment and a review of the general medical and drug history of a client within 24 hours after the client is admitted to the facility to ensure that a social model detoxification program is appropriate for the client. (b) Must not provide detoxification services for clients who exhibit life-threatening symptoms of withdrawal from alcohol and drugs. (c) Must develop and implement policies and procedures that protect the safety and health of clients. The facility must have these policies and procedures reviewed annually by a licensed physician who is familiar with the symptoms of withdrawal from alcohol and drugs. (d) Must ensure that the observation of a client during his or her treatment in the social model detoxification program is reflected in the records of the client as deemed necessary by the policies and procedures of that facility. 2. The staff of a facility that offers a social model detoxification program must complete at least 6 hours of additional education in the detoxification of persons with alcohol and other substance use disorders, as approved by the program of ongoing quality improvement pursuant to NAC 449.1218 , every 2 years. Such education must include instruction in: (a) Acute withdrawal symptoms from alcohol and drugs; and (b) First-aid procedures for clients with seizures. (Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001) NAC 449.1218 Program of ongoing quality improvement. ( NRS 449.0302 ) 1. A social model detoxification program must have a program of ongoing quality improvement designed to: (a) Monitor and evaluate, objectively and systematically, the quality and appropriateness of client care; (b) Pursue opportunities to improve client care; and (c) Resolve identified problems. 2. The program of ongoing quality improvement must: (a) Establish written policies and procedures to describe and document the monitoring and evaluation activities of the program of ongoing quality improvement. (b) Include the participation of a medical professional who is not required to be a member of the staff. For the purposes of this paragraph, “medical professional” means a licensed physician, nurse practitioner, physician assistant or registered nurse who is familiar with clients suffering from acute withdrawal symptoms from alcohol and drugs. (c) In addition to the participation of a medical professional pursuant to paragraph (b), include the participation of the administrator and two staff members of the social model detoxification program. (d) Approve the 6 hours of additional education required pursuant to NAC 449.1214 to ensure that the additional education is appropriate. 3. The findings of the program of ongoing quality improvement, including any conclusions, recommendations, actions taken and the results of the actions taken, must be documented. All documentation must be reported to the governing body and must be reflected in the minutes annually. (Added to NAC by Bd. of Health by R077-01, eff. 10-18-2001) Operation of Facility NAC 449.123 General sanitary requirements. ( NRS 449.0302 ) 1. Each facility must meet all state and local environmental health standards. 2. A facility which provides dietary services must have food service equipment of appropriate quality and type for the type of food service program used by the facility. The equipment must comply with all applicable provisions in chapter 446 of NAC. 3. All environmental health inspection reports must be on file in the facility. Any deficiencies must be corrected within 90 days and documented in the file. 4. Premises and equipment must be maintained in a sanitary condition: (a) The facility must have the necessary cleaning and maintenance equipment with sufficient storage areas and appropriate procedures to maintain a clean and orderly establishment. (b) Janitorial supplies, including aerosols, must be stored in areas separate from clean linen, food and other supplies. (c) The storage of dirty linen must be separate from the storage of clean linen, food and other supplies. 5. The facility shall establish a policy that prohibits clients from sharing items for personal use, such as combs, toothbrushes, towels or bar soap. 6. Restrooms or lavatories for the staff must be provided with soap dispensers and individual disposable towels. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 11, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001) NAC 449.126 Laundry requirements. ( NRS 449.0302 ) 1. A facility must maintain: (a) A laundry with equipment which is adequate for the sanitary washing and finishing of linen and other washable goods; or (b) A written agreement with a commercial establishment to provide laundry services for the facility. 2. The laundry must be situated in an area which is separate from any area where food is stored, prepared or served. The laundry must be well-lighted, ventilated, adequate in size to house the equipment and maintained in a sanitary manner. The equipment must be kept in good repair. 3. Soiled linen must be collected and transported to the laundry in washable or disposable covered containers in a sanitary manner. 4. Clean linen to be dried, ironed, folded, transferred or distributed must be handled in a sanitary manner, specified in writing. 5. Closets for storing linen and laundry supplies must be provided and must not be used for any other purpose. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 11, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R077-01, 10-18-2001) NAC 449.129 Design, construction, equipment and maintenance. ( NRS 449.0302 ) 1. A facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the clients and personnel of the facility and members of the general public. 2. Each facility must comply with all currently adopted life safety, fire, Division, local building and zoning codes. If there is a difference between state and local codes, the more stringent standards apply. 3. Facilities housing 17 or more clients must meet the requirements of the chapter entitled “New Hotels and Dormitories,” of the edition of NFPA 101: Life Safety Code , adopted by reference pursuant to NAC 449.0105 . Those facilities housing not more than 16 clients must meet the requirements of the chapter entitled “Lodging or Rooming Houses,” of the edition of NFPA 101: Life Safety Code , adopted by reference pursuant to NAC 449.0105 . 4. A facility is deemed to be in compliance with the provisions of this section if: (a) The facility is licensed by May 30, 2001, and: (1) The use of the physical space in the facility is not changed; and (2) There are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the health and welfare of the public; or (b) Before May 30, 2001, the facility has submitted building plans to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 and: (1) The Division determines that the plans comply with standards for construction in effect before May 30, 2001; (2) Construction of the facility is begun before February 1, 2002; (3) The facility is constructed in accordance with those standards; and (4) There are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the health and welfare of the public. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 13, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R077-01, 10-18-2001; R073-04, 8-4-2004; R098-06, 7-14-2006) NAC 449.132 Accommodations for clients. ( NRS 449.0302 ) 1. No room or space in a facility may be occupied for sleeping, living or dining which is accessible only by a ladder, by folding stairs or through a trapdoor. 2. If a basement is used for living and dining, at least one exit must be provided directly to the outside at ground level. No facility may: (a) Be situated more than one story below the ground. (b) Use any basement or space in a basement for sleeping. 3. Each room of a facility used by clients for sleeping must: (a) Be furnished with a bed, clean linen and blankets; and (b) Not be less than 50 square feet per bed. 4. Toilet and bathing facilities must be provided to clients in a manner that ensures their privacy during use and in an adequate number to meet the needs of the clients. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 13, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R077-01, 10-18-2001) NAC 449.135 Safety from fire. ( NRS 449.0302 ) 1. Portable fire extinguishers must be installed throughout each facility at the direction of the fire authority having jurisdiction. Each portable fire extinguisher available at a facility must be inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections. 2. Any facility with a kitchen range with an upper surface of more than 15 square feet must provide the range with an exhaust hood having an automatic fire protection system in accordance with the chapter titled “Standards for Ventilation Control and Fire Protection of Commercial Cooking Operations,” of the edition of NFPA 101: Life Safety Code , adopted by reference pursuant to NAC 449.0105 . 3. A portable room-heating device may be used at a facility if the device: (a) Is located at least 2 feet from any combustible material; (b) Is plugged directly into a wall socket; (c) Turns off automatically if it is tipped over; and (d) Has no exposed heating elements. 4. Receptacles or outlets serviced by extension cords are prohibited. 5. Rooms in which smoking is allowed by direction of the facility or the fire authority must be provided with plainly visible “Smoking Area” signs. 6. A facility must conduct fire drills at least monthly and a written record of each drill conducted must be retained in the facility for not less than 12 months after the drill is conducted. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities part Art. 13, eff. 3-27-76]—(NAC A by R035-97, 10-30-97; R077-01, 10-18-2001; R073-04, 8-4-2004) NAC 449.141 Health services. ( NRS 449.0302 ) 1. Facilities must provide access to health services which ensure that each client receives treatment, prescribed medication, adequate diets and other health services consistent with the program administered by the facility. 2. Facilities must implement policies and procedures designed to ensure the early detection of complications or conditions considered to be common among persons with substance use disorders. These policies and procedures must be developed in conjunction with and approved by a licensed physician. 3. Before a client’s admission to a program or facility, a general medical and drug history must be taken by a designated member of the staff who is certified or licensed by the Board of Examiners for Alcohol, Drug and Gambling Counselors or who is a licensed mental health professional who has experience with alcohol and drug counseling. Current medical information must be provided on a form that has been approved by a physician. The history must include, but is not limited to: (a) Drugs used in the past; (b) Drugs used recently; (c) Drugs of preference; (d) Frequently used drugs; (e) Drugs used in combination; (f) Dosages used; (g) Date of first usage; (h) Incidents of overdose, withdrawal or adverse drug reactions; and (i) Previous history of treatment. 4. A program may accept medical history and physical examination results from referral sources which were conducted not more than 30 days before admission in lieu of personally taking a general medical and drug history as required pursuant to subsection 3. 5. Each facility must be able to provide directly, or through written arrangements, laboratory tests as requested by a physician or federal regulations. 6. Facilities must implement written policies and procedures that are reviewed by a licensed physician defining the appropriate action to be taken when a medical emergency arises. 7. There must be one staff person in the facility who is capable of providing cardiopulmonary resuscitation at all times. Staff members providing cardiopulmonary resuscitation must be qualified by the American Red Cross or another recognized agency. 8. Clients of residential programs must undergo a tuberculin skin test that meets the requirements specified in chapter 441A of NAC. 9. Each facility shall maintain and have readily available first-aid supplies. Staff members shall have evidence that they have received training on the use of first-aid supplies. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 7, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001; R098-06, 7-14-2006) NAC 449.144 Medication. ( NRS 449.0302 ) 1. In programs that permit the self-administration of medication, there must be written policies and procedures governing this activity. The policies must require that: (a) The decisions to permit self-administration be based on individual needs. (b) The reasons for the permission be clearly documented in the client’s case record. (c) All medications that are to be self-administered be packaged in a manner complying with the Poison Prevention Packaging Act of 1970, 15 U.S.C. §§ 1471 et seq., and all current regulations stemming from that act. (d) The self-administration of prescription medication be observed by a staff member who has been oriented to the program’s policies and procedures on self-administration of prescription medication. (e) The self-administration of prescription medication be permitted only when the medication is clearly labeled. (f) There be documentation in the client’s record of the name of the medication, dose, route of administration, time and name of the person observing the self-administration or the licensed staff member who administered the medication. (g) Clients who receive medication for self-administration be given instructions concerning the safe storage and usage of the drugs and the appropriate emergency procedures to be followed if adverse reactions occur. 2. Any unusual reaction to a medication by a client must be documented in the client’s record and reported to the appropriate physician as outlined in the policies of the facility. 3. Facilities must provide a locked storage area for prescription medication that is to be self-administered by clients. Such medication must be made available to clients at appropriate times and may be dispensed only from a licensed pharmacy in accordance with all applicable provisions of NRS and NAC. 4. Members of the staff may not administer any medication unless licensed to do so. 5. All medication must be maintained in locked storage. Controlled substances must be maintained in a locked box within the locked storage. Medications requiring refrigeration must be kept in a locked box inside the refrigerator separated from food and other items. Disinfectants and medication for external use must be stored separately from medications for internal use and from medications that can be injected. All potent, poisonous or caustic drugs must be plainly labeled, stored and made accessible only to authorized persons. All medication storage must be maintained in accordance with the security requirements of federal, state and local laws. 6. Narcotic treatment facilities may issue methadone “takeouts” to a client in a facility without listing the strength of the drug if the label shows: (a) The client’s name or other identifying code; and (b) The 24-hour emergency telephone number for the narcotic treatment facility. 7. Medication prescribed for a client must not be allowed to be in the possession of another client. 8. Any unused prescription medication left behind at a facility by a client must be destroyed by the administrator or his or her designee in the presence of a witness, and a notation indicating that the medication was destroyed must be made on the client’s record. At the time a client is discharged or leaves the facility, medications that are currently being self-administered must be sent, in the original container, with the client or a responsible agent of the client. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 9, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001) NAC 449.147 Dietary services. ( NRS 449.0302 ) 1. Facilities must serve at least three meals or their equivalent daily, at regular times, with not more than 14 hours between a substantial evening meal and breakfast. A second serving must be provided for those clients who desire one. 2. Menus must be planned and followed to meet the nutritional needs of the clients in accordance with the recommended dietary allowances of the Food and Nutrition Board of the Institute of Medicine of the National Academies. 3. Therapeutic menus must be planned by a licensed dietitian or must be reviewed and approved by the client’s attending or staff physician. 4. Menus must be in writing, planned in advance, dated and posted, and kept on file for 90 days. Any substitution must be noted on the written menus so that the menu on file reflects what was actually served. 5. Adequate facilities and equipment for the preparation, serving, refrigeration and storage of food in a sanitary manner must be provided. 6. A facility with more than 10 clients must: (a) Comply with all applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto; (b) Obtain the necessary permits from the Division; (c) Maintain a report of each inspection concerning the sanitation of the facility for at least 1 year after the date of the inspection; and (d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action. 7. Clients needing special equipment, implements or utensils to assist them while eating must have such items provided. 8. If a facility operates on the cottage plan, provision must be made for food service that assures hot, palatable meals. 9. A licensed dietitian must be used as a consultant on planning meals and serving food. Consultation each month is required. 10. All facilities that contract with food management companies must comply with the applicable regulations of the Division as provided in chapter 446 of NAC. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 8, eff. 3-27-76; A 3-30-77]—(NAC A by R077-01, 10-18-2001; R073-04, 8-4-2004; R155-10, 12-16-2010; R090-12, 12-20-2012) NAC 449.150 Records of clients. ( NRS 449.0302 ) 1. Each facility must maintain an organized system for clients’ records. 2. Clients’ records must be available to members of the staff who have authority to review such records. 3. Clients’ records must be available to representatives of the Division. 4. Clients’ records must contain: (a) Identification information; (b) Past medical and social history; (c) Copies of initial and periodic examinations; (d) Evaluations and progress notes; and (e) A review and any revisions of each plan of treatment. 5. There must be an overall plan of treatment stated in quantifiable terms which outlines goals to be accomplished through individually designed activities, therapies and treatments. 6. The plan of treatment must state what service or person is responsible for treatment or services to the client. 7. Entries must be made describing treatments and services rendered, medications administered, including those that are self-administered, and any symptoms or other indications of illness or injury, including the date, time and action taken regarding each incident. 8. Records must be adequately safeguarded against destruction, loss or unauthorized use. 9. Records must be retained for at least 5 years following a client’s discharge. 10. A discharge plan, as determined by a case management services assessment of the client, must be documented for each client discharged from the facility. The discharge plan must be formulated upon a client’s admission to the facility. [Bd. of Health, Alcohol and Drug Abuse Treatment Facilities Art. 10, eff. 3-27-76]—(NAC A by R077-01, 10-18-2001) FACILITIES FOR MODIFIED MEDICAL DETOXIFICATION NAC 449.15311 Definitions. ( NRS 449.0302 ) As used in NAC 449.15311 to 449.15367 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.15313 to 449.15321 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R016-20, 11-2-2020) NAC 449.15313 “Administrator” defined. ( NRS 449.0302 ) “Administrator” means the person who is appointed by the governing body of a facility who has primary responsibility for the overall operations of the program of the facility. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15315 “Client” defined. ( NRS 449.0302 ) “Client” means a resident or patient of a facility. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15317 “Facility” defined. ( NRS 449.0302 ) “Facility” means a facility for modified medical detoxification as defined in NRS 449.00385 . (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15319 “Overall program” defined. ( NRS 449.0302 ) “Overall program” means tasks that are commonly undertaken by a board of directors, including, without limitation, general fiscal management, fund-raising projects and establishing the general long-term goals of a facility. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15321 “Program” defined. ( NRS 449.0302 ) “Program” means the program established pursuant to NAC 449.15337 . (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15323 Proof of certification required; revocation of license. ( NRS 449.0302 ) 1. As a condition of the issuance of a license to a facility, the facility shall provide proof that it is certified by the Division. 2. If the Division revokes or does not renew the certification of a facility, the Division shall revoke the license of the facility subject to the appeals procedure set forth in NAC 439.300 to 439.395 , inclusive. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15325 Governing body; bylaws and policies. ( NRS 449.0302 ) 1. Each facility shall have a governing body that has the ultimate authority for the administration of the overall program of the facility. 2. The governing body shall adopt written bylaws and policies that define the powers and duties of the governing body, its committees, the administrator and any advisory group. 3. The bylaws and policies must: (a) Identify the overall goals of the facility; (b) Include, without limitation, an organizational chart of the facility; (c) Define the major lines of authority and areas of responsibility within the program of treatment provided by the facility; (d) Define the membership of the governing body, the types of membership, the method of selection or appointment of members, offices or committees and their terms of office; and (e) Define the frequency of meetings of the governing body and attendance requirements. 4. The governing body shall: (a) Appoint a qualified administrator of the facility with authority and responsibilities appropriate to the requirements of the program; (b) Establish policies governing the responsibilities, authority and duties of the administrator that are designed to enable the administrator to perform the administrative and treatment functions of the facility; (c) Appoint a medical director of the facility who is responsible for the medical services provided at the facility; (d) Determine, in accordance with state law, which categories of practitioners are eligible to be appointed to the medical staff of the facility; (e) Appoint members to the medical staff of the facility who are accountable to the governing body for the quality of medical care provided to clients of the facility, taking into consideration any recommendations of the existing members of the medical staff; (f) Review and revise the bylaws and policies of the governing body; (g) Adopt controls designed to achieve and maintain maximum standards of service; and (h) Review and approve an annual budget to carry out the objectives of the program. 5. The governing body shall retain the ultimate responsibility for the overall program and its objectives. 6. The governing body shall meet at least semiannually. Minutes must be kept of the meetings, including, without limitation, the date of each meeting, those in attendance, topics discussed, decisions made and actions taken, and all program reports. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15327 Policies and procedures for services and operation of facility. ( NRS 449.0302 ) 1. Each facility shall have written policies and procedures available to members of the staff, clients and the public that govern the operation of the facility and services provided by the facility. 2. The policies must: (a) Ensure that only those persons are accepted as clients whose needs can be met by the facility directly or in cooperation with community resources or other providers of treatment with which it is affiliated or has contacts. (b) Ensure that a client whose physical or mental condition has changed to such an extent that the client can no longer be adequately served by the facility will be transferred promptly to an appropriate facility. Written transfer agreements or other written provisions with such other facilities must be maintained by the facility. (c) Set forth the rights of clients and members of the staff and provide for the registration and disposition of complaints without threat of discharge or reprisal against any employee or client. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15329 Transfer of client. ( NRS 449.0302 ) 1. Except in the case of an emergency, the transfer of a client must not be effected until the client, attending physician of the client, if any, and responsible agency are consulted in advance. 2. Except as otherwise provided in subsection 3, if a client is transferred to a hospital or other medical facility, a summary of discharge containing a plan for continuation of care must be prepared and forwarded to the receiving facility if the client or his or her guardian consents to release such information to the receiving facility. 3. If a client is transferred to a hospital or other medical facility as a result of a medical emergency, information required for appropriate continuation of care must be released to the receiving facility in compliance with the standards set forth in 42 C.F.R. Part 2. 4. The admission agreement must not allow the licensee or his or her designee to be given power of attorney. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15331 Handling of money of client. ( NRS 449.0302 ) 1. If a facility handles the money of a client, a written ledger account of all deposits, disbursements or other transactions must be maintained. A record must be made available to the client at least quarterly. 2. The money of a client must be given to the client within 24 hours after his or her exit from the facility. 3. Large sums of money must be maintained in a financial institution in the community where the facility is located in a separate trustee account apart from the operational accounts of the facility and must be clearly designated. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15333 Inventory of belongings of client. ( NRS 449.0302 ) If a facility holds or stores the belongings of a client, there must be an inventory of the belongings on admission, made a part of the record of the client and updated as needed. These belongings must be returned to the client upon his or her exit. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15335 Liability insurance. ( NRS 449.0302 ) Liability insurance in a sufficient amount to protect clients, members of the staff, volunteers and visitors, must be maintained by each facility. A certificate of insurance must be furnished to the Division. The certificate must include, without limitation, provision for 30 days’ notice to the Division of cancellation or the nonrenewal of a policy of insurance. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15337 Program: Requirements; review. ( NRS 449.0302 ) 1. Each facility shall have a written program outlining short-term and long-term objectives and goals. These goals must be realistic, attainable, and clearly and operationally defined. 2. Each component of the program must develop objectives that complement the goals of the program. 3. The Division shall: (a) Periodically evaluate the program; (b) Prepare a report of the evaluation; and (c) Distribute the report to the persons who manage the program and make the report available to the members of the staff of the facility and the Bureau of Licensure and Certification of the Division. 4. The facility shall provide for the medical, dental and psychological services needed to fulfill the goals of the program and meet the needs of all its clients to the extent that is possible, with assistance from available community resources. 5. If a facility provides services through outside sources, formal, written arrangements must be made ensuring that the services are supplied directly by, or under the supervision of, qualified persons. 6. Each facility shall provide case management services as needed by a client through a social worker or a registered nurse or by written agreement with a social worker or a registered nurse. 7. A plan for case management must be recorded in the records of a client and must be periodically evaluated in conjunction with the treatment plan of the client. 8. Each facility shall review its general program at least annually. Areas reviewed must include, without limitation, appropriateness of admissions, lengths of stay, discharge planning, use of services and utilization of the components of the program and outside services. Written reports of the reviews must be evaluated by the governing body, administrator and such committees as they designate. Documentation of the evaluation process must be maintained at the facility. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15339 Responsibilities and duties of administrator. ( NRS 449.0302 ) 1. The administrator of a facility is responsible to the governing body of the facility for the operation of the facility in accordance with the policies and procedures of the facility. 2. The administrator shall: (a) Organize the administrative functions of the program, delegate duties and establish a formal means of accountability on the part of subordinates. (b) Ensure that a written manual defining the policies and procedures of the program is prepared, regularly revised and updated. The manual must: (1) Contain all policies and procedures of the facility, including, without limitation, definitions and other documentation required by NAC 449.15311 to 449.15367 , inclusive; and (2) Be available to members of the staff of the facility at all times at designated and convenient locations. (c) Appoint a person who has attained the age of majority to act for him or her during any extended absence. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R016-20, 11-2-2020) NAC 449.15341 Policies and procedures concerning employees. ( NRS 449.0302 ) 1. Each facility shall have on duty, all hours of each day, members of the staff sufficient in number and qualifications to carry out policies, responsibilities and program continuity. 2. All members of the counseling staff of a facility shall be authorized by state law to provide counseling for alcohol and other substance use disorders. 3. The administrator or his or her appointee shall be present and responsible for the operations of the facility during normal hours. 4. Each facility shall have written policies and procedures for the recruitment, selection, promotion and termination of members of the staff. 5. Each facility shall have written policies and procedures concerning wages and salaries, working hours, employee benefits, vacation and sick leave, rules of conduct, and training and development of the staff. 6. Each facility shall provide an orientation session to new employees. Documentation of the session must be maintained in the personnel file of the employee. 7. Each facility shall have written policies and procedures governing disciplinary actions that clearly define the mechanism for the suspension or dismissal of members of the staff as well as the procedures for appeal. 8. Each facility shall maintain a written job description for each position at the facility. The job description must accurately reflect the actual job situation and must be reviewed annually or whenever a change in the responsibilities of the job or qualifications occurs. Job descriptions must be available on request to all members of the staff. A job description must include, without limitation: (a) The title of the job; (b) The tasks and responsibilities of the job; (c) The skills, education and experience necessary for the job; (d) The relationship of the job to other jobs within the program; and (e) The working conditions, location and shift of the job, and the materials and equipment to be used on the job. 9. Each facility shall maintain a personnel record for each employee of the facility. The record must include, without limitation: (a) The employment application; (b) Letters of recommendation; (c) Records from any investigation of the employee; (d) Verification of training, experience and certification; (e) Job performance evaluations; (f) Incident reports; and (g) Disciplinary actions taken. 10. Each facility shall maintain personnel records in a secure manner and make them available only to those persons authorized to receive personnel records in the written policies and procedures of the facility. An employee must have access to his or her own file upon request. 11. Each person employed in a facility shall have a preemployment physical examination or certification of a 3-year health record from a physician, and be tested for tuberculosis as required in chapter 441A of NAC. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15343 Nursing services. ( NRS 449.0302 ) 1. Each facility shall have an organized plan for nursing service that provides nursing services 24 hours per day. The nursing services must be provided or supervised by a registered nurse in compliance with state law, including, without limitation, chapter 632 of NRS and chapter 632 of NAC. 2. The nursing service shall have a sufficient number of registered nurses, licensed practical nurses and other personnel to provide nursing care to all clients as needed. 3. The facility shall ensure that the nursing staff develops and keeps current a plan for nursing care for each client. 4. The administrator shall appoint a chief administrative nurse to direct the nursing service. The chief administrative nurse must: (a) Be a registered nurse; (b) Be knowledgeable, skilled and competent in clinical practice and the management of nurses; (c) Be authorized by state law to provide counseling for alcohol and other substance use disorders; and (d) Comply with the provisions of chapter 632 of NRS and chapter 632 of NAC and follow professional standards established for organized nursing services. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15345 Health services. ( NRS 449.0302 ) 1. Each facility shall provide health services which ensure that each client receives treatment, prescribed medication, adequate diets and other health services consistent with the program administered by the facility. 2. There must be policies and procedures designed to ensure the early detection of complications or conditions considered to be common among persons with alcohol or other substance use disorders. The policies and procedures must be developed with assistance from and approved by the medical director of the facility. 3. Before a client is admitted to a facility, a general medical and drug history of the client must be taken by a physician or designated member of the nursing staff of the facility. The history must include, without limitation: (a) Drugs used in the past; (b) Drugs used recently; (c) Drugs of preference; (d) Frequently used drugs; (e) Drugs used in combination; (f) Dosages used; (g) Date of first usage; (h) Incidents of overdose, withdrawal or adverse drugs reactions; and (i) Previous history of treatment. 4. Except as otherwise provided in this subsection, a physical examination and review of the medical and drug history of a client must be conducted by a physician, registered nurse or physician assistant within 48 hours after the client is admitted to a facility. If the assessment performed by a physician or a member of the nursing staff before a client is admitted to the facility concludes that a physical examination of the client should be completed within less than 48 hours after the client is admitted to the facility to ensure that the needs of the client are met, the physical examination must be conducted within the time recommended in the assessment. 5. Each facility must be able to provide directly, or through written arrangements, laboratory tests as requested by a physician or federal regulations. 6. Referral to an outside health resource must be made only if the resource is able to accept the client. Any records that accompany the client must be either expurgated of any sensitive material or be available only to persons authorized to receive the information under the direction of the physician or administrator. Except where an emergency that threatens a life exists and except as otherwise provided in NAC 449.15329 , no information may be released without the prior consent of the client or his or her guardian. 7. Each facility shall have written policies and procedures defining the appropriate action to be taken when a medical emergency arises. The policies and procedures must be reviewed and approved by the medical director of the facility. 8. Each member of the staff of a facility must be qualified by the American Red Cross or another similar nationally recognized agency to administer cardiopulmonary resuscitation. 9. Each client of a facility shall, within 5 days after admission, undergo a Mantoux tuberculin skin test. If the client has no documented history of a two-step Mantoux tuberculin skin test and has not had a single Mantoux tuberculin skin test within the 12 months preceding admission to the facility, the client shall undergo a two-step Mantoux tuberculin skin test. 10. First-aid supplies must be maintained and readily available at each facility. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15347 Pharmaceutical services. ( NRS 449.0302 ) 1. Each facility shall have a pharmacy directed by a registered pharmacist or a drug room supervised by no less than a currently licensed professional nurse. The pharmacy or drug room must be administered in accordance with all applicable state and federal laws. The facility shall have a full-time, part-time or consulting pharmacist who is responsible for developing, supervising and coordinating all of the activities of the pharmacy service. 2. Each facility shall have and implement policies and procedures that minimize errors in the administration of drugs. The medical director of the facility and the pharmacist who is responsible for the pharmacy service shall approve the policies and procedures. 3. Drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice and state and federal laws. 4. When a pharmacist is not available at the facility, drugs and biologicals may be removed from the pharmacy or drug area only by a member of the staff who is authorized to remove such substances by the policies and procedures of the facility, which must be established in accordance with state and federal laws. 5. Errors in administering a drug, adverse reactions by a client to a drug and incompatibilities between a drug and a client must be immediately reported to the attending physician of the client. 6. Misuses and losses of controlled substances must be reported to the pharmacist who is responsible for the pharmacy service, the administrator and the chief administrative nurse of the facility, in accordance with all applicable state and federal laws. 7. Information relating to drug interactions and information on drug therapy, side effects, toxicology, dosage indications for use and routes of administration must be available to the professional members of the staff of the facility. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15349 Medication and biologicals. ( NRS 449.0302 ) 1. Except as otherwise provided in subsection 2, an order for medication or biologicals for a client must be in writing and signed by the practitioner, or other appropriate professional person authorized by state or federal law to order the medication or biological, who is responsible for the care of the patient. 2. When a telephone or verbal order is used to order medications or biologicals, the order must be: (a) Accepted only by a person who is authorized by the policies and procedures of the facility, which must be consistent with state law, to accept such an order; and (b) Signed or initialed by the prescribing practitioner in accordance with the policies and procedures of the facility. 3. Each order for a medication or biological must include, without limitation, the name of the medication or biological, and the dosage, time or frequency of administration and route of administration of the medication or biological. 4. Only a member of the staff of the facility who is authorized by state law to administer medication or biologicals may administer medication or biologicals at the facility. 5. Each facility shall have a system to monitor and improve the process of administering medication and biologicals. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15351 Dietary services. ( NRS 449.0302 ) 1. Facilities shall serve at least three meals or their equivalent daily, at regular times, with not more than 14 hours between a substantial evening meal and breakfast. A second serving must be provided for those clients who desire one. 2. Menus must be planned and followed to meet the nutritional needs of the clients in accordance with the recommended dietary allowances recommended by the Food and Nutrition Board of the Institute of Medicine of the National Academies. 3. Therapeutic menus must be planned by a licensed dietitian or must be reviewed and approved by the attending physician of the client or a staff physician. 4. Menus must be in writing, planned in advance, dated and posted, and kept on file at the facility for at least 90 days. Any substitution must be noted on the written menu so that the menu on file reflects what was actually served. 5. Adequate facilities and equipment for the preparation, serving, refrigeration and storage of food in a sanitary manner must be provided. 6. A facility with more than 10 clients shall: (a) Comply with all applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto; (b) Obtain the necessary permits from the Division; (c) Maintain a report of each inspection concerning the sanitation of the facility for at least 1 year after the date of the inspection; and (d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action. 7. Clients needing special equipment, implements or utensils to assist them while eating must have such items provided. 8. If a facility operates on the cottage plan, provision must be made for food service that ensures hot, palatable meals. 9. A licensed dietitian must be used as a consultant on planning meals and serving food. At least 4 hours of consultation each month is required. 10. A facility that contracts with a food management company shall comply with all applicable regulations of the State Board of Health. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004; R155-10, 12-16-2010; R090-12, 12-20-2012) NAC 449.15353 Records of clients. ( NRS 449.0302 ) 1. Each facility shall maintain an organized system for the records of clients. 2. The records of a client must be available to professional members of the staff of the facility who are directly involved with the client. 3. The records of clients must be available to representatives of the Division. 4. The records of clients must include, without limitation: (a) Identification information; (b) Past medical and social history; (c) Copies of initial and periodic examinations; (d) Evaluations and progress notes; and (e) Assessments and goals of the plan of treatment of each client. 5. The plan of treatment must state what service or person is responsible for providing treatment or services to the client. 6. Entries must be made describing treatments and services rendered, medications administered, and any symptoms or other indications of illness or injury, including, without limitation, the date, time and action taken regarding each incident. 7. Records must be adequately safeguarded against destruction, loss or unauthorized use. 8. Records must be retained for at least 5 years after the discharge of a client from a facility. 9. A discharge plan, as determined by a case management assessment of the client, must be documented for each client discharged from the facility. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15355 Safety and sanitation; temperature. ( NRS 449.0302 ) 1. The premises and equipment of each facility must be maintained in a safe, functional and sanitary condition. Each facility shall have the necessary cleaning and maintenance equipment with sufficient storage areas and appropriate procedures to maintain a clean and orderly establishment. Janitorial supplies, including, without limitation, aerosols, must be stored in areas separate from clean linen, food and other supplies. The storage of dirty linen must be separate from the storage of clean linen, food and other supplies. 2. Items for personal use, including, without limitation, combs, toothbrushes, towels and bar soap, must not be shared by clients. 3. Restrooms or lavatories for the staff of a facility must be provided with soap dispensers and individual, disposable towels. 4. Each facility shall ensure that the environment of the facility is free of hazards that may cause accidents. 5. Each facility shall maintain an effective program to control pests and rodents in order to ensure that the facility is free from pests and rodents. 6. Each facility shall provide safe and comfortable levels of temperature in the facility. The temperature of the facility must be maintained at a level that is not less than 71 degrees Fahrenheit and not more than 81 degrees Fahrenheit. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004) NAC 449.15357 Laundry requirements. ( NRS 449.0302 ) 1. Each facility shall have the proper equipment for the sanitary washing and finishing of linen and other washable goods or shall maintain a written agreement with a commercial establishment to provide laundry services. 2. The laundry area of a facility must be situated in an area of the facility that is separate and apart from any room where food is stored, prepared or served. The laundry area must be well-lighted, ventilated, adequate in size to house equipment, maintained in a sanitary manner and kept in good repair. 3. Soiled linen must be collected and transported to the laundry in washable or disposable containers in a sanitary manner. Soiled linen must not be transported through areas of the facility used for preparing or serving food. 4. Clean linen to be dried, ironed, folded, transferred or distributed must be handled in a sanitary manner in accordance with a written plan maintained by the facility. 5. Closets for storing linen and laundry supplies must be provided and must not be used for any other purpose. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15359 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of facility for licensure. ( NRS 449.0302 ) 1. Except as otherwise provided in subsection 4, before any new construction of a facility or any remodeling of an existing facility is begun: (a) The facility must submit a copy of the building plans for the new construction or remodeling to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 . The entity’s review of those plans is advisory only and does not constitute approval for licensure of the facility. (b) The building plans must be approved by the Division. 2. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility. 3. The Division shall not issue a license to operate a facility until the Bureau has approved the construction of the facility. 4. The provisions of subsection 1 do not apply to plans for remodeling a facility if the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting in the area, replacing flooring in the area, repairing windows in the area or replacing window and wall coverings in the area. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R076-01, 10-18-2001; R069-04, 8-4-2004) NAC 449.15361 Design, construction, equipment and maintenance. ( NRS 449.0302 ) 1. Each facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the clients and personnel of the facility and members of the general public. 2. Each facility shall comply with all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Environmental, life safety, fire, health and local building codes, Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply. 3. Each facility shall comply with the provisions of NFPA 101: Life Safety Code , as adopted by reference pursuant to NAC 449.0105 . Facilities housing 17 or more clients shall meet the requirements of the chapter entitled “Hotel and Dormitories,” of the edition of NFPA 101: Life Safety Code adopted by reference pursuant to NAC 449.0105 . Those facilities housing not more than 16 clients shall meet the requirements of the chapter entitled “Lodging or Rooming Houses,” of the edition of NFPA 101: Life Safety Code adopted by reference pursuant to NAC 449.0105 . (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004) NAC 449.15363 Accommodations for clients. ( NRS 449.0302 ) 1. No room or space of a facility may be occupied for sleeping, living or dining that is accessible only by a ladder, by folding stairs or through a trapdoor. 2. If a basement of a facility is used for living and dining, at least one exit must be provided directly to the outside at ground level. No facility may: (a) Be situated more than one story below the ground; and (b) Use any basement or space in a basement for sleeping. 3. Each room of a facility used by clients for sleeping must: (a) Be provided and furnished with a bed, clean linen and blankets; (b) Not be less than 60 square feet per bed; and (c) Not be used for sleeping by more than four clients. 4. Toilet facilities and bathing facilities must be provided to clients in a manner that ensures their privacy while bathing and in an adequate number to meet the needs of the clients. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000) NAC 449.15365 Safety from fire. ( NRS 449.0302 ) 1. Devices for the detection of combustion other than heat detectors must be installed on the ceiling of each story of a facility, in front of doors to stairways in a facility, and at not more than 30 feet apart in the corridors of all floors of a facility, including, without limitation, the center. Smoke detectors must also be installed in the center of any lounge or recreational area of a facility. The smoke detectors may be single station units with an integral alarm. 2. Portable fire extinguishers must be installed throughout each facility at the direction of the fire authority having jurisdiction. Each portable fire extinguisher available at a facility must be inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections. 3. A portable room-heating device may be used if the device: (a) Is located 2 feet or more from any combustible material; (b) Is plugged directly into a wall socket; (c) Turns off automatically if tipped over; and (d) Has no exposed heating elements. 4. Receptacles or outlets serviced by extension cords are prohibited in facilities. 5. Rooms in which smoking is allowed by direction of the facility or the fire authority must be provided with plainly visible “Smoking Area” signs. 6. Each facility shall conduct fire drills at least monthly, and a written record of each drill conducted must be retained in the facility for not less than 12 months after the drill is conducted. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004) NAC 449.15367 Preparations for disasters; reporting of fire or disaster. ( NRS 449.0302 ) 1. Each facility shall develop a written plan for disasters that outlines procedures for members of the staff and clients to follow in case of fire or another emergency and provides for meeting the needs of clients if the facility must be evacuated or is destroyed. 2. A simple floor plan showing the routes for evacuating must be posted in prominent locations on each floor of the facility. 3. The facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster. 4. Each facility shall conduct a disaster drill at least annually and retain a written record of the drill in the facility for not less than 12 months after the drill is conducted. 5. Each facility shall adopt procedures to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water. (Added to NAC by Bd. of Health by R129-99, 11-29-99, eff. 1-1-2000; A by R069-04, 8-4-2004) FACILITIES FOR TREATMENT WITH NARCOTICS; MEDICATION UNITS General Provisions NAC 449.154 Definitions. ( NRS 449.0302 , 449.0303 ) As used in NAC 449.154 to 449.15485 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.15415 to 449.15438 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002) NAC 449.15415 “DEA” defined. ( NRS 449.0302 , 449.0303 ) “DEA” means the Drug Enforcement Administration of the United States Department of Justice. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98) NAC 449.1542 “Facility for treatment with narcotics” defined. ( NRS 449.0302 , 449.0303 ) “Facility for treatment with narcotics” means any person or any public or private facility that provides a narcotic treatment program described in 42 C.F.R. Part 8. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002) NAC 449.1543 “Medical director” defined. ( NRS 449.0302 , 449.0303 ) “Medical director” means a physician who is licensed to practice medicine in this State and who is responsible for the administration of all medical services at a facility for treatment with narcotics or a medication unit and for ensuring that the facility or the medication unit complies with all applicable federal, state and local laws and regulations. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98) NAC 449.15435 “Medication unit” defined. ( NRS 449.0302 , 449.0303 ) “Medication unit” means any person or any public or private facility that: 1. Is established as part of or operates in conjunction with a facility for treatment with narcotics but is separated geographically from the facility for treatment with narcotics; and 2. Is limited to: (a) Administering or dispensing narcotics; and (b) Collecting specimens in accordance with chapter 652 of NRS for drug testing or analysis relating to treatment with narcotics. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98) NAC 449.15438 “SAMHSA” defined. ( NRS 449.0302 , 449.0303 ) “SAMHSA” means the Substance Abuse and Mental Health Services Administration of the United States Department of Health and Human Services. (Added to NAC by Bd. of Health by R053-02, eff. 7-24-2002) NAC 449.1544 Division is state authority for certain federal regulations. ( NRS 449.0302 , 449.0303 ) The Division is the state authority for the purposes of 42 C.F.R. Part 8. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002) Licensing NAC 449.15445 License and federal certification required to operate facility or unit. ( NRS 449.0302 , 449.0303 ) 1. A person or a public or private facility shall not operate or provide the services of a facility for treatment with narcotics or represent that it operates or provides the services of a facility for treatment with narcotics, unless the person or the public or private facility is: (a) Licensed by the Division pursuant to NAC 449.154 to 449.15485 , inclusive, to operate the facility for treatment with narcotics; and (b) Certified by the SAMHSA pursuant to 42 C.F.R. Part 8 to operate the facility for treatment with narcotics. 2. A person or a public or private facility shall not operate or provide the services of a medication unit or represent that it operates or provides the services of a medication unit, unless the person or the public or private facility is: (a) Licensed by the Division pursuant to NAC 449.154 to 449.15485 , inclusive, to operate the medication unit and the facility for treatment with narcotics that is associated with the medication unit; and (b) Certified by the SAMHSA pursuant to 42 C.F.R. Part 8 to operate the medication unit and the facility for treatment with narcotics that is associated with the medication unit. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002) NAC 449.1545 Filing requirements; recommendation for certification. ( NRS 449.0302 , 449.0303 ) 1. If a person or a public or private facility wants to operate a facility for treatment with narcotics or a medication unit, the person or the public or private facility must: (a) File with the SAMHSA an application for certification pursuant to 42 C.F.R. Part 8; (b) File with the Bureau an application for a license pursuant to NAC 449.011 and include with the application: (1) If there is an accreditation body that has been approved pursuant to 42 C.F.R. § 8.3, proof that the applicant has applied for accreditation from such accreditation body; and (2) Any other information requested by the Bureau; and (c) Demonstrate that the proposed facility for treatment with narcotics or the proposed medication unit is able to comply with the requirements set forth in NAC 449.1548 . 2. A person or a public or private facility must file an application for a license for each facility for treatment with narcotics that it wants to operate, whether or not the person or the public or private facility is already licensed to operate one or more other facilities for treatment with narcotics. 3. A person or a public or private facility must file an application for a license for each medication unit that it wants to operate, whether or not the person or the public or private facility is already licensed to operate one or more other medication units. 4. The Division may make a recommendation to the SAMHSA that an applicant for certification of a facility for treatment with narcotics or a medication unit be certified, if the applicant has: (a) Satisfied all the requirements for licensure by the Division pursuant to NAC 449.154 to 449.15485 , inclusive; (b) Submitted all items required pursuant to NAC 449.011 ; and (c) Provided satisfactory evidence to the Division that the facility is in substantial compliance with the requirements of 42 C.F.R. Part 8. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002) NAC 449.15455 Investigation and prelicensure survey. ( NRS 449.0302 , 449.0303 ) 1. If an application for a license is filed pursuant to NAC 449.1545 , the Bureau shall conduct pursuant to NAC 449.0112 : (a) An investigation; and (b) A prelicensure survey. 2. The investigation and any prelicensure survey conducted by the Bureau must include, but are not limited to, an evaluation of whether the proposed facility for treatment with narcotics or the proposed medication unit is able to comply with the requirements set forth in NAC 449.1548 . (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002) NAC 449.1547 Suspension, revocation or cancellation of license; provisional license; denial of application. ( NRS 449.0302 , 449.0303 ) 1. The Division may suspend or revoke a license issued pursuant to NAC 449.154 to 449.15485 , inclusive, or cancel such a license and issue a provisional license based upon any grounds for such action set forth in NAC 449.002 to 449.99939 , inclusive, or chapter 449 of NRS. 2. The Division shall deny an application for a license pursuant to NAC 449.1545 if the SAMHSA denies an application for certification pursuant to 42 C.F.R. Part 8. 3. The Division shall suspend or revoke a license issued pursuant to NAC 449.154 to 449.15485 , inclusive, if the facility for treatment with narcotics or the medication unit operates without certification from the SAMHSA pursuant to 42 C.F.R. Part 8. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002) Operation NAC 449.1548 General operational requirements. ( NRS 449.0302 , 449.0303 ) In addition to all other requirements set forth in NAC 449.154 to 449.15485 , inclusive, each facility for treatment with narcotics and each medication unit shall: 1. Have a medical director who has a valid and current license to practice medicine in this State; 2. Employ, contract with or allow a person to act as an alcohol and drug counselor only if the person is certified by the Board of Examiners for Alcohol, Drug and Gambling Counselors to be such a counselor; 3. Obtain and maintain with the State Board of Pharmacy a valid and current registration relating to the use of narcotics; 4. Be in full compliance with all applicable provisions of 42 C.F.R. Part 8, all other applicable federal laws and regulations and all other requirements of the SAMHSA and the DEA; 5. Be in full compliance with all applicable provisions of chapters 449 and 453 of NRS and in substantial compliance with all applicable provisions of NAC 449.002 to 449.99939 , inclusive, and chapter 453 of NAC; 6. Maintain records and documentation of treatment pursuant to NRS 453.690 ; 7. Provide the Division and the State Board of Pharmacy with access to all records and documentation relating to the purchase, distribution and use of narcotics; 8. Comply with the rules of confidentiality and privilege set forth in NRS 453.720 ; 9. Develop and maintain a system to ensure that prospective and existing clients are not receiving narcotics from any other facility for treatment with narcotics or any other medication unit; and 10. Comply with all applicable local laws and regulations, including, but not limited to, zoning laws and regulations. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002; R098-06, 7-14-2006) NAC 449.15485 Continuing review of operations; investigation of complaints. ( NRS 449.0302 , 449.0303 ) 1. The operation of a facility for treatment with narcotics or a medication unit is subject to continuing review by the Division. 2. The Division shall investigate all complaints against a facility for treatment with narcotics or a medication unit directly or in conjunction with other federal, state or local governmental agencies, including, but not limited to, the SAMHSA, the DEA, the State Board of Pharmacy or the Division. (Added to NAC by Bd. of Health by R229-97, eff. 4-15-98; A by R053-02, 7-24-2002) HALFWAY HOUSES FOR PERSONS RECOVERING FROM ALCOHOL OR OTHER SUBSTANCE USE DISORDERS NAC 449.1549 Definitions. ( NRS 449.0302 ) As used in NAC 449.1549 to 449.154945 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.154901 , 449.154903 and 449.154905 have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154901 “Administrator” defined. ( NRS 449.0302 ) “Administrator” means a person: 1. Whose name appears on a license issued by the Bureau as administrator of record for a facility; and 2. Who is legally responsible for the management of the facility. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154903 “Client” defined. ( NRS 449.0302 ) “Client” means a person who is admitted to a facility. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154905 “Facility” defined. ( NRS 449.0302 ) “Facility” means a halfway house for persons recovering from alcohol or other substance use disorders as defined in NRS 449.008 . (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.15491 Administrator: Qualifications. ( NRS 449.0302 ) An administrator must: 1. Be at least 21 years of age; 2. Have the tests and obtain the certifications required by NAC 441A.375 for a person employed in a facility for the dependent; and 3. Maintain evidence that he or she satisfies the requirements of this section in a file that is maintained on the premises of the facility. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154911 Administrator: General duties. ( NRS 449.0302 ) An administrator shall: 1. Post the license issued by the Bureau in a conspicuous place within the facility. 2. Organize and manage the facility. 3. Establish policies, procedures and rules for the operation of the facility, including, without limitation, the policies and procedures required to be established by NAC 449.154915 . 4. Ensure that the records of the facility are maintained in accordance with the requirements of the policies, procedures and rules for the operation of the facility established pursuant to subsection 3. 5. Ensure that the facility complies with any applicable state statutes and regulations and local ordinances. 6. Ensure that the clients of the facility are afforded the opportunity to exercise their individual rights in a manner consistent with the rules of the facility. 7. Ensure that the facility is maintained in a safe and clean condition. 8. Review and approve changes in the policies and procedures established pursuant to subsection 3 at least annually. This review must be signed and dated. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154913 General operational guidelines. ( NRS 449.0302 ) An administrator shall ensure that: 1. Alcohol or drugs are not allowed on the premises of the facility; 2. The policies, procedures and rules established pursuant to NAC 449.154911 are carried out; 3. Each client complies with those policies, procedures and rules; 4. The facility provides an environment that will facilitate the reintegration of the clients of the facility into the community; and 5. The operation of the facility is not compromised by a client who violates the policies, procedures or rules of the facility. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154915 Policies and procedures: Establishment; maintenance of manual. ( NRS 449.0302 ) 1. An administrator shall establish written policies and procedures concerning: (a) The manner in which records of clients will be maintained and protected against unauthorized use; (b) The disclosure of confidential information about clients; (c) The criteria the facility will use to determine whether to: (1) Admit a client to the facility; and (2) Discharge a client from the facility; (d) The discharge of a client for a violation of the rules of the facility; (e) The discharge of a client for the use of alcohol or drugs; (f) The rights and responsibilities of a client; and (g) The evacuation of clients in case of fire or other emergency as required by NAC 449.154945 . 2. The administrator shall maintain a manual of policies, procedures and rules of the facility that includes the policies and procedures established pursuant to subsection 1. The manual must be available on the premises of the facility at all times. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154917 Limitation on admissions. ( NRS 449.0302 ) An administrator shall ensure that the facility does not admit more clients to the facility than the number of beds for which it is licensed. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154919 Health and sanitation. ( NRS 449.0302 ) 1. An administrator shall ensure that the facility: (a) Has a safe and sufficient supply of water, adequate drainage and an adequate system for the disposal of sewage; and (b) Complies with all local ordinances and state and federal laws and regulations relating to zoning, sanitation, safety and accessibility to persons with disabilities. 2. A container used to store garbage outside of a facility must be kept reasonably clean and must be covered in such a manner that rodents are unable to get inside the container. At least once each week, the container must be emptied and the contents of the container must be removed from the premises of the facility. 3. To the extent practicable, the premises of the facility must be kept free from: (a) Offensive odors; (b) Hazards, including obstacles that impede the free movement of clients within and outside the facility; (c) Insects and rodents; and (d) Accumulations of dirt, garbage and other refuse. 4. The administrator shall ensure that the premises of the facility are clean and that the interior, exterior and landscaping of the facility are well maintained. 5. All windows that are capable of being opened in the facility and all doors that are left open to provide ventilation for the facility must be screened to prevent the entry of insects. 6. The administrator shall ensure that electrical lighting is maintained in the facility as necessary to ensure the comfort and safety of the clients of the facility. 7. The temperature in the facility must be maintained at a level that is not less than 68 degrees Fahrenheit and not more than 82 degrees Fahrenheit. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154921 Laundry facilities. ( NRS 449.0302 ) 1. An administrator shall ensure that laundry facilities are provided in the facility commensurate with the number of clients in the facility. At least one washer and at least one dryer must be provided in the facility. 2. The laundry area in a facility must be maintained in a sanitary manner. All the equipment in the laundry area must be maintained in good working condition. All dryers must be ventilated to the outside of the building. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154923 Kitchens; storage of food. ( NRS 449.0302 ) 1. The kitchen in a facility and the equipment in the kitchen must be clean and must allow for the sanitary preparation of food. The equipment must be in good working condition. 2. Perishable food must be refrigerated at a temperature of 40 degrees Fahrenheit or less. Frozen food must be kept at a temperature of 0 degrees Fahrenheit or less. 3. Food must not be stored in any area in which cleaning or pest control products are stored. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154925 Bedrooms; bedding. ( NRS 449.0302 ) 1. A bedroom in a facility that is used by more than one client must have at least 45 square feet of floor space for each client who resides in the bedroom. A bedroom that is occupied by only one client must have at least 80 square feet of floor space. 2. The arrangement of the beds and other furniture in the bedroom must accommodate the clients occupying the bedroom in comfort and safety. 3. A bed with a comfortable and clean mattress must be provided for each client. The bed must be made with two clean sheets, a blanket, a pillow and a bedspread. Linens must be changed at least once each week and more often if the linens become dirty. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154927 Use of certain areas as bedroom prohibited. ( NRS 449.0302 ) A hall, stairway, unfinished attic, garage, storage area or shed or other similar area of a facility must not be used as a bedroom. Any other room must not be used as a bedroom if it is used for any other purpose. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154929 Bathrooms and toilet facilities; toilet articles. ( NRS 449.0302 ) 1. All bathrooms and toilet facilities in the facility must be sufficiently lighted. 2. Each client must have his or her own towels and washcloths. Paper towels may be used for hand towels. The towels and washcloths must be changed as often as is necessary to maintain cleanliness, but in no event less often than once each week. A soap dispenser that provides liquid or granular soap may be used instead of individual bars of soap. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154931 Accommodations for residents with restricted mobility. ( NRS 449.0302 ) A facility that has a client who uses a wheelchair or a walker must: 1. Have hallways, doorways and exits wide enough to accommodate a wheelchair or walker; and 2. Have ramps at all primary exits. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154933 First aid. ( NRS 449.0302 ) 1. A first-aid kit must be available at the facility. The first-aid kit must include, without limitation: (a) A germicide safe for use by humans; (b) Sterile gauze pads; (c) Adhesive bandages, rolls of gauze and adhesive tape; (d) Disposable gloves; (e) A shield or mask to be used by a person who is administering cardiopulmonary resuscitation; and (f) A thermometer or other device that may be used to determine the bodily temperature of a person. 2. Except for first aid in an emergency, no treatment or medication may be administered to a client. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154935 Medication. ( NRS 449.0302 ) 1. Except as otherwise provided in NAC 449.154933 , an administrator or another client shall not administer or assist in the administration of medication to a client. 2. Medication for self-administration may be kept at the facility. That medication must: (a) Be disposed of immediately when it expires or when a physician orders the medication to be discontinued; (b) Be stored and controlled in a manner that protects the medication from unauthorized use; and (c) Not be used by more than one of the clients. 3. The provisions of paragraph (a) of subsection 2 do not apply to over-the-counter medication. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154937 Telephones; listing of facility’s telephone number. ( NRS 449.0302 ) An administrator shall ensure that: 1. The facility has at least one telephone that is in good working condition in the facility; and 2. The telephone number of the facility is listed in the telephone directory. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154939 Notification to Bureau under certain circumstances. ( NRS 449.0302 ) An administrator shall notify the Bureau within 24 hours after the occurrence of an incident that: 1. Involved significant harm to a client of the facility if the client of the facility required medical treatment as a result of the incident; 2. May cause imminent danger to the health or safety of a client of the facility; or 3. May jeopardize the integrity of the operation of the facility. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154941 Rights of clients. ( NRS 449.0302 ) An administrator shall ensure that: 1. A client of the facility is not abused, neglected or exploited by another client of the facility or any person who is visiting the facility; 2. A client is not prohibited from speaking to any person who advocates for the rights of the clients of the facility; 3. Each client is treated with respect and dignity; 4. The facility provides a safe and comfortable environment; 5. A client is not prohibited from interacting socially in a manner that is consistent with the rules of the facility; 6. To the extent practicable and in a manner that is consistent with the rules of the facility, each client is allowed to make his or her own decisions; and 7. The telephone number of the local office of the Bureau and the name and telephone number of the administrator is conspicuously posted on the premises of the facility. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154943 Client files: Maintenance; contents; confidentiality. ( NRS 449.0302 ) 1. An administrator shall ensure that the facility maintains a separate file for each client of the facility and retains the file for at least 5 years after the client permanently leaves the facility. The file must be kept locked in a location that is protected against unauthorized use. Each file must contain the information obtained by the facility that is related to the client, including, without limitation: (a) The full name, address, date of birth and social security number of the client; (b) The address and telephone number of the client’s physician and any next of kin or guardian of the client; (c) A statement of the allergies of the client, if any, and any special diet or medication he or she requires; (d) Evidence of compliance with the provisions of NAC 441A.380 ; (e) A list of the rules of the facility that is signed by the client; and (f) The name and telephone number of the vendors and medical professionals that provide services for the client. 2. Except as otherwise provided in this subsection, the file of the client must be kept confidential. The file of a client must be made available upon request at any time to an employee of the Bureau who is acting in his or her capacity as an employee of the Bureau. (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) NAC 449.154945 Safety from fire. ( NRS 449.0302 ) 1. An administrator shall ensure that the facility complies with the regulations adopted by the State Fire Marshal pursuant to chapter 477 of NRS and any local ordinances relating to safety from fire. The facility must be approved for occupancy by the State Fire Marshal. 2. The administrator shall ensure that the facility has a plan for the evacuation of clients in case of fire or other emergency. The plan must be: (a) Understood by all clients; (b) Posted in a common area of the facility; and (c) Discussed with each client at the time of his or her admission. 3. At least one portable fire extinguisher must be available at the facility. Any portable fire extinguishers available at the facility must be inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections. 4. The administrator shall ensure that a written policy on smoking is developed and carried out by the facility. The policy must be: (a) Developed with the purpose of preventing a fire caused by smoking in the facility; and (b) Posted in a common area of the facility. 5. Smoke detectors installed in a facility must be maintained in proper operating condition at all times and must be tested monthly. The results of the tests conducted pursuant to this subsection must be recorded and maintained at the facility. 6. If a fire sprinkler system is installed in a facility, the system must be maintained in proper operating condition at all times and must be inspected in accordance with the provisions of NAC 477.460 . (Added to NAC by Bd. of Health by R123-01, 12-17-2001, eff. 1-1-2002) FACILITIES FOR TRANSITIONAL LIVING FOR RELEASED OFFENDERS General Provisions NAC 449.154951 Definitions. ( NRS 449.0302 ) As used in NAC 449.154951 to 449.154999 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.154953 to 449.154959 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154953 “Administrator” defined. ( NRS 449.0302 ) “Administrator” means a person: 1. Whose name appears on a license issued by the Bureau as administrator of record for a facility; and 2. Who is legally responsible for the management of the facility. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154955 “Facility” defined. ( NRS 449.0302 ) “Facility” means a facility for transitional living for released offenders as defined in NRS 449.0055 . (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154957 “Resident” defined. ( NRS 449.0302 ) “Resident” means a person who: 1. Is a person who has been released from prison as that term is defined in subsection 2 of NRS 449.0055 ; and 2. Is admitted to a facility. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154959 “Supportive services” defined. ( NRS 449.0302 ) 1. “Supportive services” mean services provided by a facility, directly or indirectly through arrangements with other providers, which are intended to assist a resident with reintegration into the community. 2. Those services may include, without limitation: (a) Referrals and the provision of information concerning: (1) Health care, including mental health care; (2) Access to housing, benefits or employment; (3) Resume writing; and (4) Required counseling for sex offenders. (b) Training concerning: (1) Life skills; (2) Resume writing; and (3) Any other topic pursuant to the policies of the facility. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) Administration NAC 449.154961 Administrator: Qualifications. ( NRS 449.0302 ) An administrator must: 1. Be at least 21 years of age; 2. Have the physical examination or certification required by paragraph (a) of subsection 3 of NAC 441A.375 for a person employed in a facility for the dependent; and 3. Maintain evidence that he or she satisfies the requirements of this section in a file that is maintained on the premises of the facility. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154963 Administrator: General duties. ( NRS 449.0302 ) An administrator shall: 1. Post the license issued by the Bureau in a conspicuous place within the facility. 2. Organize and manage the facility. 3. Establish policies, procedures and rules for the operation of the facility, including, without limitation, the policies and procedures required to be established by NAC 449.154967 . 4. Ensure that the records of the facility are maintained in accordance with the requirements of the policies, procedures and rules for the operation of the facility established pursuant to subsection 3. 5. Ensure that the facility complies with any applicable state statutes and regulations and local ordinances. 6. Ensure that the residents of the facility are afforded the opportunity to exercise their individual rights in a manner consistent with the rules of the facility. 7. Ensure that the facility is maintained in a safe and clean condition. 8. Review and approve changes in the policies and procedures established pursuant to subsection 3 at least annually. This review must be signed and dated. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154965 Operation of facility. ( NRS 449.0302 ) An administrator shall ensure that: 1. Alcohol or drugs are not allowed on the premises of the facility; 2. The policies, procedures and rules established pursuant to NAC 449.154963 are carried out; 3. Each resident complies with those policies, procedures and rules; 4. The facility provides an environment that will facilitate the reintegration of the residents of the facility into the community; and 5. The operation of the facility is not compromised by a resident who violates the policies, procedures or rules of the facility. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154967 Policies and procedures. ( NRS 449.0302 ) 1. An administrator shall establish written policies and procedures concerning: (a) The manner in which records of residents will be maintained and protected against unauthorized use; (b) The disclosure of confidential information about residents; (c) The criteria the facility will use to determine whether to: (1) Admit a resident to the facility; and (2) Discharge a resident from the facility; (d) The discharge of a resident for a violation of the rules of the facility; (e) The discharge of a resident for the use of alcohol or drugs; (f) The rights and responsibilities of a resident; and (g) The evacuation of residents in case of fire or other emergency as required by NAC 449.154999 . 2. The administrator shall maintain a manual of policies, procedures and rules of the facility that includes, without limitation, the policies and procedures established pursuant to subsection 1. The manual must be available on the premises of the facility at all times. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154969 Preparations for disasters and other emergencies. ( NRS 449.0302 ) 1. An administrator shall develop a written plan for disasters that outlines procedures for members of the staff of the facility and residents of the facility to follow in case of a disaster or other emergency. The plan must include, without limitation, provisions outlining procedures to be followed with regard to: (a) Workplace threats and violence, bomb threats, and the possession of firearms or explosives by a resident; (b) Medical emergencies; (c) Natural disasters typical of the particular geographic area in which the facility is located; and (d) Other disasters, including, without limitation, a power failure, an interruption in the normal supply of water to the facility and threats by terrorists. 2. The plan must include, without limitation, provisions concerning the provision of temporary shelter and other services for residents of the facility who are required to evacuate the facility because of a disaster. 3. The provisions of the plan must be communicated to each member of the staff of the facility and each resident of the facility. 4. Each facility shall conduct a drill for evacuation of the facility at least once each quarter and shall ensure that each shift of the staff of the facility participates in such a drill at least annually. 5. Each facility shall retain a written record of each drill conducted pursuant to subsection 4 on file at the facility for not less than 12 months after the drill is conducted. The administrator shall make such records available for inspection by the Division upon request. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) Operation NAC 449.154971 Limitation on number of admissions. ( NRS 449.0302 ) An administrator shall ensure that the facility does not admit more residents to the facility than the number of beds for which it is licensed. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154973 Prerequisites to provision of particular services. ( NRS 449.0302 ) 1. In addition to satisfying the requirements of NAC 449.011 , an applicant for a license to operate a facility must include with his or her application a statement indicating whether he or she will be operating a facility: (a) That only provides a housing and living environment; (b) That provides or arranges for the provision of supportive services for residents of the facility to assist the residents with reintegration into the community, in addition to providing a housing and living environment; or (c) That provides or arranges for the provision of alcohol and other substance use disorder programs, in addition to providing a housing and living environment and providing or arranging for the provision of other supportive services. 2. If the applicant wishes to operate a facility described in paragraph (c) of subsection 1, the applicant must: (a) Obtain certification of its program pursuant to paragraph (d) of subsection 1 of NRS 458.025 and include evidence of that certification with his or her application; and (b) Satisfy the requirements set forth in NAC 449.019 to 449.150 , inclusive, for a facility for the treatment of alcohol or other substance use disorders. 3. If the applicant wishes to operate a facility described in paragraph (b) or (c) of subsection 1 which has residents who are under the supervision of a parole officer, the applicant must: (a) Obtain the approval of the Division of Parole and Probation of the Department of Public Safety; and (b) Include evidence of that approval with his or her application. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006; A by R016-20, 11-2-2020) NAC 449.154975 Sanitation, safety and comfort. ( NRS 449.0302 ) 1. An administrator shall ensure that the facility: (a) Has a safe and sufficient supply of water, adequate drainage and an adequate system for the disposal of sewage; and (b) Complies with all local ordinances and state and federal laws and regulations relating to zoning, sanitation, safety and accessibility to persons with disabilities. 2. A container used to store garbage outside of a facility must be kept reasonably clean and must be covered in such a manner that rodents are unable to get inside the container. At least once each week, the container must be emptied and the contents of the container must be removed from the premises of the facility. 3. To the extent practicable, the premises of the facility must be kept free from: (a) Offensive odors; (b) Hazards, including obstacles that impede the free movement of residents within and outside the facility; (c) Insects and rodents; and (d) Accumulations of dirt, garbage and other refuse. 4. The administrator shall ensure that the premises of the facility are clean and that the interior, exterior and landscaping of the facility are well maintained. 5. All windows that are capable of being opened in the facility and all doors that are left open to provide ventilation for the facility must be screened to prevent the entry of insects. 6. The administrator shall ensure that electrical lighting is maintained in the facility as necessary to ensure the comfort and safety of the residents of the facility. 7. The temperature in the facility must be maintained at a level that is not less than 68 degrees Fahrenheit and not more than 82 degrees Fahrenheit. 8. The administrator shall ensure that any pest control work performed at the facility is performed by a person licensed to engage in pest control pursuant to chapter 555 of NRS. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154977 Laundry facilities. ( NRS 449.0302 ) 1. An administrator shall ensure that laundry facilities are provided in the facility commensurate with the number of residents in the facility. At least one washer and at least one dryer must be provided in the facility. 2. The laundry area in a facility must be maintained in a sanitary manner. All the equipment in the laundry area must be maintained in good working condition. All dryers must be ventilated to the outside of the building. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154979 Kitchens; preparation and storage of food. ( NRS 449.0302 ) 1. The kitchen in a facility and the equipment in the kitchen must be clean and must allow for the sanitary preparation of food. The equipment must be in good working condition. 2. Perishable food must be refrigerated at a temperature of 40 degrees Fahrenheit or less. Frozen food must be kept at a temperature of 0 degrees Fahrenheit or less. 3. Food must not be stored in any area in which cleaning or pest control products are stored. 4. A facility with more than 10 residents must: (a) Comply with applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto; and (b) Obtain the necessary permits from the Division. 5. The equipment used for cooking and storing food in a facility with more than 10 residents must be inspected and approved by the Division and the state and local fire safety authorities. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006; A by R155-10, 12-16-2010) NAC 449.154981 Bedrooms and bedding. ( NRS 449.0302 ) 1. A bedroom in a facility that is used by more than one resident must have at least 50 square feet of floor space for each resident who resides in the bedroom. A bedroom that is occupied by only one resident must have at least 80 square feet of floor space. 2. The arrangement of the beds and other furniture in the bedroom must accommodate the residents occupying the bedroom in comfort and safety. 3. A bed with a comfortable and clean mattress must be provided for each resident. The bed must be made with a mattress cover, two clean sheets, a blanket, a pillow and a bedspread. Linens must be changed at least once each week and more often if the linens become dirty. 4. Each mattress used in a facility must comply with the provisions of NRS 444.010 to 444.040 , inclusive, and the regulations adopted pursuant thereto. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154983 Use of certain areas as bedroom prohibited. ( NRS 449.0302 ) A hall, stairway, unfinished attic, garage, storage area or shed or other similar area of a facility must not be used as a bedroom. Any other room must not be used as a bedroom if it is used for any other purpose. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154985 Bathrooms and toilet facilities; toiletries. ( NRS 449.0302 ) 1. All bathrooms and toilet facilities in the facility must be sufficiently lighted. 2. Each facility must have: (a) A flush toilet and lavatory for each four residents; and (b) A tub or shower for each six residents. 3. Each resident must have his or her own towels and washcloths. Paper towels may be used for hand towels. The towels and washcloths must be changed as often as is necessary to maintain cleanliness, but in no event less often than once each week. A soap dispenser that provides liquid or granular soap may be used instead of individual bars of soap. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154987 First aid. ( NRS 449.0302 ) 1. A first-aid kit must be available at the facility. The first-aid kit must include, without limitation: (a) A germicide safe for use by humans; (b) Sterile gauze pads; (c) Adhesive bandages, rolls of gauze and adhesive tape; (d) Disposable gloves; (e) A shield or mask to be used by a person who is administering cardiopulmonary resuscitation; and (f) A thermometer or other device that may be used to determine the bodily temperature of a person. 2. Except for first aid in an emergency, no treatment or medication may be administered to a resident. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154989 Medication. ( NRS 449.0302 ) 1. Medication for self-administration may be kept at the facility. That medication must: (a) Except as otherwise provided in subsection 3, be disposed of immediately when it expires or when a physician orders the medication to be discontinued; (b) Be stored and controlled in a manner that protects the medication from unauthorized use; and (c) Not be used by more than one of the residents. 2. Medication kept at the facility must be controlled and distributed in a manner that is consistent with applicable state and federal law. 3. The provisions of paragraph (a) of subsection 1 do not apply to over-the-counter medication. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154991 Telephones; listing of facility’s telephone number. ( NRS 449.0302 ) An administrator shall ensure that: 1. The facility has at least one telephone that is in good working condition in the facility; and 2. The telephone number of the facility is listed in the telephone directory. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154993 Notification of occurrence of certain incidents. ( NRS 449.0302 ) 1. An administrator shall notify the Bureau within 24 hours after the occurrence of an incident that: (a) Involved significant harm to a resident of the facility if the resident of the facility required medical treatment as a result of the incident; (b) May cause imminent danger to the health or safety of a resident of the facility; or (c) May jeopardize the integrity of the operation of the facility. 2. The administrator shall report to the Division of Public and Behavioral Health any fire or other disaster that takes place in the facility within 24 hours after the fire or other disaster occurs. 3. The administrator shall notify the Division of Parole and Probation of the Department of Public Safety of the occurrence of any of the incidents described in this section. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154995 Rights of residents. ( NRS 449.0302 ) An administrator shall ensure that: 1. A resident of the facility is not abused, neglected or exploited by another resident of the facility or any person who is visiting the facility; 2. A resident is not prohibited from speaking to any person who advocates for the rights of the residents of the facility; 3. Each resident is treated with respect and dignity; 4. The facility provides a safe and comfortable environment; 5. A resident is not prohibited from interacting socially in a manner that is consistent with the rules of the facility; 6. To the extent practicable and in a manner that is consistent with the rules of the facility, each resident is allowed to make his or her own decisions; 7. The telephone number of the local office of the Bureau and the name and telephone number of the administrator is conspicuously posted on the premises of the facility; and 8. Each resident of the facility is allowed to exercise his or her right to vote. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154997 Files for residents. ( NRS 449.0302 ) 1. An administrator shall ensure that the facility maintains a separate file for each resident of the facility and retains the file for at least 5 years after the resident permanently leaves the facility. The file must be kept locked in a location that is protected against unauthorized use. Each file must contain the information obtained by the facility that is related to the resident, including, without limitation: (a) The full name, address and date of birth of the resident; (b) The address and telephone number of any next of kin or guardian of the resident; (c) Evidence of compliance with the provisions of NAC 441A.380 ; (d) A list of the rules of the facility that is signed by the resident; and (e) The name and telephone number of the parole officer of the resident, if any. 2. Except as otherwise provided in this subsection, the file of the resident must be kept confidential. The file of a resident must be made available upon request at any time to an employee of the Bureau who is acting in his or her capacity as an employee of the Bureau. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) NAC 449.154999 Safety from fire. ( NRS 449.0302 ) 1. An administrator shall ensure that the facility complies with the regulations adopted by the State Fire Marshal pursuant to chapter 477 of NRS and any local ordinances relating to safety from fire. 2. A facility with more than 16 beds must be equipped with a sufficient number of sprinklers to cover the entire area of the facility. 3. The administrator shall ensure that the facility has a plan for the evacuation of residents in case of fire or other emergency. The plan must be: (a) Understood by all residents; (b) Posted in a common area of the facility; and (c) Discussed with each resident at the time of his or her admission. 4. At least one portable fire extinguisher must be available at the facility. Any portable fire extinguishers available at the facility must be inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections. 5. The administrator shall ensure that a written policy on smoking is developed and carried out by the facility. The policy must be: (a) Developed with the purpose of preventing a fire caused by smoking in the facility; and (b) Posted in a common area of the facility. 6. Smoke detectors installed in a facility must be maintained in proper operating condition at all times and must be tested monthly. The results of the tests conducted pursuant to this subsection must be recorded and maintained at the facility. 7. If an automatic fire sprinkler system is installed in a facility, the system must be inspected: (a) Not less than once each calendar quarter by a person who understands the manner in which the system operates and the manner in which the system must be maintained; and (b) Not less than once each calendar year by a person who is licensed to inspect such a system pursuant to the provisions of chapter 477 of NAC. (Added to NAC by Bd. of Health by R094-06, eff. 7-14-2006) HOMES FOR INDIVIDUAL RESIDENTIAL CARE NAC 449.15511 Definitions. ( NRS 449.0302 ) As used in NAC 449.15511 to 449.15529 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.15513 to 449.15519 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.15513 “Caregiver” defined. ( NRS 449.0302 ) “Caregiver” means a person who provides care, assistance and protective supervision to a resident of a home. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.15515 “Director” defined. ( NRS 449.0302 ) “Director” means a person: 1. Whose name appears on a license issued by the Bureau as the director of record for a home; and 2. Who is legally responsible for the care of the residents and the daily operation of the home. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.15517 “Home” defined. ( NRS 449.0302 ) “Home” means a home for individual residential care. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.15519 “Protective supervision” defined. ( NRS 449.0302 ) “Protective supervision” means supervision that protects the residents of a home from potential danger to their physical and mental well-being. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.15521 Director: Qualifications. ( NRS 449.0302 ) The director of a home must: 1. Be at least 21 years of age and have a high school diploma or its equivalent. A person who proposes to act as the director of a home must provide the Bureau with evidence that he or she satisfies the requirements of this subsection. 2. Possess the appropriate knowledge, skills and abilities to meet the needs of the residents of the home. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.15523 Director: Duties. ( NRS 449.0302 ) The director of a home shall: 1. Post the license to operate the home in a conspicuous place within the home. 2. Ensure that the needs of each resident of the home are assessed upon admission of the resident to the home, and that the assessment is updated as the needs of the resident change. Such an assessment must include: (a) Documentation of the abilities of the resident to function independently; and (b) A complete list of the matters for which the resident requires assistance. 3. Ensure that the residents of the home: (a) Are treated with dignity and respect and are not abused, neglected or exploited; and (b) Receive: (1) The personal care they require; (2) A balanced daily diet that meets their nutritional needs; (3) Protective supervision and adequate services to maintain and enhance their physical, mental and emotional well-being; and (4) The names of, and the telephone numbers for the registration of complaints with, the Bureau and the Aging and Disability Services Division of the Department of Health and Human Services. 4. Ensure that a caregiver, who is capable of meeting the needs of the residents and has been trained in first aid and cardiopulmonary resuscitation, is on the premises of the home at all times when a resident is present. 5. Ensure that appropriate sanitary procedures are carried out for the handling, cleaning and storage of linens and personal laundry in the home. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.15525 Requirements for safety and sanitation of facility. ( NRS 449.0302 ) 1. The interior and exterior of a home must be clean and free of hazards and offensive odors. 2. A home must contain: (a) Appropriate and well-maintained furnishings; (b) At least one functional, portable fire extinguisher; (c) A first-aid kit; (d) Equipment that is sufficiently clean and adequate for the preparation, service and storage of food; and (e) Adequate areas and equipment to carry out appropriate sanitary procedures for the handling, cleaning and storage of linens and personal laundry. 3. The temperature of a home must be maintained at levels that are comfortable and safe. Portable heaters are prohibited in a home. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.15527 Agreement between operator of home and resident concerning rates; maintenance of records of residents. ( NRS 449.0302 ) The operator of a home shall: 1. Enter into a written agreement with each resident of the home that sets forth the basic rate for the services of the home and the charges for any optional services. 2. Maintain a separate, organized file for each resident of the home and retain the file for 5 years after the resident permanently leaves the home. Each file must include: (a) The full name, address, date of birth and social security number of the resident; (b) The address and telephone number of the resident’s physician and a person who is responsible for the resident; (c) A copy of the results of a general physical examination of the resident conducted by his or her physician; and (d) A current copy of the assessment of the needs of the resident conducted pursuant to NAC 449.15523 . (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.15529 On-site survey of home by Bureau. ( NRS 449.0302 ) The Bureau shall conduct: 1. An initial on-site survey of a home: (a) After the Bureau receives a completed application for a license to operate the home and the fee required pursuant to NAC 449.016 ; and (b) Before the issuance of a license to operate the home. 2. Additional on-site surveys of a home not less than once every 3 years after conducting the survey of the home pursuant to subsection 1. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) RESIDENTIAL FACILITIES FOR GROUPS General Provisions NAC 449.156 Definitions. ( NRS 439.200 , 449.0302 , 449.0304 ) As used in NAC 449.156 to 449.27706 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.1565 to 449.178 , inclusive, have the meanings ascribed to them in those sections. (Supplied in codification; A by Bd. of Health, 3-6-86; R003-97, 10-30-97; R204-99, 2-10-2000; R071-04, 8-4-2004; R122-05, 11-17-2005; R097-06, 7-14-2006; R109-18, 1-30-2019) NAC 449.1565 “Administer” defined. ( NRS 449.0302 ) “Administer” means the direct application of a drug or medicine referred to in NRS 454.181 to 454.371 , inclusive, by injection, inhalation, ingestion or any other means, to the body of a resident of a residential facility. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.157 “Administrator” defined. ( NRS 449.0302 ) “Administrator” means a person: 1. Who is licensed by the Board of Examiners for Long-Term Care Administrators pursuant to chapter 654 of NRS; 2. Whose name appears on a license issued by the Bureau as administrator of record for a residential facility; and 3. Who is legally responsible for the care of residents and the daily operation of the facility. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.1575 “Board” defined. ( NRS 449.0302 ) “Board” means the State Board of Health. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.1585 “Caregiver” defined. ( NRS 449.0302 ) “Caregiver” means an employee of a residential facility who provides care, assistance or protective supervision to a resident of the facility. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.1591 “Category 1 resident” defined. ( NRS 449.0302 ) “Category 1 resident” means: 1. In a residential facility with not more than 10 residents, a resident who, without the assistance of any other person, is physically and mentally capable of moving himself or herself from the room in which the resident sleeps to outside the facility in 4 minutes or less; or 2. In a residential facility with more than 10 residents, a resident who, without the assistance of any other person, is physically and mentally capable of moving himself or herself from the room in which the resident sleeps to the other side of a smoke or fire barrier or outside the facility, whichever is nearest, in 4 minutes or less. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.1595 “Category 2 resident” defined. ( NRS 449.0302 ) “Category 2 resident” means: 1. In a residential facility with not more than 10 residents, a resident who, without the assistance of any other person, is not physically or mentally capable of moving himself or herself from the room in which the resident sleeps to outside the facility in 4 minutes or less. 2. In a residential facility with more than 10 residents, a resident who, without the assistance of any other person, is not physically or mentally capable of moving himself or herself from the room in which the resident sleeps to the other side of a smoke or fire barrier or outside the facility, whichever is nearest, in 4 minutes or less. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.1597 “Dietary supplement” defined. ( NRS 449.0302 ) “Dietary supplement” has the meaning ascribed to it in 21 U.S.C. 321(ff) as that section existed on August 17, 1999. (Added to NAC by Bd. of Health by R204-99, eff. 2-10-2000) NAC 449.1599 “Discharge” defined. ( NRS 449.0302 ) “Discharge” means the release of a resident from a residential facility which does not involve a transfer. (Added to NAC by Bd. of Health by R071-04, eff. 8-4-2004) NAC 449.160 “Division” defined. ( NRS 449.0302 ) “Division” means the Division of Public and Behavioral Health of the Department of Health and Human Services. (Added to NAC by Bd. of Health, eff. 3-6-86) NAC 449.161 “Grade” defined. ( NRS 449.0302 ) “Grade” means a letter that is assigned to a residential facility by the Bureau based on the severity and scope scores of the facility as determined by the Bureau. (Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005) NAC 449.164 “Hospice care” defined. ( NRS 449.0302 ) “Hospice care” has the meaning ascribed to it in NRS 449.0115 . (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.169 “Medical professional” defined. ( NRS 449.0302 ) “Medical professional” means a physician or a physician assistant, nurse practitioner, registered nurse, physical therapist, occupational therapist, speech-language pathologist or practitioner of respiratory care who is trained and licensed to perform medical procedures and care prescribed by a physician. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.170 “Placard” defined. ( NRS 449.0302 ) “Placard” means a certificate issued to a residential facility by the Bureau that includes the grade assigned to the facility by the Bureau. (Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005) NAC 449.172 “Residential facility” defined. ( NRS 449.0302 ) “Residential facility” means a residential facility for groups as defined in NRS 449.017 . (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.173 “Residential facility which provides care to persons with Alzheimer’s disease” defined. ( NRS 449.0302 ) “Residential facility which provides care to persons with Alzheimer’s disease” means a residential facility that provides care and protective supervision for persons with Alzheimer’s disease or a related disease, including, without limitation, senile dementia, organic brain syndrome or other cognitive impairment. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.175 “Severity and scope score” defined. ( NRS 449.0302 ) “Severity and scope score” has the meaning ascribed to it in NAC 449.99839 . (Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005) NAC 449.176 “Staff of a facility” defined. ( NRS 449.0302 ) “Staff of a facility” means the administrator, caregivers and other employees of a residential facility. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.178 “Transfer” defined. ( NRS 449.0302 ) “Transfer” means the movement of a resident from a residential facility to another facility for inpatient or residential care. (Added to NAC by Bd. of Health by R071-04, eff. 8-4-2004) Licensing NAC 449.179 Submission and approval of plan for new construction or remodeling; inspection; evidence of compliance. ( NRS 449.0302 ) 1. Except for a residential facility with less than 11 beds, before a residential facility is constructed or an existing facility is remodeled, the facility must: (a) Submit the plan for construction or remodeling to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 ; (b) Notify the Bureau of a tentative date for the completion of the construction or remodeling; and (c) Obtain approval of the plan from the Division. 2. The plan for construction or remodeling must include a description of the materials that will be used to complete the project. 3. Before issuing a license to operate a residential facility, the Bureau shall inspect the facility to ensure that it complies with: (a) The provisions of NAC 449.156 to 449.27706 , inclusive; and (b) The applicable zoning ordinances and regulations. 4. An applicant for a license to operate a residential facility must submit to the Bureau with his or her application evidence that the applicant and the facility are in compliance with the provisions of NRS 449.001 to 449.240 , inclusive, and NAC 449.156 to 449.27706 , inclusive. 5. The Bureau shall not perform the inspection required pursuant to subsection 3 until the applicant has submitted to the Bureau the application required pursuant to NRS 449.040 , the fee required pursuant to NAC 449.016 and the evidence required pursuant to subsection 4. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R076-01, 10-18-2001; R071-04, 8-4-2004; R118-05, 11-17-2005) NAC 449.180 Requirements for purchasing licensed facility. ( NRS 449.0302 ) If an applicant for a license to operate a residential facility desires to purchase a currently licensed facility, the facility must comply with all current state and local requirements relating to health and safety. [Bd. of Health, Group Care Facilities Appendix §§ 1, 1.1 & 2-2.7, eff. 10-13-77]—(NAC A 3-6-86; R003-97, 10-30-97) NAC 449.190 License: Contents; validity; transferability; issuance of more than one type. ( NRS 449.0302 ) 1. A license to operate a residential facility must include: (a) The name of the administrator of the facility; (b) The name and address of the facility; (c) The type of facility; (d) The maximum number of residents authorized to reside at the facility; and (e) The category of residents who may reside at the facility. 2. The license becomes invalid if the facility is moved to a location other than the location stated on the license. The license may not be transferred to another owner. 3. A residential facility may be licensed as more than one type of residential facility if the facility provides evidence satisfactory to the Bureau that it complies with the requirements for each type of facility and can demonstrate that the residents will be protected and receive necessary care and services. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.191 Denial, suspension or revocation of endorsement: Grounds. ( NRS 449.0302 , 449.165 ) In addition to the grounds set forth in NRS 449.160 and NAC 449.1915 , the Division may deny an application for an endorsement made pursuant to NAC 449.2751 to 449.2768 , inclusive, on a license to operate a residential facility or may suspend or revoke an existing endorsement based upon any of the following grounds: 1. The failure or refusal of an applicant or licensee to comply with any of the provisions of chapter 449 of NRS or the regulations adopted by the Board. 2. The failure or refusal of an applicant or licensee to comply with a reasonable order from the Division to remove a resident from a facility. 3. Providing services at the facility without an endorsement, if an endorsement is required before providing those types of services. 4. Accepting for care, at any given time, more residents than the number specified in the license. 5. The failure or refusal of a licensee to return an adequate plan of correction to the Division within 10 days after the receipt by the licensee of a statement of deficiencies. 6. The failure or refusal to cooperate fully with an investigation or inspection by the Bureau. 7. Misappropriation of the property of a resident of a facility. 8. Abuse, neglect or exploitation of a person who is infirm, a person with an intellectual disability, a person with a disability or a person who is 60 years of age or older. 9. The residential facility has demonstrated an inability to care for residents adequately, as demonstrated by a history of deficiencies affecting the health or safety of residents or employees. 10. The license has been revoked or suspended due to a failure to comply with the provisions of NAC 449.002 to 449.99939 , inclusive, or chapter 449 of NRS and was subsequently reinstated within the immediately preceding year. (Added to NAC by Bd. of Health by R119-10, eff. 1-13-2011) NAC 449.1915 Suspension or revocation of license and endorsement if residential facility has been assigned grade of D on two or more consecutive surveys or resurveys, or both. ( NRS 449.0302 , 449.165 ) In addition to the grounds set forth in NRS 449.160 and NAC 449.0118 , 449.191 , 449.2751 and 449.27706 , the Division may suspend or revoke a license to operate a residential facility, including any endorsement on the license, if the residential facility has been assigned, pursuant to NAC 449.27702 , a grade of D on two or more consecutive surveys or resurveys, or both. (Added to NAC by Bd. of Health by R119-10, eff. 1-13-2011) Administration and Personnel NAC 449.194 Responsibilities of administrator. ( NRS 449.0302 ) The administrator of a residential facility shall: 1. Provide oversight and direction for the members of the staff of the facility as necessary to ensure that residents receive needed services and protective supervision and that the facility is in compliance with the requirements of NAC 449.156 to 449.27706 , inclusive, and chapter 449 of NRS. 2. Designate one or more employees to be in charge of the facility during those times when the administrator is absent. Except as otherwise provided in this subsection, employees designated to be in charge of the facility when the administrator is absent must have access to all areas of and records kept at the facility. Confidential information may be removed from the files to which the employees in charge of the facility have access if the confidential information is maintained by the administrator. The administrator or an employee who is designated to be in charge of the facility pursuant to this subsection shall be present at the facility at all times. The name of the employee in charge of the facility pursuant to this subsection must be posted in a public place within the facility during all times that the employee is in charge. 3. Maintain in the facility, and make available upon request, a copy of the provisions of NAC 449.156 to 449.27706 , inclusive, and the report of the latest investigation of the facility conducted by the Bureau pursuant to NRS 449.0307 . 4. Ensure that the records of the facility are complete and accurate. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.196 Qualifications and training of caregivers. ( NRS 449.0302 ) 1. A caregiver of a residential facility must: (a) Be at least 18 years of age; (b) Be responsible and mature and have the personal qualities which will enable him or her to understand the problems of elderly persons and persons with disabilities; (c) Understand the provisions of NAC 449.156 to 449.27706 , inclusive, and sign a statement that he or she has read those provisions; (d) Demonstrate the ability to read, write, speak and understand the English language; (e) Possess the appropriate knowledge, skills and abilities to meet the needs of the residents of the facility; and (f) Receive annually not less than 8 hours of training related to providing for the needs of the residents of a residential facility. 2. If a resident of a residential facility uses prosthetic devices or dental, vision or hearing aids, the caregivers employed by the facility must be knowledgeable of the use of those devices. 3. If a caregiver assists a resident of a residential facility in the administration of any medication, including, without limitation, an over-the-counter medication or dietary supplement, the caregiver must: (a) Before assisting a resident in the administration of a medication, receive the training required pursuant to paragraph (e) of subsection 6 of NRS 449.0302 , which must include at least 16 hours of training in the management of medication consisting of not less than 12 hours of classroom training and not less than 4 hours of practical training, and obtain a certificate acknowledging the completion of such training; (b) Receive annually at least 8 hours of training in the management of medication and provide the residential facility with satisfactory evidence of the content of the training and his or her attendance at the training; (c) Complete the training program developed by the administrator of the residential facility pursuant to paragraph (e) of subsection 1 of NAC 449.2742 ; and (d) Annually pass an examination relating to the management of medication approved by the Bureau. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004; R118-05, 11-17-2005; R119-10, 1-13-2011) NAC 449.197 Medical services may be provided only by medical professional. ( NRS 439.200 , 449.0302 , 449.0304 ) Except as otherwise provided in NAC 449.1985 , a member of the staff of a residential facility shall not provide medical services to a resident of the facility unless the member of the staff is a medical professional. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R109-18, 1-30-2019) NAC 449.1985 Performance of certain tasks by caregiver. ( NRS 439.200 , 449.0302 , 449.0304 ) 1. A caregiver of a residential facility may perform a task described in NRS 449.0304 if the caregiver: (a) Before performing the task, annually thereafter and when any device used for performing the task is changed: (1) Has received training concerning the task that meets the requirements of subsections 5 and 6; and (2) Has demonstrated an understanding of the manner in which the task must be performed; (b) Follows the manufacturer’s instructions when operating any device used for performing the task; (c) Performs the task in conformance with the Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, 42 U.S.C. § 263a, if applicable, and any other applicable federal law or regulation; and (d) If the resident has diabetes, complies with the requirements of subsection 3 and NAC 449.2726 . 2. If a person with diabetes who is a resident does not have the physical or mental capacity to perform a blood glucose test on himself or herself and a caregiver of the residential facility performs a blood glucose test on the resident, the Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, 42 U.S.C. § 263a, shall be deemed to be applicable for the purposes of paragraph (c) of subsection 1. 3. If a caregiver conducts a blood glucose test, the caregiver must ensure that the device for monitoring blood glucose is not used on more than one person. 4. A caregiver may weigh a resident of a residential facility only if: (a) The caregiver has received training on the manner in which to weigh a person that meets the requirements of subsections 5 and 6; and (b) The resident has consented to being weighed by the caregiver. 5. The training described in this section must be provided by: (a) A physician, physician assistant or licensed nurse; (b) For the training described in paragraph (b) or (c) of subsection 1 of NRS 449.0304 , a registered pharmacist; or (c) An employee of the residential facility who has: (1) Received training pursuant to paragraph (a) of subsection 1 or paragraph (a) of subsection 4, as applicable, from a physician, a physician assistant, a licensed nurse or, if applicable, a registered pharmacist; (2) At least 1 year of experience performing the task for which he or she is providing training; and (3) Demonstrated competency in performing the task for which he or she is providing training. 6. Any training described in this section must include, without limitation: (a) Instruction concerning how to accurately perform the task for which the caregiver is being trained in conformance with nationally recognized infection control guidelines which may include, without limitation, guidelines published by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services; (b) Instruction concerning how to accurately interpret the information obtained from performing the task; and (c) A description of any action, including, without limitation, notifying a physician, that must be taken based on such information. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.199 Staffing requirements; limitation on number of residents; written schedule for each shift; direct supervision of certain employees. ( NRS 449.0302 ) 1. The administrator of a residential facility shall ensure that a sufficient number of caregivers are present at the facility to conduct activities and provide care and protective supervision for the residents. There must be at least one caregiver on the premises of the facility if one or more residents are present at the facility. 2. Except as otherwise provided in NAC 449.2756 , the administrator of a residential facility which has more than 20 residents shall ensure that at least one employee is awake and on duty at the facility at all times. An additional employee must be available to provide care within 10 minutes after being informed that his or her services are needed. 3. A residential facility must not accept residents in excess of the number of residents specified on the license issued to the owner of the facility. 4. The administrator of a residential facility shall maintain monthly a written schedule that includes the number and type of members of the staff of the facility assigned for each shift. The schedule must be amended if any changes are made to the schedule. The schedule must be retained for at least 6 months after the schedule expires. 5. An employee of a residential facility who is less than 18 years of age must be under the direct supervision of an employee who is 18 years of age or older. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.200 Personnel files. ( NRS 449.0302 ) 1. Except as otherwise provided in subsection 2, a separate personnel file must be kept for each member of the staff of a facility and must include: (a) The name, address, telephone number and social security number of the employee; (b) The date on which the employee began his or her employment at the residential facility; (c) Records relating to the training received by the employee; (d) The health certificates required pursuant to chapter 441A of NAC for the employee; (e) Evidence that the references supplied by the employee were checked by the residential facility; and (f) Evidence of compliance with NRS 449.122 to 449.125 , inclusive. 2. The personnel file for a caregiver of a residential facility must include, in addition to the information required pursuant to subsection 1: (a) A certificate stating that the caregiver is currently certified to perform first aid and cardiopulmonary resuscitation; and (b) Proof that the caregiver is 18 years of age or older. 3. The administrator may keep the personnel files for the facility in a locked cabinet and may, except as otherwise provided in this subsection, restrict access to this cabinet by other employees of the facility. Copies of the documents which are evidence that an employee has been certified to perform first aid and cardiopulmonary resuscitation and that the employee has been tested for tuberculosis must be available for review at all times. The administrator shall make the personnel files available for inspection by the Bureau within 72 hours after the Bureau requests to review the files. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R204-99, 2-10-2000; R073-03, 1-22-2004) NAC 449.202 Rights of staff members during investigation of facility; duties of investigator. ( NRS 449.0302 ) 1. Upon the request of the administrator of a residential facility or any other member of the staff of the facility, a person who is conducting an investigation of the facility pursuant to NRS 449.0307 shall: (a) Identify himself or herself and provide the name and telephone number of his or her supervisor; and (b) Inform the administrator or other member of the staff of the facility of the reason for the investigation. 2. The person who is conducting the investigation shall: (a) Treat the members of the staff of the facility in a professional and respectful manner; (b) Conduct an unbiased investigation; and (c) Provide to the administrator of the facility an accurate report of the findings of the investigation, including a description of each deficiency found and a citation to the section of NAC 449.002 to 449.99939 , inclusive, or chapter 449 of NRS which has been violated. 3. After the investigation has been completed, the person conducting the investigation shall, upon the request of a member of the staff of the facility: (a) Provide the member of the staff of the facility with the opportunity to: (1) Ask questions concerning the findings of the investigation; and (2) Review with the person who conducted the investigation the provisions of NAC 449.002 to 449.99939 , inclusive, and chapter 449 of NRS that the investigator believes were violated; and (b) Provide to the member of the staff of the facility the details of any complaints received by the Division concerning the facility, other than details that may reveal the identity of the person who submitted the complaint. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) General Operational Requirements NAC 449.204 System of financial accounting; insurance. ( NRS 449.0302 ) 1. A residential facility shall: (a) Maintain a recognized system of financial accounting; and (b) Maintain a contract of insurance for protection against liability to third persons in amounts appropriate for the protection of residents, employees, volunteers and visitors to the facility. 2. A certificate of insurance must be furnished to the Division as evidence that the contract required by subsection 1 is in force, and a license must not be issued until that certificate is furnished. Each contract of insurance must contain an endorsement providing for a notice of 30 days to the Bureau before the effective date of a cancellation or nonrenewal of the policy. [Bd. of Health, Group Care Facilities §§ 5.1-5.4, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004) NAC 449.205 Advertising and promotional materials. ( NRS 449.0302 ) Advertising and promotional materials for a residential facility must be accurate and not misrepresent accommodations, services or programs offered by the facility. (Added to NAC by Bd. of Health, eff. 3-6-86; A by R003-97, 10-30-97) NAC 449.208 Restrictions on conducting other businesses or providing other services on premises. ( NRS 449.0302 ) No other business may be conducted or other services may be provided on the premises of a residential facility if the business or services would interfere with the operation of the facility or the care provided to the residents of the facility. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.209 Health and sanitation. ( NRS 449.0302 ) 1. A residential facility must: (a) Have a safe and sufficient supply of water, adequate drainage and an adequate system for the disposal of sewage; and (b) Comply with all local ordinances and state and federal laws and regulations relating to zoning, sanitation, accessibility to persons with disabilities and safety. 2. Containers used to store garbage outside of the facility must be kept reasonably clean and must be covered in such a manner that rodents are unable to get inside the containers. At least once each week, the containers must be emptied and the contents of the containers must be removed from the premises of the facility. 3. Containers used to store garbage in the kitchen and laundry room of the facility must be covered with a lid unless the containers are kept in an enclosed cupboard that is clean and prevents infestation by rodents or insects. Containers used to store garbage in bedrooms and bathrooms are not required to be covered unless they are used for food, bodily waste or medical waste. 4. To the extent practicable, the premises of the facility must be kept free from: (a) Offensive odors; (b) Hazards, including obstacles that impede the free movement of residents within and outside the facility; (c) Insects and rodents; and (d) Accumulations of dirt, garbage and other refuse. 5. The administrator of a residential facility shall ensure that the premises are clean and that the interior, exterior and landscaping of the facility are well maintained. 6. All windows that are capable of being opened in the facility and all doors that are left open to provide ventilation for the facility must be screened to prevent the entry of insects. 7. The facility must maintain electrical lighting as necessary to ensure the comfort and safety of the residents of the facility. 8. The temperature in the facility must be maintained at a level that is not less than 68 degrees Fahrenheit and not more than 82 degrees Fahrenheit. 9. If the door of a bathroom opens into any room in which food or utensils for eating are handled or stored, the door must close automatically. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99) NAC 449.211 Automatic sprinkler systems. ( NRS 449.0302 ) 1. After January 14, 1997, the Division shall withhold the issuance of an initial license to operate a residential facility that does not have an automatic sprinkler system which complies with the provisions of chapter 477 of NRS and any local ordinances relating to the installation of automatic sprinkler systems. 2. Except as otherwise provided in subsection 3, a residential facility with less than seven residents that is issued a license on or before January 14, 1997, shall install an automatic sprinkler system that complies with the provisions of chapter 477 of NRS and any local ordinances relating to the installation of automatic sprinkler systems if: (a) The ownership of the facility is transferred to a new owner; (b) The number of beds in the facility is increased; (c) The facility is currently authorized to admit or retain category 1 residents only and wishes to apply for authorization to admit or retain category 2 residents; or (d) The facility is not currently authorized to admit or retain residents who suffer from Alzheimer’s disease or other related dementia and the facility wishes to apply for authorization to admit or retain such residents. 3. A residential facility with less than seven residents that was issued its initial license on or before January 14, 1997, may not admit or retain a category 2 resident, unless an automatic sprinkler system that complies with the provisions of chapter 477 of NRS and any local ordinances relating to the installation of automatic sprinkler systems is installed in the facility. Not more than one resident who is confined to a wheelchair or who is required to use a walker may be admitted to such a facility at any time unless such an automatic sprinkler system is installed in the facility. 4. An automatic sprinkler system that has been installed in a residential facility must be inspected: (a) Not less than once each calendar quarter by a person who understands the manner in which the system operates and the manner in which it should be maintained; and (b) Not less than once each calendar year by a person who is licensed to inspect such a system pursuant to the provisions of chapter 477 of NAC. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.213 Laundry and linen services. ( NRS 449.0302 ) 1. A residential facility shall: (a) Provide laundry and linen services on the premises of the facility; or (b) Contract with a commercial laundry for the provision of those services. 2. A residential facility that provides its own laundry and linen services shall have accommodations which are adequate for the proper and sanitary washing and finishing of linen and other washable goods. 3. The laundry room in a residential facility must be situated in an area which is separate from an area where food is stored, prepared or served. The laundry must be adequate in size for the needs of the facility and maintained in a sanitary manner. The laundry room must contain at least one washer and at least one dryer. All the equipment must be kept in good repair. All dryers must be ventilated to outside the building. If a washer or dryer is located outside the residential facility, the washer or dryer must be in a room or enclosure. 4. Clothes, bedding, linens and any other materials laundered pursuant to subsection 1 must be made clean by the laundering process. If a residential facility provides its own laundry and linen services, the residential facility shall: (a) Make appropriate use of detergents, soaps, heat or chemicals; and (b) Take precautions to ensure that no resident, member of the staff of the facility or other person in the facility is harmed by exposure to the detergents, soaps, heat or chemicals used in the laundering process. [Bd. of Health, Group Care Facilities § 14.8, eff. 12-18-75; A 5-7-82; §§ 14.8.1-14.10.2, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R204-99, 2-10-2000; R073-03, 1-22-2004) NAC 449.216 Common areas; dining rooms. ( NRS 449.0302 ) 1. A residential facility must have at least one centrally located common area in which residents may socialize and participate in recreational activities. A common area may include, without limitation, a living room, dining room, enclosed porch or solarium. 2. The common areas must be large enough to accommodate those to be served without overcrowding the areas. A minimum area of 15 square feet of total common area space per person must be provided. 3. All common areas must be furnished and equipped with comfortable furniture. 4. The dining room must be of sufficient size to accommodate all the residents comfortably. A minimum area of 10 square feet per person must be provided. 5. The dining room must be conveniently located near the kitchen to ensure the rapid and efficient serving of food. [Bd. of Health, Group Care Facilities §§ 15.1-15.2.3, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97) NAC 449.217 Kitchens; storage of food; adequate supplies of food; permits; inspections. ( NRS 449.0302 ) 1. The equipment in a kitchen of a residential facility and the size of the kitchen must be adequate for the number of residents in the facility. The kitchen and the equipment must be clean and must allow for the sanitary preparation of food. The equipment must be in good working condition. 2. Perishable foods must be refrigerated at a temperature of 40 degrees Fahrenheit or less. Frozen foods must be kept at a temperature of 0 degrees Fahrenheit or less. 3. Sufficient storage must be available for all food and equipment used for cooking and storing food. Food that is stored must be appropriately packaged. 4. The administrator of a residential facility shall ensure that there is at least a 2-day supply of fresh food and at least a 1-week supply of canned food in the facility at all times. 5. Pesticides and other toxic substances must not be stored in any area in which food, kitchen equipment, utensils or paper products are stored. Soaps, detergents, cleaning compounds and similar substances must not be stored in any area in which food is stored. 6. A residential facility with more than 10 residents shall: (a) Comply with the standards prescribed in chapter 446 of NAC; and (b) Obtain the necessary permits from the Division. 7. The equipment used for cooking and storing food and for washing dishes in a residential facility with more than 10 residents must be inspected and approved by the Division and the state and local fire safety authorities. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004; R155-10, 12-16-2010) NAC 449.2175 Service of food; seating; menus; special diets; nutritional requirements; dietary consultants. ( NRS 449.0302 ) 1. A residential facility shall have adequate facilities and equipment for the preparation, service and storage of food. 2. Tables and chairs must be of proper height and of sufficient number to provide seating for the number of residents authorized for the facility. They must be sturdy and have easily washable surfaces. Chairs must be constructed so that they do not overturn easily. 3. Menus must be in writing, planned a week in advance, dated, posted and kept on file for 90 days. 4. A resident who has been placed on a special diet by a physician or licensed dietitian must be provided a meal that complies with the diet. The administrator of the facility shall ensure that records of any modifications to the menu to accommodate for special diets prescribed by a physician or licensed dietitian are kept on file for at least 90 days. 5. Any substitution for an item on the menu must be documented and kept on file with the menu for at least 90 days after the substitution occurs. A substitution must be posted in a conspicuous place during the serving of the meal. 6. Each meal must provide a reasonable portion of the daily dietary allowances recommended by the Food and Nutrition Board of the Institute of Medicine of the National Academies. 7. Meals must be nutritious, served in an appropriate manner, suitable for the residents and prepared with regard for individual preferences and religious requirements. At least three meals a day must be served at regular intervals. The times at which meals will be served must be posted. Not more than 14 hours may elapse between the meal in the evening and breakfast the next day. Snacks must be made available between meals for the residents who are not prohibited by their physicians from eating between meals. 8. A resident must be served meals in his or her bedroom for not more than 14 consecutive days if the resident is temporarily unable to eat in the dining room because of an injury or illness. The facility may serve meals to other residents in their rooms upon request. If a meal is served to a resident in his or her room because the resident is unable to eat in the dining room, the facility shall maintain a record of the times and reasons for serving meals to the resident in his or her room. 9. A residential facility with more than 10 residents shall employ or otherwise obtain the services of a person to serve as a consultant for the planning and serving of meals who: (a) Is a licensed dietitian; or (b) Is a graduate from an accredited college with a major in food and nutrition and has 2 years of supervisory experience in a medical facility or facility for the dependent or has participated in a course of training for a supervisor of the service of food. 10. The person providing services pursuant to subsection 9 shall provide those services not less than once each calendar quarter. The administrator of the facility shall keep a written record of the consultations on file at the facility. The consultations must include: (a) The development and review of weekly menus; (b) Training for the employees who work in the kitchen; (c) Advice regarding compliance with the nutritional program of the facility; and (d) Any observations of the person providing the services regarding the preparation and service of meals in the facility to ensure that the facility is in compliance with the nutritional program of the facility. [Bd. of Health, Group Care Facilities §§ 12.1-12.8.1, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004; R090-12, 12-20-2012) NAC 449.218 Bedrooms: Floor space; windows and doors; privacy; storage space; bedding; personal furnishings; lighting. ( NRS 439.200 , 449.0302 ) 1. A bedroom in a residential facility that is shared by two or three residents must have at least 60 square feet of floor space for each resident who resides in the bedroom. A resident may not share a bedroom with more than two other residents. A bedroom that is occupied by only one resident must have at least 80 square feet of floor space. 2. Each bedroom in a residential facility must have one or more windows to the outside that can be opened from the inside of the room without the use of tools or a door to the outside which is at least 36 inches wide and can be opened from the inside. 3. The combined size of the panes of glass of the windows in a bedroom in a facility that was issued a license on or after January 14, 1997, must equal not less than 8 percent of the floor space in the room. 4. The arrangement of the beds and other furniture in the bedroom must provide privacy for and promote the safety of the residents occupying the bedroom. Adjustable curtains, shades, blinds or similar devices must be provided for visual privacy. 5. Each resident must be provided: (a) At least 10 square feet of space for storage in a bedroom for each bed in the bedroom; and (b) At least 24 inches of space in a permanent or portable closet for hanging garments. 6. A separate bed with a comfortable and clean mattress must be made available for each resident. The bed must be at least 36 inches wide. Two clean sheets, a blanket, a pillow and a bedspread must be available for each bed. Linens must be changed at least once each week and more often if the linens become dirty. Additional bedding, including protective mattress covers, must be provided if necessary. 7. Upon the request of a resident, a residential facility may authorize the resident to use personal furniture and furnishings that comply with the requirements of subsection 6 if their use does not jeopardize the health and safety of any of the residents of the facility. 8. There must be a light outside the entrance to each bedroom to provide a resident with adequate lighting to reach safely a switch for turning on a light fixture inside the bedroom. Upon the request of a resident, bedside lighting must be provided. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004; R119-10, 1-13-2011; R048-22, 12-29-2022) NAC 449.220 Bedroom doors. ( NRS 449.0302 ) 1. A bedroom door in a residential facility which is equipped with a lock must open with a single motion from the inside unless the lock provides security for the facility and can be operated without a key or any special knowledge. 2. A bedroom door must not be equipped with a deadbolt lock or chain stop unless the door opens directly to the outside of the facility. The doors of a bedroom and the doors of the closets in the bedroom may be equipped with locks for use by residents if: (a) The doors may be unlocked with a single motion from inside the bedroom or closet without the use of a key; and (b) The doors of the bedroom may be unlocked from outside the room and the keys are readily available at all times. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.221 Use of certain areas in facility as bedroom prohibited. ( NRS 449.0302 ) A hall, stairway, unfinished attic, garage, storage area or shed or other similar area of a residential facility must not be used as a bedroom. Any other room must not be used as a bedroom if it: 1. Can only be reached by passing through a bedroom occupied by another resident; or 2. Is used for any other purpose. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.222 Bathrooms and toilet facilities; toilet articles. ( NRS 449.0302 ) 1. Each residential facility with less than seven residents that was issued an initial license before January 14, 1997, must have bathroom facilities in sufficient number to accommodate the residents, the members of the staff of the facility and other persons at the facility. 2. Each residential facility that is issued an initial license on or after January 14, 1997, must have: (a) A flush toilet and lavatory for each four residents; and (b) A tub or shower for each six residents. 3. The bottoms of tubs and showers must have surfaces that inhibit falling and slipping. Cabinets that are attached to the floor or grab bars must be adjacent to the tubs, toilets and showers. 4. All bathrooms and toilet facilities must be located convenient to sleeping, recreational and living areas. A bathroom must have a window that can be opened or a vent to outside the facility. 5. Provision must be made for privacy in all bathrooms and toilet facilities in rooms intended for use by more than one person. 6. Bathroom doors that are equipped with locks must open with a single motion from the inside without the use of a key. If a key is required to open a lock from outside the bathroom, the key must be readily available at all times. 7. Each resident must have his or her own toilet articles and must be provided with toilet paper, individual towels and washcloths. Paper towels may be used for hand towels. The towels and washcloths must be changed as often as is necessary to maintain cleanliness, but in no event less often than once each week. A soap dispenser may be used instead of individual bars of soap. 8. All bathrooms and toilet facilities must be sufficiently lighted, and night-lights must be provided in hallways that lead from the bedrooms to the bathrooms and toilet facilities. [Bd. of Health, Group Care Facilities §§ 15.4-15.4.6 & 15.6, eff. 12-18-75; § 15.5, eff. 12-18-75; A 5-7-82]—(NAC A by R003-97, 10-30-97) NAC 449.224 Housing for staff members. ( NRS 449.0302 ) 1. Bedrooms must be provided for any members of the staff of a residential facility and their families who live at a residential facility. The bedrooms must comply with the provisions of subsections 2 to 8, inclusive, of NAC 449.218 and the provisions of NAC 449.220 and 449.221 . 2. Members of the staff of the facility and their families who live at the facility shall be deemed residents of the facility for the purposes of determining the number of toilets, lavatories and tubs or showers the facility is required to have pursuant to NAC 449.222 . All toilets, lavatories and tubs or showers used by the members of the staff of the facility or their families must comply with the provisions of NAC 449.222 . (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.226 Safety requirements for residents with restricted mobility or poor eyesight; water hazards; auditory systems for bathrooms and bedrooms; access by vehicles. ( NRS 449.0302 ) 1. A resident of a residential facility who uses a wheelchair or a walker must not be required to use a bedroom on a floor other than the first floor of the facility that is entirely above the level of the ground, unless the facility is designed and equipped in such a manner that the resident can move between floors without assistance. 2. Stairways, inclines, ramps, open porches and other areas that are potentially hazardous for residents who have poor eyesight must be adequately lighted. 3. If a residential facility with a resident who is mentally or physically disabled has a fishpond, pool, hot tub, jacuzzi or other body of water on the premises of the facility, the body of water must be fenced, covered or blocked in some other manner at all times when it is not being used by a resident. 4. In a residential facility with more than 10 residents: (a) Each resident must be provided with, or the bedroom and bathroom of each resident must be equipped with, an auditory system that is monitored by a member of the staff of the facility. (b) An auditory system must be available for use in the bathroom of each resident of the facility if the facility was issued its initial license on or after January 14, 1997, so that a resident needing assistance can alert a member of the staff of the facility of that fact from the toilet and the shower. (c) A bathroom that is located in a common area of the facility must be equipped with an auditory system that is monitored by a member of the staff of the facility. 5. Residential facilities must be easily accessible by vehicle in the case of an emergency. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99) NAC 449.227 Accommodations for residents with restricted mobility. ( NRS 449.0302 ) A residential facility with a resident who uses a wheelchair or a walker shall: 1. Have hallways, doorways and exits wide enough to accommodate a wheelchair or walker; 2. Have ramps to accommodate access to areas used by residents; and 3. Provide assistance to such a resident at all steps located inside the facility on the first floor that is entirely above grade. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.229 Requirements and precautions regarding safety from fire. ( NRS 449.0302 ) 1. The administrator of a residential facility shall ensure that the facility complies with the regulations adopted by the State Fire Marshal pursuant to chapter 477 of NRS and all local ordinances relating to safety from fire. The facility must be approved for residency by the State Fire Marshal. 2. The Bureau shall notify the State Fire Marshal or the appropriate local government, as applicable, if, during an inspection of a residential facility, the Bureau knows of or suspects the presence of a violation of a regulation of the State Fire Marshal or a local ordinance relating to safety from fire. 3. An exit door in a residential facility must not be equipped with a lock that requires a key to open it from the inside unless approved by the State Fire Marshal or his or her designee. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004; R119-10, 1-13-2011) NAC 449.231 First aid and cardiopulmonary resuscitation. ( NRS 449.0302 ) 1. Within 30 days after an administrator or caregiver of a residential facility is employed at the facility, the administrator or caregiver must be trained in first aid and cardiopulmonary resuscitation. The advanced certificate in first aid and adult cardiopulmonary resuscitation issued by the American Red Cross or an equivalent certification will be accepted as proof of that training. 2. A first-aid kit must be available at the facility. The first-aid kit must include, without limitation: (a) A germicide safe for use by humans; (b) Sterile gauze pads; (c) Adhesive bandages, rolls of gauze and adhesive tape; (d) Disposable gloves; (e) A shield or mask to be used by a person who is administering cardiopulmonary resuscitation; and (f) A thermometer or other device that may be used to determine the bodily temperature of a person. 3. Except for first aid in an emergency, no treatment or medication may be administered to a resident without the approval of a physician. [Bd. of Health, Group Care Facilities §§ 16.9-16.12.3, eff. 12-18-75; § 16.13, eff. 5-7-82]—(NAC A 3-6-86; R003-97, 10-30-97) NAC 449.232 Telephones; emergency telephone numbers for each resident; listing of facility’s telephone number. ( NRS 449.0302 ) 1. Each residential facility shall have a telephone that the residents may use to make local calls. 2. A list of telephone numbers to be called in case of an emergency for each resident must be located near the telephone. The list must include the telephone number of the resident’s physician and the telephone number of a friend of the resident or one of the members of the resident’s family. 3. The telephone number of the facility must be listed in the telephone directory under the name of the facility. (Added to NAC by Bd. of Health, eff. 3-6-86; A by R003-97, 10-30-97; R073-03, 1-22-2004) NAC 449.241 Limitations on use of volunteers; requirements concerning residents who volunteer to assist staff or perform other duties. ( NRS 449.0302 ) 1. Volunteers may be used to supplement the services and programs of a residential facility, but may not be used to replace members of the staff of the facility. 2. A resident may volunteer to help the employees of the facility in a manner that does not create an unsafe condition for the resident, other residents or the members of the staff of the facility. 3. A resident must not be required to perform duties normally performed by the staff of the facility. If a resident volunteers to perform such duties, the administrator of the facility shall ensure that the resident’s records include a statement that the resident has volunteered to perform those duties. 4. A resident who is performing duties pursuant to this section must not be allowed access to confidential files. (Added to NAC by Bd. of Health, eff. 3-6-86; A by R003-97, 10-30-97) NAC 449.258 Written policies for facility; policy on visiting hours; residents’ mail; compliance with policies. ( NRS 449.0302 ) 1. Written policies for a residential facility that comply with the provisions of NAC 449.156 to 449.27706 , inclusive, must be developed. 2. A policy on visiting hours must be established to promote contact by the residents with persons who are not residents of the facility. The policy regarding visits must be flexible to ensure that every resident has the opportunity to retain and strengthen ties with family and friends. 3. Assurances must be provided that incoming and outgoing mail for a resident will not be interfered with in any way, unless written permission is obtained from the resident or his or her representative. Permission obtained from the resident or the representative may specifically state the type of mail that may be interfered with by the members of the staff of the facility. Permission granted by a resident or the representative pursuant to this subsection may be revoked by the resident at any time. 4. The employees of the facility shall comply with the policies developed pursuant to this section. [Bd. of Health, Group Care Facilities §§ 11.1-11.7.1, eff. 12-18-75]—(NAC A by R003-97, 10-30-97; R073-03, 1-22-2004) NAC 449.259 Supervision and treatment of residents generally. ( NRS 449.0302 ) 1. A residential facility shall: (a) Provide each resident with protective supervision as necessary; (b) Inform all caregivers of the required supervision; (c) Provide each resident with the opportunity to attend the religious service of his or her choice and participate in personal and private pastoral counseling; (d) Permit a resident to rest in his or her room at any time; (e) Permit a resident to enter or leave the facility at any time if the resident: (1) Is physically and mentally capable of leaving the facility; and (2) The resident complies with the rules established by the administrator of the facility for leaving the facility; (f) Provide laundry services for each resident unless a resident elects in writing to make other arrangements; (g) Ensure that each resident’s clothes are clean, comfortable and presentable; and (h) Inform each resident or his or her representative of the actions that the resident should take to protect the resident’s valuables. 2. The administrator of a residential facility may require a resident who leaves the facility to inform a member of the staff of the facility upon his or her departure and return. 3. The employees of a residential facility shall: (a) Treat each resident in a kind and considerate manner; and (b) Respect each resident’s independence and ability to make decisions on his or her own, whenever possible. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.260 Activities for residents. ( NRS 449.0302 ) 1. The caregivers employed by a residential facility shall: (a) Ensure that the residents are afforded an opportunity to enjoy their privacy, participate in physical activities, relax and associate with other residents; (b) Provide group activities that provide mental and physical stimulation and develop creative skills and interests; (c) Plan recreational opportunities that are suited to the interests and capacities of the residents; (d) Provide each resident with a written program of activities; (e) Provide for the residents at least 10 hours each week of scheduled activities that are suited to their interests and capacities; (f) Encourage the residents to participate in the activities scheduled pursuant to paragraph (e); and (g) Post, in a common area of the facility, a calendar of activities for each month that notifies residents of the major activities that will occur in the facility. The calendar must be: (1) Prepared at least 1 month in advance; and (2) Kept on file at the facility for not less than 6 months after it expires. 2. The administrator of a residential facility with at least 20 residents shall appoint a member of the staff of the facility who will be responsible for the organization, conduct and evaluation of activities for the residents. The person so appointed shall ensure that the activities are suited to the interests and capacities of the residents. 3. The administrator of a residential facility with 50 or more residents shall, in addition to appointing a member of the staff of the facility pursuant to subsection 2, appoint such other members of the staff as the administrator deems necessary to assist the person who is responsible for conducting the activities. 4. A residential facility shall have areas of sufficient size to conduct indoor and outdoor activities, including, without limitation: (a) A common area that complies with the provisions of NAC 449.216 ; and (b) An outdoor activity area that is easily accessible for the residents and is safe from vehicular traffic. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.262 Provision of dental, optical and hearing care and social services; report of suspected abuse, neglect, isolation or exploitation; restrictions on use of restraints, confinement or sedatives. ( NRS 449.0302 ) 1. The administrator of a residential facility shall ensure that residents are provided with or are assisted in obtaining dental and optical care, treatment for hearing and hearing impairment and social services. The employees of the facility shall maintain a record of the services or assistance provided pursuant to this subsection. 2. If an employee of the facility suspects that a resident is being abused, neglected, isolated or exploited, the employee shall report that fact in the manner prescribed in NRS 200.5093 . 3. The members of the staff of a residential facility shall not: (a) Use restraints on any resident; (b) Lock a resident in a room inside the facility; or (c) Provide sedatives to a resident unless that sedative has been prescribed for that resident by a physician to treat specific symptoms. A caregiver shall make a record of the behavior of a resident who has been prescribed a sedative. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.267 Money and property of residents. ( NRS 449.0302 ) 1. An employee of a residential facility shall not handle a resident’s money without first being requested to do so in writing by the resident or his or her representative. 2. An accurate record must be kept of all money deposited with the facility for use by the resident, including withdrawals. The record must include: (a) A separate accounting of the money held by the facility on behalf of the resident; (b) Receipts for expenditures made by the facility on behalf of the resident; and (c) A written acknowledgment by the resident for each withdrawal of his or her money. 3. Unless a resident otherwise requests in writing, all money in excess of $400 held by the facility on behalf of the resident must be maintained in a financial institution in an account separate from the facility’s operating accounts and must be clearly designated as such. 4. Each resident must have access to his or her money held at the facility on his or her behalf during normal business hours on each business day. 5. If a member of the staff of a residential facility receives from a resident a request to make a withdrawal of money in such an amount that the member of the staff has reason to believe that the resident is being or has been exploited, the member of the staff shall report the transaction to: (a) If the resident is 60 years of age or older: (1) The local office of the Aging and Disability Services Division of the Department of Health and Human Services; (2) The local law enforcement agency; (3) The office for protective services for the county in which the facility is located if that county has such an office; or (4) The toll-free telephone service designated by the Aging and Disability Services Division pursuant to NRS 200.5093 . (b) If the resident is less than 60 years of age: (1) The office for protective services for the county in which the facility is located if that county has such an office; or (2) The local law enforcement agency if the county in which the facility is located does not have an office for protective services. 6. Except as otherwise provided in subsection 7, an operator or employee of a residential facility shall not accept appointment as a guardian or conservator of the estate of any resident, become a substitute payee for any payments made to any resident or accept an appointment as an attorney in fact for any resident. 7. If a resident whose only source of income is in the form of monthly checks is legally determined to be unable to manage his or her money and documentary evidence can be produced showing that efforts to obtain a legal guardian have failed, the facility may be the substitute payee on the checks. Records of all checks received, deposited or dispersed by the facility must be maintained in the resident’s file. 8. Money that is held by a residential facility on behalf of a resident must be returned to the resident or his or her representative within 30 days after the resident is discharged from the facility. 9. An employee of a residential facility shall not borrow money from a resident. [Bd. of Health, Group Care Facilities §§ 11.15-11.19.1, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004) NAC 449.268 Rights of residents; procedure for filing grievance, complaint or report of incident; investigation and response. ( NRS 449.0302 ) 1. The administrator of a residential facility shall ensure that: (a) The residents are not abused, neglected or exploited by a member of the staff of the facility, another resident of the facility or any person who is visiting the facility; (b) A resident is not prohibited from speaking to any person who advocates for the rights of the residents of the facility; (c) The residents are treated with respect and dignity; (d) The facility is a safe and comfortable environment; (e) Residents are not prohibited from interacting socially; (f) Residents are allowed to make their own decisions whenever possible; (g) Residents are aware that they may file a complaint or grievance with the administrator and that a resident who files such a complaint receives a response in a timely manner; (h) A resident is informed as soon as practicable that the resident is being moved to a new room or that he or she is receiving a new roommate; and (i) Residents are afforded the opportunity to initiate an advance directive or power of attorney for health care and that the employees of the facility comply with the wishes contained in such a document. 2. The administrator of a residential facility shall provide a procedure to respond immediately to grievances, incidents and complaints. The procedure must include a method for ensuring that the administrator or a person designated by the administrator is notified of the grievance, incident or complaint. The administrator or a person designated by the administrator shall personally investigate the matter. A resident who files a grievance or complaint or reports an incident pursuant to this subsection must be notified of the action taken in response to the grievance, complaint or report or be given a reason why no action needs to be taken. 3. The employees of the facility shall comply with the procedures adopted pursuant to subsection 2. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) Admitting, Transferring and Discharging Residents NAC 449.2702 Written policy on admissions; eligibility for residency. ( NRS 449.0302 ) 1. Each residential facility shall have a written policy on admissions which includes: (a) A statement of nondiscrimination regarding admission to the facility and treatment after admission; and (b) The requirements for eligibility as a resident of that type of facility. 2. A person who wishes to reside in a residential facility with residents that require a higher category of care than the person requires may reside in the facility if he or she is not otherwise prohibited from residing in the facility. 3. A person who is admitted to a residential facility must be at least 18 years of age. 4. Except as otherwise provided in NAC 449.275 and 449.2754 , a residential facility shall not admit or allow to remain in the facility any person who: (a) Is bedfast; (b) Requires restraint; (c) Requires confinement in locked quarters; or (d) Requires skilled nursing or other medical supervision on a 24-hour basis. 5. A person may not reside in a residential facility if the person’s physician or the Bureau determines that the person does not comply with the requirements for eligibility. 6. As used in this section: (a) “Bedfast” means a condition in which a person is: (1) Incapable of changing his or her position in bed without the assistance of another person; or (2) Immobile. (b) “Restraint” means: (1) A psychopharmacologic drug that is used for discipline or convenience and is not required to treat medical symptoms; (2) A manual method for restricting a resident’s freedom of movement or the resident’s normal access to his or her body; or (3) A device or material or equipment which is attached to or adjacent to a resident’s body that cannot be removed easily by the resident and restricts the resident’s freedom of movement or the resident’s normal access to his or her body. [Bd. of Health, Group Care Facilities § 7.1, eff. 12-18-75; §§ 7.2-7.4.2, eff. 12-18-75; A 5-7-82; §§ 7.5-7.6.4, eff. 12-18-75]—(NAC A 3-6-86; 8-1-91; R003-97, 10-30-97; R073-03, 1-22-2004; R118-05, 11-17-2005) NAC 449.2704 Disclosure of information concerning rates and payment for services. ( NRS 449.0302 ) The administrator of a residential facility shall, upon request, make the following information available in writing: 1. The basic rate for the services provided by the facility; 2. The schedule for payment; 3. The services included in the basic rate; 4. The charges for optional services which are not included in the basic rate; and 5. The residential facility’s policy on refunds of amounts paid but not used. (Added to NAC by Bd. of Health, eff. 3-6-86; A by R003-97, 10-30-97; R052-99, 9-27-99) NAC 449.2706 Transfer of resident whose condition deteriorates. ( NRS 449.0302 ) 1. If a resident’s condition deteriorates to such an extent that: (a) The residential facility is unable to provide the services necessary to treat the resident properly; or (b) The resident no longer complies with the requirements for admission to the facility, Ê the facility shall plan for the transfer of the resident pursuant to NRS 449A.100 and 449A.103 to another facility that is able to provide the services necessary to treat the resident properly. 2. A resident, his or her next of kin and the responsible agency, if any, must be consulted and adequate arrangements must be made to meet the resident’s needs through other means before he or she permanently leaves the facility. [Bd. of Health, Group Care Facilities §§ 10.1-10.3, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004) NAC 449.2707 Transfer of resident: Effective date. ( NRS 449.0302 ) The transfer of a resident from a residential facility occurs: 1. Except as otherwise provided in subsection 2, on the date that the resident is admitted to the facility to which he or she is moved; or 2. If the resident is moved to a unit or department of a hospital, other than the emergency department of the hospital, on the date that the resident is accepted at the hospital for care or observation. (Added to NAC by Bd. of Health by R071-04, eff. 8-4-2004) NAC 449.2708 Discharge of resident; notice of discharge; issuance of notice to quit to resident for improper or harmful behavior. ( NRS 449.0302 ) 1. A resident may be discharged from a residential facility without his or her approval if: (a) The resident fails to pay his or her bill within 5 days after it is due; (b) The resident fails to comply with the rules or policies of the facility; or (c) The administrator of the facility or the Bureau determines that the facility is unable to provide the necessary care for the resident. 2. Except as otherwise provided in this section, before a resident may be discharged from a residential facility without his or her approval pursuant to this section, the facility must provide the resident, his or her representative and the person who pays the bill on behalf of the resident, if any, with written notice that the resident will be discharged. 3. A residential facility shall discharge a resident who is transferred pursuant to NRS 449A.100 and 449A.103 and admitted to another facility for a higher level of care. Written notice pursuant to subsection 2 that the resident will be discharged is not required if the condition of the resident necessitates immediate transfer to receive emergency care. 4. If the resident or any of his or her visitors are engaging in behavior which is a threat to the mental or physical health or safety of the resident or other persons in the facility, the facility may issue a notice to quit to the resident. The notice to quit must include: (a) The reasons for its issuance, with specific facts relating to the date, time and place of the incidents that posed a threat to the physical or mental health or safety of the resident or other persons in the facility; and (b) The names of persons who witnessed the incidents and the circumstances under which the incidents occurred. Ê If the resident or his or her visitors do not comply with the notice to quit, the resident may be discharged from the facility without his or her approval pursuant to subsection 2. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004) Restrictions on Admitting or Retaining Residents With Certain Medical Needs or Conditions NAC 449.271 Residents requiring gastrostomy care or suffering from staphylococcus infection or other serious infection or medical condition. ( NRS 439.200 , 449.0302 ) 1. Except as otherwise provided in subsection 2 and NAC 449.2736 , a person must not be admitted to a residential facility or permitted to remain as a resident of a residential facility if he or she: (a) Requires gastrostomy care; (b) Suffers from a staphylococcus infection or other serious infection; or (c) Suffers from any other serious medical condition that is not described in NAC 449.2712 to 449.2734 , inclusive. 2. If a governmental entity with jurisdiction, including, without limitation, a local board of health, a local health officer, the Division, the Chief Medical Officer or the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, declares the existence of an epidemic or pandemic, a residential facility located in the area in which the epidemic or pandemic is occurring may permit a resident suffering from a serious infection to remain a resident if the resident does not have symptoms that require a higher level of care than the residential facility is capable of providing. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R048-22, 12-29-2022) NAC 449.2712 Residents requiring use of oxygen. ( NRS 449.0302 ) 1. A person who requires the use of oxygen must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless he or she: (a) Is mentally and physically capable of operating the equipment that provides the oxygen; or (b) Is capable of: (1) Determining his or her need for oxygen; and (2) Administering the oxygen to himself or herself with assistance. 2. The caregivers employed by a residential facility with a resident who requires the use of oxygen shall: (a) Monitor the ability of the resident to operate the equipment in accordance with the orders of a physician; and (b) Ensure that: (1) The resident’s physician evaluates periodically the condition of the resident which necessitates his or her use of oxygen; (2) Signs which prohibit smoking and notify persons that oxygen is in use are posted in areas of the facility in which oxygen is in use or is being stored; (3) Persons do not smoke in those areas where smoking is prohibited; (4) All electrical equipment is inspected for defects which may cause sparks; (5) All oxygen tanks kept in the facility are secured in a stand or to a wall; (6) The equipment used to administer oxygen is in good working condition; (7) A portable unit for the administration of oxygen in the event of a power outage is present in the facility at all times when a resident who requires oxygen is present in the facility; and (8) The equipment used to administer oxygen is removed from the facility when it is no longer needed by the resident. 3. The administrator of a residential facility shall ensure that the caregivers who may be required to administer oxygen have demonstrated the ability to operate properly the equipment used to administer oxygen. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.2714 Residents requiring use of intermittent positive pressure breathing equipment. ( NRS 449.0302 ) 1. A person who requires the use of intermittent positive pressure breathing equipment must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless: (a) The resident is mentally and physically capable of operating and disinfecting the equipment and is capable of determining when its use is required; or (b) The equipment is operated by a medical professional who has been trained to operate the equipment. 2. The caregivers employed by a residential facility with a resident who requires the use of intermittent positive pressure breathing equipment shall: (a) Monitor the ability of the resident to operate the equipment in accordance with the orders of a physician; and (b) Ensure that: (1) The resident’s physician evaluates periodically the condition of the resident which necessitates his or her use of the equipment; (2) The equipment is operated by a medical professional trained in the operation of the equipment if the resident requires assistance; (3) The equipment is in good working condition; and (4) The equipment is removed from the facility when it is no longer needed by the resident. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.2716 Residents having colostomy or ileostomy. ( NRS 449.0302 ) 1. A person who has a colostomy or ileostomy must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless: (a) The resident is mentally and physically capable of properly caring for his or her colostomy or ileostomy, with or without assistance, and the resident’s physician has stated in writing that the colostomy or ileostomy is completely healed; or (b) The care for the colostomy or ileostomy is provided by a medical professional who is trained to provide that care. 2. The caregivers employed by a residential facility with a resident who has a colostomy or ileostomy shall ensure that: (a) All bags used by the resident are discarded appropriately; and (b) Privacy is afforded to the resident when care for the colostomy or ileostomy is being provided. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.2718 Residents requiring manual removal of fecal impactions or use of enemas or suppositories. ( NRS 449.0302 ) 1. A person who requires the manual removal of fecal impactions or the use of enemas or suppositories must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless: (a) The resident is able to provide the care for himself or herself; or (b) The care is administered according to the written instructions of a physician by a medical professional who has been trained to provide that care. 2. The caregivers employed by a residential facility with a resident who requires the manual removal of fecal impactions or the use of enemas or suppositories shall ensure that privacy is afforded to the resident when that care is being provided. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R204-99, 2-10-2000) NAC 449.272 Residents requiring use of indwelling catheter. ( NRS 449.0302 ) 1. A person who requires the use of an indwelling catheter must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless: (a) The resident is physically and mentally capable of caring for all aspects of the condition, with or without the assistance of a caregiver; (b) Irrigation of the catheter is performed in accordance with the physician’s orders by a medical professional who has been trained to provide that care; and (c) The catheter is inserted and removed only in accordance with the orders of a physician by a medical professional who has been trained to insert and remove a catheter. 2. The caregivers employed by a residential facility with a resident who requires the use of an indwelling catheter shall ensure that: (a) The bag and tubing of the catheter are changed by: (1) The resident, with or without the assistance of a caregiver; or (2) A medical professional who has been trained to provide that care; (b) Waste from the use of the catheter is disposed of properly; (c) Privacy is afforded to the resident while care is being provided; and (d) The bag of the catheter is emptied by a caregiver who has received instruction in the handling of such waste and the signs and symptoms of urinary tract infections and dehydration. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.2722 Residents having unmanageable condition of bowel or bladder incontinence; residents having manageable condition of bowel or bladder incontinence. ( NRS 449.0302 ) 1. A person who has an unmanageable condition of bowel or bladder incontinence must not be admitted to a residential facility or permitted to remain as a resident of a residential facility. 2. A person who has a manageable condition of bowel or bladder incontinence must not be admitted to a residential facility or permitted to remain as a resident of a residential facility unless the condition can be managed by: (a) The resident without the assistance of any other person; (b) Requiring the resident to participate in a structured bowel or bladder retraining program to assist the resident in restoring a normal pattern of continence; (c) A program which includes scheduled toileting at regular intervals; or (d) Requiring the resident to use products that keep him or her clean and dry at all times. 3. The caregivers employed by a residential facility with a resident who has a manageable condition of bowel or bladder incontinence shall ensure that: (a) If the resident can benefit from scheduled toileting, he or she is assisted or reminded to go to the bathroom at regular intervals; (b) The resident is checked during those periods when he or she is known to be incontinent, including during the night; (c) The resident is kept clean and dry; (d) Retraining programs are designed by a medical professional with training and experience in the care of persons with bowel or bladder dysfunction; (e) The retraining programs established for a resident are followed; and (f) Privacy is afforded to the resident when care is being provided. 4. The caregivers employed by the facility shall not: (a) Withhold fluids from a resident to control incontinence; or (b) Have a resident catheterized to control incontinence for the convenience of the employees of the facility. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.2724 Residents having contractures. ( NRS 449.0302 ) 1. A person who has contractures must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless the contractures do not adversely affect the ability of the resident to perform normal bodily functions and: (a) The resident is able to care for the contractures without assistance; or (b) Supervision in caring for the contractures is provided by a medical professional who is trained to provide such supervision. 2. The caregivers employed by a residential facility with a resident who has contractures shall ensure that the performance by the resident of any exercises to improve the resident’s range of motion or any other exercises prescribed by a physician is supervised by a medical professional who has been trained to provide such supervision. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.2726 Residents having diabetes. ( NRS 439.200 , 449.0302 , 449.0304 ) 1. A person who has diabetes must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless: (a) The resident’s glucose testing is performed by: (1) The resident himself or herself without assistance; or (2) With the consent of the resident, a caregiver who meets the requirements of NAC 449.196 ; and (b) The resident’s medication is administered: (1) By the resident himself or herself without assistance; (2) By a medical professional, or licensed practical nurse, who is: (I) Acting within his or her authorized scope of practice and in accordance with all applicable statutes and regulations; and (II) Trained to administer the medication; or (3) If the conditions set forth in subsection 2 are satisfied, with the assistance of a caregiver employed by the residential facility. 2. A caregiver employed by a residential facility may assist a resident in the administration of the medication prescribed to the resident for his or her diabetes if: (a) A physician, physician assistant or advanced practice registered nurse has determined that the resident’s physical and mental condition is stable and is following a predictable course. (b) The amount of the medication prescribed to the resident for his or her diabetes is at a maintenance level and does not require a daily assessment, including, without limitation, the use of a sliding scale. (c) A written plan of care by a physician or registered nurse has been established that: (1) Addresses possession and assistance in the administration of the medication for the resident’s diabetes; and (2) Includes a plan, which has been prepared under the supervision of a registered nurse or licensed pharmacist, for emergency intervention if an adverse condition results. (d) The medication prescribed to the resident for his or her diabetes is not administered by injection or intravenously or is administered using an auto-injection device in accordance with the requirements of NRS 449.0304 and NAC 449.1985 . (e) The caregiver has successfully completed training and examination approved by the Division regarding the administration of such medication. 3. The caregivers employed by a residential facility with a resident who has diabetes shall ensure that: (a) Sufficient amounts of medicines, equipment to perform tests, syringes, needles and other supplies are maintained and stored in a secure place in the facility; (b) Syringes and needles are disposed of appropriately in a sharps container which is stored in a safe place; and (c) The caregivers responsible for the resident have received instruction in the recognition of the symptoms of hypoglycemia and hyperglycemia by a medical professional who has been trained in the recognition of those symptoms. 4. The caregivers of a residential facility with a resident who has diabetes and requires a special diet shall provide variations in the types of meals served and make available food substitutions in order to allow the resident to consume meals as prescribed by the resident’s physician. The substitutions must conform with the recommendations for food exchanges contained in the Exchange Lists For Meal Planning , published by the American Diabetes Association, Incorporated, and the American Dietetic Association, which is hereby adopted by reference. A copy of the publication may be obtained from the American Diabetes Association, Incorporated, Order Fulfillment Department, P.O. Box 930850, Atlanta, Georgia 31193-0850, at a cost of $2.50. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004; R109-18, 1-30-2019) NAC 449.2728 Residents requiring regular intramuscular, subcutaneous or intradermal injections. ( NRS 439.200 , 449.0302 , 449.0304 ) 1. Except as otherwise provided by NAC 449.2726 , a person who requires regular intramuscular, subcutaneous or intradermal injections must not be admitted to a residential facility or be permitted to remain as a resident of the facility unless the injections are administered by: (a) The resident; or (b) A medical professional, or licensed practical nurse, acting within his or her authorized scope of practice and in accordance with all applicable statutes and regulations, Ê who has been trained to administer those injections. 2. The caregivers employed by a residential facility with a resident who requires regular intramuscular, subcutaneous or intradermal injections shall ensure that: (a) Sufficient amounts of medicines, equipment to perform tests, syringes, needles and other supplies are maintained and stored in a secure place in the facility; and (b) Syringes and needles are disposed of appropriately in a sharps container which is stored in a safe place. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004; R109-18, 1-30-2019) NAC 449.2732 Residents requiring protective supervision. ( NRS 449.0302 ) 1. Except as otherwise provided in subsection 2, a person who requires protective supervision may not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless: (a) The resident is able to follow instructions; (b) The resident is able to make his or her needs known to the caregivers employed by the facility; (c) The resident can be protected from harming himself or herself and other persons; and (d) The caregivers employed by the facility can meet the needs of the resident. 2. If a person who requires protective supervision is unable to follow instructions or has difficulty making his or her needs known to the employees of the facility, the person may be admitted to the facility or be permitted to remain as a resident of the facility if the facility complies with the provisions of NAC 449.2754 and 449.2756 . 3. The administrator of a residential facility with a resident who requires protective services shall ensure that: (a) The caregivers employed by the facility are capable of providing the supervision for that resident without neglecting the needs of the other residents of the facility; and (b) There is a written plan for providing protective supervision for that resident. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97) NAC 449.2734 Residents having tracheostomy or open wound requiring treatment by medical professional; residents having pressure or stasis ulcers. ( NRS 449.0302 ) 1. A person who has a tracheostomy or an open wound that requires treatment by a medical professional must not be admitted to a residential facility or be permitted to remain as a resident of a residential facility unless: (a) The wound is in the process of healing or the tracheostomy is stable or can be cared for by the resident without assistance; (b) The care is provided by or under the supervision of a medical professional who has been trained to provide that care; or (c) The wound is the result of surgical intervention and care is provided as directed by the surgeon. 2. If a person who has a pressure or stasis ulcer or who is at risk of developing a pressure or stasis ulcer is admitted to a residential facility or permitted to remain as a resident of a residential facility: (a) The condition must have been diagnosed by a physician; (b) The condition must be cared for by a medical professional who is trained to provide care for and reassessment of that condition; and (c) Before a caregiver provides care to the person who has a pressure or stasis ulcer or who is at risk of developing a pressure or stasis ulcer, the caregiver must receive training related to the prevention and care of pressure sores from a medical professional who is trained to provide care for that condition. 3. The administrator of the facility shall ensure that records of the care provided to a person who has a pressure or stasis ulcer pursuant to subsection 2 are maintained at the facility. The records must include an explanation of the cause of the pressure or stasis ulcer. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R204-99, 2-10-2000; R073-03, 1-22-2004) NAC 449.2736 Procedure to exempt certain residents from restrictions. ( NRS 449.0302 ) 1. The administrator of a residential facility may submit to the Division a written request for permission to admit or retain a resident who is prohibited from being admitted to a residential facility or remaining as a resident of the facility pursuant to NAC 449.271 to 449.2734 , inclusive. 2. A written request submitted pursuant to this section must include, without limitation: (a) Records concerning the resident’s current medical condition, including updated medical reports, other documentation of current health, a prognosis and the expected duration of the condition; (b) A plan for ensuring that the resident’s medical needs can be met by the facility; (c) A plan for ensuring that the level of care provided to the other residents of the facility will not suffer as a result of the admission or retention of the resident who is the subject of the request; and (d) A statement signed by the administrator of the facility that the needs of the resident who is the subject of the written request will be met by the caregivers employed by the facility. 3. A written request submitted to the Division pursuant to this section must be received: (a) Before the administrator admits a resident; or (b) At the onset of a medical condition set forth in NAC 449.271 to 449.2734 , inclusive. 4. A residential facility must receive the permission requested pursuant to subsection 1 before the facility admits a resident who is otherwise prohibited from being admitted to the facility pursuant to NAC 449.271 to 449.2734 , inclusive. 5. A residential facility may retain a resident who is otherwise prohibited from remaining as a resident of the facility pursuant to NAC 449.271 to 449.2734 , inclusive, for 10 days after the facility submits to the Division the written request required pursuant to subsection 1. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R204-99, 2-10-2000) NAC 449.2738 Review of medical condition of resident; relocation or transfer of resident having certain medical needs or conditions. ( NRS 449.0302 ) 1. If, after conducting an inspection or investigation of a residential facility, the Bureau determines that it is necessary to review the medical condition of a resident, the Bureau shall inform the administrator of the facility of the need for the review and the information the facility is required to submit to the Bureau to assist in the performance of the review. The administrator shall, within a period prescribed by the Bureau, provide to the Bureau: (a) The assessments made by physicians concerning the physical and mental condition of the resident; and (b) Copies of prescriptions for medication or orders of physicians for services or equipment necessary to provide care for the resident. 2. If the Bureau or the resident’s physician determines that the facility is prohibited from caring for the resident pursuant to NAC 449.271 to 449.2734 , inclusive, or is unable to care for the resident in the proper manner, the administrator of the facility must be notified of that determination. Upon receipt of such a notification, the administrator shall, within a period prescribed by the Bureau, submit a plan to the Bureau for the safe and appropriate relocation of the resident pursuant to NRS 449A.100 to a place where the proper care will be provided. 3. If an inspection or investigation reveals that the conditions at a residential facility may immediately jeopardize the health and safety of a resident, the administrator of the facility shall, as soon as practicable, ensure that the resident is transferred to a facility which is capable of properly providing for his or her care. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) Medical Services, Medical Records and Other Records Concerning Residents NAC 449.274 Medical care of resident after illness, injury or accident; periodic physical examination of resident; rejection of medical care by resident; written records. ( NRS 449.0302 ) 1. If a resident of a residential facility becomes ill or is injured, the resident’s physician and a member of the resident’s family must be notified at the onset of illness or at the time of the injury. The facility shall: (a) Make all necessary arrangements to secure the services of a licensed physician to treat the resident if the resident’s physician is not available; and (b) Request emergency services when such services are necessary. 2. A resident who is suffering from an illness or injury from which the resident is expected to recover within 14 days after the onset of the illness or the time of the injury may be cared for in the facility. The decision as to the period within which the resident is expected to recover from the illness or injury and the needs of the resident must be made by the resident’s physician or, if he or she is unavailable, by another licensed physician. 3. A written record of all accidents, injuries and illnesses of the resident which occur in the facility must be made by the caregiver who first discovers the accident, injury or illness. The record must include: (a) The date and time of the accident or injury or the date and time that the illness was discovered; (b) A description of the manner in which the accident or injury occurred or the manner in which the illness was discovered; and (c) A description of the manner in which the members of the staff of the facility responded to the accident, injury or illness and the care provided to the resident. Ê This record must accompany the resident if he or she is transferred to another facility. 4. The facility shall ensure that appropriate medical care is provided to the resident by: (a) A caregiver who is trained to provide that care; (b) An independent contractor who is trained to provide that care; or (c) A medical professional. 5. Before admission and each year after admission, or more frequently if there is a significant change in the physical condition of a resident, the facility shall obtain the results of a general physical examination of the resident by his or her physician. The resident must be cared for pursuant to any instructions provided by the resident’s physician. 6. The members of the staff of the facility shall: (a) Ensure that the resident receives the personal care that he or she requires. (b) Monitor the ability of the resident to care for his or her own health conditions and document in writing any significant change in his or her ability to care for those conditions. 7. This section does not prohibit a resident from rejecting medical care. If a resident rejects medical care, an employee of the facility shall record the rejection in writing and request that the resident sign that record as a confirmation of his or her rejection of medical care. If the resident rejects medical care that a physician has directed the facility to provide, the facility shall inform the resident’s physician of that fact within 4 hours after the care is rejected. The facility shall maintain a record of the notice provided to the physician pursuant to this subsection. 8. As used in this section, “significant change” means a change in a resident’s condition that results in a category 1 resident becoming a category 2 resident or otherwise results in an increase in the level of care required by the resident. [Bd. of Health, Group Care Facilities §§ 8.1-8.4, eff. 12-18-75]—(NAC A 3-6-86; R003-97, 10-30-97; R073-03, 1-22-2004) NAC 449.2742 Administration of medication: Responsibilities of administrator, caregivers and employees of facility. ( NRS 439.200 , 449.0302 , 449.0304 ) 1. The administrator of a residential facility that provides assistance to residents in the administration of medications shall: (a) Ensure that a physician, pharmacist or registered nurse who does not have a financial interest in the facility: (1) Reviews for accuracy and appropriateness, at least once every 6 months, the regimen of drugs taken by each resident of the facility, including, without limitation, any over-the-counter medications and dietary supplements taken by a resident; and (2) Provides a written report of that review to the administrator of the facility. (b) Include a copy of each report submitted to the administrator pursuant to paragraph (a) in the file maintained pursuant to NAC 449.2749 for the resident who is the subject of the report. (c) Make and maintain a report of any actions that are taken by the caregivers employed by the facility in response to a report submitted pursuant to paragraph (a). (d) Develop and maintain a plan for managing the administration of medications at the residential facility, including, without limitation: (1) Preventing the use of outdated, damaged or contaminated medications; (2) Managing the medications for each resident in a manner which ensures that any prescription medications, over-the-counter medications and nutritional supplements are ordered, filled and refilled in a timely manner to avoid missed dosages; (3) Verifying that orders for medications have been accurately transcribed in the record of the medication administered to each resident in accordance with NAC 449.2744 ; (4) Monitoring the administration of medications and the effective use of the records of the medication administered to each resident; (5) Ensuring that each caregiver who administers a medication is in compliance with the requirements of subsection 6 of NRS 449.0302 and NAC 449.196 ; (6) Ensuring that each caregiver who administers a medication is adequately supervised; (7) Communicating routinely with the prescribing physician or other physician of the resident concerning issues or observations relating to the administration of the medication; and (8) Maintaining reference materials relating to medications at the residential facility, including, without limitation, a current drug guide or medication handbook, which must not be more than 2 years old or providing access to websites on the Internet which provide reliable information concerning medications. (e) Develop and maintain a training program for caregivers of the residential facility who administer medication to residents, including, without limitation, an initial orientation on the plan for managing medications at the facility for each new caregiver and an annual training update on the plan. The administrator shall maintain documentation concerning the provision of the training program and the attendance of caregivers. (f) In his or her first year of employment as an administrator of the residential facility, receive, from a program approved by the Bureau, at least 16 hours of training in the management of medication consisting of not less than 12 hours of classroom training and not less than 4 hours of practical training and obtain a certificate acknowledging completion of such training. (g) After receiving the initial training required by paragraph (f), receive annually at least 8 hours of training in the management of medication and provide the residential facility with satisfactory evidence of the content of the training and his or her attendance at the training. (h) Annually pass an examination relating to the management of medication approved by the Bureau. 2. Within 72 hours after the administrator of the facility receives a report submitted pursuant to paragraph (a) of subsection 1, a member of the staff of the facility shall notify the resident’s physician of any concerns noted by the person who submitted the report. The report must be reviewed and initialed by the administrator. 3. Before assisting a resident in the administration of any medication, including, without limitation, any over-the-counter medication or dietary supplement, a caregiver must obtain written information describing the side effects, possible adverse reactions, contraindications and toxicity of the medication. 4. Except as otherwise provided in this subsection, a caregiver shall assist in the administration of medication to a resident if the resident needs the caregiver’s assistance. A caregiver may assist the ultimate user of: (a) Controlled substances or dangerous drugs only if the conditions prescribed in subsection 6 of NRS 449.0302 are met. (b) Insulin using an auto-injection device only if the conditions prescribed in NRS 449.0304 and NAC 449.1985 are met. 5. An over-the-counter medication or a dietary supplement may be given to a resident only if the resident’s physician has approved the administration of the medication or supplement in writing or the facility is ordered to do so by another physician. The over-the-counter medication or dietary supplement must be administered in accordance with the written instructions of the physician. The administration of over-the-counter medications and dietary supplements must be included in the record required pursuant to paragraph (b) of subsection 1 of NAC 449.2744 . 6. Except as otherwise provided in this subsection, a medication prescribed by a physician must be administered as prescribed by the physician. If a physician orders a change in the amount or times medication is to be administered to a resident: (a) The caregiver responsible for assisting in the administration of the medication shall: (1) Comply with the order; (2) Indicate on the container of the medication that a change has occurred; and (3) Note the change in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744 ; (b) Within 5 days after the change is ordered, a copy of the order or prescription signed by the physician must be included in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744 ; and (c) If the label prepared by a pharmacist does not match the order or prescription written by a physician, the physician, registered nurse or pharmacist must interpret that order or prescription and, within 5 days after the change is ordered, the interpretation must be included in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744 . 7. If a resident refuses, or otherwise misses, an administration of medication, a physician must be notified within 12 hours after the dose is refused or missed. 8. An employee of a residential facility shall not draw medication into a syringe or administer an injection unless authorized by law to do so. 9. If the medication of a resident is discontinued, the expiration date of the medication of a resident has passed, or a resident who has been discharged from the facility does not claim the medication, an employee of a residential facility shall destroy the medication, by an acceptable method of destruction, in the presence of a witness and note the destruction of the medication in the record maintained pursuant to NAC 449.2744 . 10. The administrator of a facility is responsible for any assistance provided to a resident of the residential facility in the administration of medication, including, without limitation, ensuring that all medication is administered in accordance with the provisions of this section. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R204-99, 2-10-2000; R073-03, 1-22-2004; R119-10, 1-13-2011; R109-18, 1-30-2019) NAC 449.2744 Administration of medication: Maintenance and contents of logs and records. ( NRS 449.0302 ) 1. The administrator of a residential facility that provides assistance to residents in the administration of medications shall maintain: (a) A log for each medication received by the facility for use by a resident of the facility. The log must include: (1) The type and quantity of medication received by the facility; (2) The date of its delivery; (3) The name of the person who accepted the delivery; (4) The name of the resident for whom the medication is prescribed; and (5) The date on which any unused medication is removed from the facility or destroyed. (b) A record of the medication administered to each resident. The record must include: (1) The type of medication administered; (2) The date and time that the medication was administered; (3) The date and time that a resident refuses, or otherwise misses, an administration of medication; and (4) Instructions for administering the medication to the resident that reflect each current order or prescription of the resident’s physician. 2. The administrator of the facility shall keep a log of caregivers assigned to administer medications that indicates the shifts during which each caregiver was responsible for assisting in the administration of medication to a resident. This requirement may be met by including on a resident’s medication sheet an indication of who assisted the resident in the administration of the medication, if the caregiver can be identified from this indication. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004) NAC 449.2746 Administration of medication: Restrictions concerning medication taken as needed by resident; written records. ( NRS 449.0302 ) 1. A caregiver employed by a residential facility shall not assist a resident in the administration of a medication that is taken as needed unless: (a) The resident is able to determine his or her need for the medication; (b) The determination of the resident’s need for the medication is made by a medical professional qualified to make that determination; or (c) The caregiver has received written instructions indicating the specific symptoms for which the medication is to be given, the exact amount of medication that may be given and the frequency with which the medication may be given. 2. A caregiver who administers medication to a resident as needed shall record the following information concerning the administration of the medication: (a) The reason for the administration; (b) The date and time of the administration; (c) The dose administered; (d) The results of the administration of the medication; (e) The initials of the caregiver; and (f) Instructions for administering the medication to the resident that reflect each current order or prescription of the resident’s physician. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004) NAC 449.2748 Medication: Storage; duties upon discharge, transfer and return of resident. ( NRS 449.0302 ) 1. Medication, including, without limitation, any over-the-counter medication, stored at a residential facility must be stored in a locked area that is cool and dry. The caregivers employed by the facility shall ensure that any medication or medical or diagnostic equipment that may be misused or appropriated by a resident or any other unauthorized person is protected. Medications for external use only must be kept in a locked area separate from other medications. A resident who is capable of administering medication to himself or herself without supervision may keep the resident’s medication in his or her room if the medication is kept in a locked container for which the facility has been provided a key. 2. Medication stored in a refrigerator, including, without limitation, any over-the-counter medication, must be kept in a locked box unless the refrigerator is locked or is located in a locked room. 3. Medication, including, without limitation, any over-the-counter medication or dietary supplement, must be: (a) Plainly labeled as to its contents, the name of the resident for whom it is prescribed and the name of the prescribing physician; and (b) Kept in its original container until it is administered. 4. Except as otherwise provided in subsection 5, when a resident is discharged or transferred from a residential facility, all medications prescribed for the resident must be provided to the resident or to the facility to which he or she is transferred. 5. If a resident is transferred to a hospital or skilled nursing facility, the residential facility shall hold the resident’s medications until the resident returns or for 30 days after the transfer, whichever is less, unless the hospital or skilled nursing facility requests the residential facility to provide the hospital or skilled nursing facility with the medications. If the resident does not return within 30 days after the transfer, the residential facility shall promptly dispose of any remaining medications. Upon the return of the resident from the hospital or skilled nursing facility, the residential facility shall, if there has been any change in the resident’s medication regimen: (a) Contact a physician, within 24 hours after the resident returns, to clarify the change; and (b) Document the physician contact in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744 . (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R204-99, 2-10-2000; R073-03, 1-22-2004) NAC 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information. ( NRS 449.0302 ) 1. A separate file must be maintained for each resident of a residential facility and retained for at least 5 years after he or she permanently leaves the facility. The file must be kept locked in a place that is resistant to fire and is protected against unauthorized use. The file must contain all records, letters, assessments, medical information and any other information related to the resident, including, without limitation: (a) The full name, address, date of birth and social security number of the resident. (b) The address and telephone number of the resident’s physician and the next of kin or guardian of the resident or any other person responsible for the resident. (c) A statement of the resident’s allergies, if any, and any special diet or medication he or she requires. (d) A statement from the resident’s physician concerning the mental and physical condition of the resident that includes: (1) A description of any medical conditions which require the performance of medical services; (2) The method in which those services must be performed; and (3) A statement of whether the resident is capable of performing the required medical services. (e) Evidence of compliance with the provisions of chapter 441A of NRS and the regulations adopted pursuant thereto. (f) The types and amounts of protective supervision and personal services needed by the resident. (g) An evaluation of the resident’s ability to perform the activities of daily living and a brief description of any assistance he or she needs to perform those activities. The facility shall prepare such an evaluation: (1) Upon the admission of the resident; (2) Each time there is a change in the mental or physical condition of the resident that may significantly affect his or her ability to perform the activities of daily living; and (3) In any event, not less than once each year. (h) A list of the rules for the facility that is signed by the administrator of the facility and the resident or a representative of the resident. (i) The name and telephone number of the vendors and medical professionals that provide services for the resident. (j) A document signed by the administrator of the facility when the resident permanently leaves the facility. 2. The document required pursuant to paragraph (j) of subsection 1 must indicate the location to which the resident was transferred or the person in whose care the resident was discharged. If the resident dies while a resident of the facility, the document must include the time and date of the death and the dates on which the person responsible for the resident was contacted to inform him or her of the death. 3. Except as otherwise provided in this subsection, a resident’s file must be kept confidential. A resident’s file must be made available upon request at any time to an employee of the Bureau who is acting in his or her capacity as an employee of the Bureau. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004) Special Types of Services and Facilities NAC 449.275 Residential facility which provides residents with hospice care: Responsibilities of staff; retention of resident with special medical needs. ( NRS 449.0302 ) 1. A residential facility that provides services to a resident who elects to receive hospice care shall obtain a copy of the plan of care required pursuant to NAC 449.0186 for that resident. 2. The members of the staff of the facility shall: (a) Maintain at the facility a written record of the care and services provided to a resident who receives hospice care; and (b) Report any deviation from the established plan of care to the resident’s physician within 24 hours after the deviation occurs. 3. If the Division grants a request made pursuant to NAC 449.2736 by the administrator of a residential facility that provides hospice care, the residential facility may retain a resident who: (a) Is bedfast, as defined in NAC 449.2702 ; or (b) Requires skilled nursing or other medical care on a 24-hour basis. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004) NAC 449.2751 Residential facility which provides assisted living services: Application for endorsement; general requirements. ( NRS 449.0302 ) 1. Each residential facility that wishes to provide assisted living services must apply to the Division to obtain an endorsement on its license authorizing the residential facility to provide assisted living services. 2. The Division may deny an application for an endorsement that is made pursuant to subsection 1 or suspend or revoke an existing endorsement granted pursuant to subsection 1: (a) Based upon the grounds set forth in NAC 449.191 or 449.1915 ; or (b) If the residential facility for which the applicant is applying or the residential facility which has an endorsement does not satisfy the requirements set forth in this section or subsections 7 and 8 of NRS 449.0302 . 3. If a residential facility provides assisted living services, the written policies that the residential facility is required to develop pursuant to NAC 449.258 must include, without limitation, procedures to be followed: (a) To ensure that the residential facility complies with the requirements set forth in subsections 7 and 8 of NRS 449.0302 ; (b) By the administrator to ensure that residents of the residential facility whose physical or mental condition is significantly changing over time are identified; (c) To obtain a medical professional to assess and monitor, as necessary, but not less than once every quarter in each calendar year, each resident of the residential facility whose physical or mental condition is declining over time; and (d) To provide services to residents of the residential facility pursuant to the assessment and monitoring performed pursuant to paragraph (c). 4. The administrator of a residential facility that provides assisted living services shall ensure that: (a) A medical professional is notified whenever there has been a significant change in the physical or mental condition of a resident of the residential facility whose physical or mental condition is declining over time; and (b) The residential facility maintains a list of resources for financial assistance and other social services that may decrease the need for a resident of the residential facility whose physical or mental condition is declining over time to move out of the residential facility. 5. The services provided by a residential facility that provides assisted living services must include, without limitation, services that will enable the residential facility to retain residents who have the medical needs or conditions described in NAC 449.2712 to 449.2734 , inclusive, and 449.275 . (Added to NAC by Bd. of Health by R097-06, eff. 7-14-2006; A by R119-10, 1-13-2011) NAC 449.2754 Residential facility which provides care to persons with Alzheimer’s disease: Application for endorsement; general requirements. ( NRS 449.0302 ) 1. A residential facility which offers or provides care for a resident with Alzheimer’s disease or related dementia must obtain an endorsement on its license authorizing it to operate as a residential facility which provides care to persons with Alzheimer’s disease. The Division may deny an application for an endorsement or suspend or revoke an existing endorsement based upon the grounds set forth in NAC 449.191 or 449.1915 . 2. If a residential facility is authorized to operate as a residential facility which provides care to persons with Alzheimer’s disease and as another type of facility, the entire facility must comply with the requirements of this section or the residents who suffer from Alzheimer’s disease or other related dementia must be located in a separate portion of the facility that complies with the provisions of this section. 3. A residential facility which provides care to persons with Alzheimer’s disease may admit or retain a resident who requires confinement in locked quarters. 4. A residential facility which provides care to persons with Alzheimer’s disease must be administered by a person who: (a) Has not less than 3 years of experience in caring for residents with Alzheimer’s disease or related dementia in a licensed facility; or (b) Has a combination of education and training that the Bureau determines is equivalent to the experience required pursuant to paragraph (a). 5. The administrator of such a facility shall prescribe and maintain on the premises of the facility a written statement which includes: (a) The facility’s policies and procedures for providing care to its residents; (b) Evidence that the facility has established interaction groups within the facility which consist of not more than six residents for each caregiver during those hours when the residents are awake; (c) A description of: (1) The basic services provided for the needs of residents who suffer from dementia; (2) The activities developed for the residents by the members of the staff of the facility; (3) The manner in which the behavioral problems will be managed; (4) The manner in which the medication for residents will be managed; (5) The activities that will be developed by the members of the staff of the facility to encourage the involvement of family members in the lives of the residents; and (6) The steps the members of the staff of the facility will take to: (I) Prevent residents from wandering from the facility; and (II) Respond when a resident wanders from the facility; and (d) The criteria for admission to and discharge and transfer from the facility. 6. The written statement required pursuant to subsection 5 must be available for review by members of the staff of the facility, visitors to the facility and the Bureau. 7. The administrator shall ensure that the facility complies with the provisions of the statement required pursuant to subsection 5. 8. The members of the staff of the facility shall develop a program of activities that promotes the mental and physical enhancement of the residents. The following activities must be conducted at least weekly: (a) Activities to enhance the gross motor skills of the residents; (b) Social activities; (c) Activities to enhance the sensory abilities of the residents; and (d) Outdoor activities. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004; R119-10, 1-13-2011) NAC 449.2756 Residential facility which provides care to persons with Alzheimer’s disease: Standards for safety; personnel required; training for employees. ( NRS 449.0302 ) 1. The administrator of a residential facility which provides care to persons with Alzheimer’s disease shall ensure that: (a) Swimming pools and other bodies of water are fenced or protected by other acceptable means. (b) Operational alarms, buzzers, horns or other audible devices which are activated when a door is opened are installed on all doors that may be used to exit the facility. (c) At least one member of the staff is awake and on duty at the facility at all times. (d) Each employee of the facility who has direct contact with and provides care to residents with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, successfully completes the training and continuing education required pursuant to NAC 449.2768 . (e) Knives, matches, firearms, tools and other items that could constitute a danger to the residents of the facility are inaccessible to the residents. (f) The facility has an area outside the facility or a yard adjacent to the facility that: (1) May be used by the residents for outdoor activities; (2) Has at least 40 square feet of space for each resident in the facility; (3) Is fenced; and (4) Is maintained in a manner that does not jeopardize the safety of the residents. Ê All gates leading from the secured, fenced area or yard to an unsecured open area or yard must be locked and keys for gates must be readily available to the members of the staff of the facility at all times. (g) All toxic substances are not accessible to the residents of the facility. 2. The training required pursuant to NAC 449.2768 may be used to satisfy the requirement of paragraph (f) of subsection 1 of NAC 449.196 for the year in which the training is received. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004; R071-04, 8-4-2004) NAC 449.2758 Residential facility which provides care for elderly persons or persons with disabilities: Training for caregivers. ( NRS 449.0302 ) 1. Within 60 days after being employed by a residential facility for elderly persons or persons with disabilities, a caregiver must receive not less than 4 hours of training related to the care of those residents. 2. As used in this section, “residential facility for elderly persons or persons with disabilities” means a residential facility that provides care to elderly persons or persons with disabilities who require assistance or protective supervision because they suffer from infirmities or disabilities. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004) NAC 449.2762 Residential facility which offers or provides care for adults with intellectual disabilities or adults with developmental disabilities: Application for endorsement; training for caregivers. ( NRS 449.0302 ) 1. A residential facility which offers or provides care and protective supervision for a resident with an intellectual disability or a resident with a developmental disability must obtain an endorsement on its license authorizing it to operate as a residential facility for adults with intellectual disabilities. The Division may deny an application for an endorsement or suspend or revoke an existing endorsement based upon the grounds set forth in NAC 449.191 or 449.1915 . 2. Within 60 days after being employed by a residential facility for adults with intellectual disabilities, a caregiver must receive not less than 4 hours of training related to the care of persons with intellectual disabilities. 3. If a resident with an intellectual disability is referred to the facility by a referring agency, the members of the staff of the facility may conduct a program to modify the behavior of the resident if that program is developed by the agency that referred the resident to the facility. 4. As used in this section, “residential facility for adults with intellectual disabilities” means a residential facility that provides care and protective supervision for persons with intellectual disabilities or persons with developmental disabilities, including, without limitation, birth trauma, anoxia, brain trauma or other genetic or developmental disorders. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004; R119-10, 1-13-2011) NAC 449.2764 Residential facility which offers or provides care for persons with mental illnesses: Application for endorsement; training for employees. ( NRS 449.0302 ) 1. A residential facility which offers or provides care and protective supervision for a resident with mental illness must obtain an endorsement on its license authorizing it to operate as a residential facility for persons with mental illnesses. The Division may deny an application for an endorsement or suspend or revoke an existing endorsement based upon the grounds set forth in NAC 449.191 or 449.1915 . 2. A person who provides care for a resident of a residential facility for persons with mental illnesses shall, within 60 days after becoming employed at the facility, attend not less than 8 hours of training concerning care for residents who are suffering from mental illnesses. 3. As used in this section, “residential facility for persons with mental illnesses” means a residential facility that provides care and protective supervision for persons with mental illnesses, including, without limitation, schizophrenia, bipolar disorder, psychosis and other related disorders. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R052-99, 9-27-99; R073-03, 1-22-2004; R119-10, 1-13-2011) NAC 449.2766 Residential facility which offers or provides care for persons with chronic illnesses and debilitating diseases: Application for endorsement; training for employees. ( NRS 449.0302 ) 1. A residential facility which offers or provides care and protective supervision for a resident with a chronic illness or progressively debilitating disease must obtain an endorsement on its license authorizing it to operate as a residential facility for persons with chronic illnesses. The Division may deny an application for an endorsement or suspend or revoke an existing endorsement based upon the grounds set forth in NAC 449.191 or 449.1915 . 2. Within 60 days after being employed by a residential facility for persons with chronic illnesses, an employee of the facility shall obtain at least 4 hours of in-service training relating to the care provided to such persons and in the actions necessary to control infections. 3. Evidence of training received pursuant to subsection 2 must be included in the employee’s personnel file. 4. As used in this section, “residential facility for persons with chronic illnesses” means a residential facility that provides care and protective supervision for persons with chronic illnesses or progressively debilitating diseases, including, without limitation, acquired immunodeficiency syndrome and cancer. (Added to NAC by Bd. of Health by R003-97, eff. 10-30-97; A by R073-03, 1-22-2004; R119-10, 1-13-2011) NAC 449.2768 Residential facility which provides care to persons with dementia: Training for employees. ( NRS 449.0302 , 449.094 ) 1. Except as otherwise provided in subsection 2, the administrator of a residential facility which provides care to persons with any form of dementia shall ensure that: (a) Each employee of the facility who has direct contact with and provides care to residents with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, successfully completes: (1) Within the first 40 hours that such an employee works at the facility after he or she is initially employed at the facility, at least 2 hours of training in providing care, including emergency care, to a resident with any form of dementia, including, without limitation, Alzheimer’s disease, and providing support for the members of the resident’s family. (2) In addition to the training requirements set forth in subparagraph (1), within 3 months after such an employee is initially employed at the facility, at least 8 hours of training in providing care to a resident with any form of dementia, including, without limitation, Alzheimer’s disease. (3) If such an employee is licensed or certified by an occupational licensing board, at least 3 hours of continuing education in providing care to a resident with dementia, which must be completed on or before the anniversary date of the first date the employee was initially employed at the facility. The requirements set forth in this subparagraph are in addition to those set forth in subparagraphs (1) and (2), may be used to satisfy any continuing education requirements of an occupational licensing board, and do not constitute additional hours or units of continuing education required by the occupational licensing board. (4) If such an employee is a caregiver, other than a caregiver described in subparagraph (3), at least 3 hours of training in providing care to a resident with dementia, which must be completed on or before the anniversary date of the first date the employee was initially employed at the facility. The requirements set forth in this subparagraph are in addition to those set forth in subparagraphs (1) and (2). (b) The facility maintains proof of completion of the hours of training and continuing education required pursuant to this section in the personnel file of each employee of the facility who is required to complete the training or continuing education. 2. A person employed by a facility which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, is not required to complete the hours of training or continuing education required pursuant to this section if he or she has completed that training within the previous 12 months. (Added to NAC by Bd. of Health by R071-04, eff. 8-4-2004) Deficiencies NAC 449.27702 Determination of severity and scope of deficiency; assignment of grade. ( NRS 449.0302 ) 1. The Bureau shall determine: (a) The severity of a deficiency of a residential facility in accordance with the provisions of NAC 449.99861 ; and (b) The scope of a deficiency of a residential facility in accordance with the provisions of NAC 449.9986 . 2. After the Bureau conducts a survey of a residential facility, the Bureau shall add the severity and scope scores for all deficiencies of the facility indicated in the survey and assign a grade to the facility as follows: Sum of Severity and Scope Scores Grade 0 to 15 points A At least 16 points but not more than 24 points, or any deficiency with a severity level of 3 and a scope level of 3 B At least 25 points but not more than 34 points, or any deficiency with a severity level of 4 and a scope level of 1 C At least 35 points, or any deficiency with a severity level of 4 and a scope level of at least 2 D (Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005) NAC 449.27704 Placard: Issuance and display; failure to comply. ( NRS 449.0302 ) 1. After the Bureau assigns a grade to a residential facility pursuant to NAC 449.27702 , the Bureau shall issue a placard to the residential facility. 2. The administrator shall, within 24 hours after receipt of the placard, display or cause the placard to be displayed conspicuously in a public area of the residential facility. 3. If the placard is not displayed in accordance with the provisions of subsection 2, the Bureau will assess against the residential facility a deficiency with a severity and scope score equal to the highest severity and scope score indicated in the most recent survey of the facility conducted by the Bureau. (Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005) NAC 449.27706 Resurvey: Application and fee; failure to comply. ( NRS 439.150 , 439.200 , 449.0302 ) 1. If the Bureau issues a placard to a residential facility that includes a grade of “B,” the administrator may submit an application to the Bureau for a resurvey of the facility not later than 30 days after the facility receives the placard. The fee for an application for a resurvey is $400 and must accompany the application. 2. If the Bureau issues a placard to a residential facility that includes a grade of “C” or “D,” the administrator must submit an application to the Bureau for a resurvey of the facility not later than 30 days after the facility receives the placard. The fee for an application for a resurvey is $600 and must accompany the application. 3. The Bureau may revoke the license of a residential facility that is required to submit an application for a resurvey pursuant to subsection 2 if the facility fails to submit the application in accordance with the provisions of that subsection. 4. As used in this section, “resurvey” has the meaning ascribed to it in NAC 449.99838 . (Added to NAC by Bd. of Health by R122-05, eff. 11-17-2005; A by R155-10, 12-16-2010) BUSINESSES THAT PROVIDE REFERRALS TO GROUP HOUSING ARRANGEMENTS NAC 449.27811 Definitions. ( NRS 439.200 , 449.0302 , 449.0305 ) As used in NAC 449.27811 to 449.27831 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.27813 to 449.27819 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R132-99, eff. 11-29-99; A by R048-22, 12-29-2022) NAC 449.27813 “Client” defined. ( NRS 439.200 , 449.0302 , 449.0305 ) “Client” means a person who is referred by a referral agency for compensation to a group housing arrangement. (Added to NAC by Bd. of Health by R132-99, eff. 11-29-99; A by R048-22, 12-29-2022) NAC 449.27817 “Financial assessment” defined. ( NRS 439.200 , 449.0302 , 449.0305 ) “Financial assessment” means an assessment to determine the intended source of payment by a client for services which will be provided by a group housing arrangement for 6 months, including the eligibility status of the client for services as determined by Medicaid and Medicare. (Added to NAC by Bd. of Health by R132-99, eff. 11-29-99; A by R048-22, 12-29-2022) NAC 449.27818 “Group housing arrangement” defined. ( NRS 439.200 , 449.0302 , 449.0305 ) “Group housing arrangement” means a residential facility for groups or any other group housing arrangement that provides assistance, food, shelter or limited supervision to a person with a mental illness, intellectual disability, developmental disability or physical disability or who is aged or infirm. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) NAC 449.27819 “Needs assessment” defined. ( NRS 449.0302 , 449.0305 ) “Needs assessment” means an assessment of a client to document the abilities of the client to function independently, including a complete list of the areas in which the client requires assistance. (Added to NAC by Bd. of Health by R132-99, eff. 11-29-99) NAC 449.27823 License not required by certain persons to make referrals; application for licensure; referral through licensed referral agency. ( NRS 439.200 , 449.0302 , 449.0305 ) 1. A licensed nurse or social worker working in a medical facility or a facility for the dependent licensed by the Bureau may make a referral for a client of the facility or program to a group housing arrangement without first obtaining a license to operate as a referral agency. A person employed by this State or the governing body of any county or city within this State, who is employed in a position in which the person’s duties require him or her to make referrals for clients to group housing arrangements, may make those referrals without first obtaining a license to operate as a referral agency. 2. An applicant for a license to operate as a referral agency must submit to the Division a completed application on a form provided by the Division. The application for the initial license must include, without limitation: (a) Evidence that the applicant has obtained a contract of insurance for protection against liability to third persons which may be incurred while operating as a referral agency; and (b) The physical address of the applicant where the records of the referral agency will be maintained. 3. A licensed nurse, public guardian, social worker, physician, physician assistant or hospital may provide a referral to a group housing arrangement through a licensed referral agency. (Added to NAC by Bd. of Health by R132-99, eff. 11-29-99; A by R124-05, 11-17-2005; R048-22, 12-29-2022) NAC 449.27827 Requirements for employees. ( NRS 439.200 , 449.0302 , 449.0305 ) 1. Employees of a referral agency must have a working knowledge of the provisions of NRS and NAC that govern the licensing of group housing arrangements. 2. An employee of a referral agency who is not licensed as a nurse, social worker, physician or physician assistant shall not gather any information needed to complete a needs assessment or financial assessment of a client, or engage in the process of referring a client to a group housing arrangement. (Added to NAC by Bd. of Health by R132-99, eff. 11-29-99; A by R048-22, 12-29-2022) NAC 449.27829 Responsibilities of referral agency. ( NRS 439.200 , 449.0302 , 449.0305 ) 1. A referral agency shall: (a) Complete a needs assessment and financial assessment for each client and make referrals for the services that would best meet the physical, psychosocial and financial needs and wishes of the client; and (b) Submit to the group housing arrangement to which a client is referred a copy of the needs assessment completed by the referral agency for the client. 2. A referral agency shall not: (a) Accept any fee, inducement or incentive, for any reason, from a group housing arrangement, or from any person or entity associated with a group housing arrangement; or (b) Give a discharge planner, case manager, social worker or any other person who has the responsibility of discharge planning, a fee or incentive for prospective clients. (Added to NAC by Bd. of Health by R132-99, eff. 11-29-99; A by R048-22, 12-29-2022) NAC 449.27831 Contract for services; fees; maintenance of client records. ( NRS 439.200 , 449.0302 , 449.0305 ) 1. Before a referral agency may provide any services to a client, the referral agency must obtain a written contract from the client or his or her legal representative to provide the services. The contract must: (a) Be signed by a representative of the referral agency and the person who is paying for the services or his or her representative; and (b) Include, without limitation, a description of the services to be provided pursuant to the contract and all fees associated with the provision of those services. 2. If, within 30 days after a client is admitted to a group housing arrangement, the referral of the client to the group housing arrangement is determined by the facility, the Bureau or a physician to be inappropriate, the referral agency shall: (a) Refund the full amount of the fee paid by the client or his or her representative; or (b) Assist the client with an acceptable referral to another group housing arrangement for no additional fee. 3. A referral agency shall not receive more than one fee from a client within any 6-month period unless, during that period, the client or his or her representative requests another referral by the referral agency. 4. A referral agency shall maintain an organized file for each client that includes, without limitation: (a) A copy of the needs assessment and financial assessment completed by the referral agency for the client; (b) A copy of the completed contract to provide the services to the client; and (c) Information outlining the process used by the referral agency for determining the appropriate referral of the client. Ê A referral agency shall maintain its file of a client for at least 5 years at the place of business of the referral agency. (Added to NAC by Bd. of Health by R132-99, eff. 11-29-99; A by R048-22, 12-29-2022) HOSPITALS General Provisions NAC 449.279 Definitions. ( NRS 439.200 , 449.0302 ) As used in NAC 449.279 to 449.394 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.286 to 449.300 , inclusive, have the meanings ascribed to them in those sections. (Supplied in codification; A by Bd. of Health by R050-99, 9-27-99; R133-18, 12-19-2018; R048-22, 12-29-2022) NAC 449.286 “Governing body” defined. ( NRS 449.0302 ) “Governing body” means the person or group of persons, including a board of trustees, board of directors or other body, in whom the final authority and responsibility is vested for conduct of a hospital. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.287 “Hospital” defined. ( NRS 449.0302 ) “Hospital” has the meaning ascribed to it in NRS 449.012 . (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.289 “Inpatient” defined. ( NRS 439.200 , 449.0302 ) “Inpatient” means a person who has been formally admitted into a hospital for diagnosis or treatment and: 1. Is expected, at the time of admission, to receive care or occupy a bed at the hospital at midnight on at least 2 consecutive days; or 2. Actually receives care or occupies a bed at the hospital at midnight on at least 2 consecutive days. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R133-18, 12-19-2018) NAC 449.297 “Outpatient” defined. ( NRS 439.200 , 449.0302 ) “Outpatient” means a person who has been registered or accepted for care in a hospital but who is not an inpatient. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R133-18, 12-19-2018) NAC 449.298 “Outpatient department” defined. ( NRS 449.0302 ) “Outpatient department” means that part of a hospital used for the treatment and diagnosis of patients not residing in the hospital. [Bd. of Health, Health Facilities Reg. Part I part Ch. III, eff. 10-9-69] NAC 449.299 “Patient” defined. ( NRS 449.0302 ) “Patient” means a person who: 1. Is receiving diagnostic, therapeutic or preventive health services; or 2. Is under observation or treatment for an illness or injury, or under care during and after pregnancy. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.300 “Restraint” defined. ( NRS 449.0302 ) “Restraint” means the control of the activity of a patient to protect the patient or others from injury by the seclusion of the patient or the use of mechanical devices. The term does not include the control of the activity of a patient by the use of mechanical supports that are used in rehabilitative situations to achieve proper body alignment. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) Licensing and Administration NAC 449.307 Applicability of license; coverage against certain liabilities. ( NRS 449.0302 ) 1. A hospital must be operated and conducted in the name designated on the license, with the name of the person responsible for its operation also appearing on the face of the license. The license is not transferable. 2. Each hospital must retain proof that it is adequately covered against liabilities resulting from claims incurred in the course of operation. 3. Except as otherwise provided in this subsection, separate licenses are required for hospitals which are maintained on separate premises even though the hospitals are under the same management. The provisions of this subsection do not apply to outpatient departments, clinics or separate buildings on the same grounds. 4. A separate license is not required for the provision of special services within a hospital. This subsection does not relieve a hospital to which a special service is being added from the requirement of obtaining the approval of the Division to amend its license pursuant to NRS 449.087 before providing that service. [Bd. of Health, Health Facilities Reg. Part II Ch. II §§ 1-4, eff. 10-9-69; A 8-26-74]—(NAC A by R044-97, 10-30-97; R050-99, 9-27-99; R117-05, 11-17-2005) NAC 449.310 Limitation on number of patients; annual on-site inspection not required under certain circumstances. ( NRS 449.0302 ) 1. A hospital shall not have more patients than the number of beds for which it is licensed, except in emergencies. If there is an emergency, the hospital shall notify the Bureau. 2. If a hospital is accredited by the Joint Commission on Accreditation of Healthcare Organizations or the American Osteopathic Association, the Bureau is not required to make an annual on-site inspection of the hospital. [Bd. of Health, Health Facilities Reg. Part II Ch. II §§ 5-9, eff. 10-9-69; A 8-26-74]—(NAC A by R035-97, 10-30-97; R050-99, 9-27-99) NAC 449.312 Change in ownership, use or construction; correction of deficiencies. ( NRS 449.0302 ) 1. Upon a change in ownership, change of use or change in construction, a hospital shall notify the Bureau of the changes and identify all areas of noncompliance with the guidelines specified in NAC 449.3154 before the change in ownership, use or construction may take place. 2. Upon a change of use or change in construction, a hospital must come into compliance with the guidelines before it may admit patients into the area in which the change is made. 3. The Bureau shall notify a hospital in writing of the existence of any deficiencies and the hospital shall correct those deficiencies within a reasonable amount of time. Except for major deficiencies, including deficiencies which require structural alterations of a building or a portion of a building, and except as otherwise provided in this subsection, reasonable time for the purposes of this subsection shall be deemed to be not more than 180 days. Upon written request and just cause shown, the Bureau may grant an extension of the time in which a deficiency must be corrected based on extenuating circumstances. 4. If the deficiencies are likely to cause serious injury, serious harm or impairment to public health and welfare, the hospital shall take immediate action to correct the deficiencies or the hospital will not be allowed to continue to operate. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XVI subsec. F, eff. 10-9-69; A 8-26-74; Ch. II part § XI, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.313 Responsibilities and duties of governing body; bylaws; appointment and duties of chief executive officer; protocol for organ donations; annual operating budget. ( NRS 449.0302 ) 1. A hospital shall have an effective governing body which is legally responsible for the conduct of the hospital. 2. The governing body of a hospital shall adopt a workable set of bylaws which must be in writing and available to all members. The governing body shall: (a) Determine, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff of the hospital; (b) Appoint members to the medical staff after considering the recommendations of the existing members of the medical staff; (c) Ensure that the medical staff has bylaws; (d) Approve the bylaws of the medical staff and any other rules and regulations adopted by the medical staff; (e) Ensure that the medical staff is accountable to the governing body for the quality of care which the medical staff provides to patients; and (f) Ensure that the criteria for the selection of members to the medical staff include competence, training, experience and judgment. 3. The governing body shall appoint a qualified chief executive officer using as its criteria the actual experience, nature and duration of hospital administration and graduate work in hospital administration of the appointee. Following his or her selection, the chief executive officer is responsible for the management of the hospital and for providing liaisons among the governing body, medical staff, nursing staff and other departments, units and services within the hospital. The chief executive officer shall keep the governing body fully informed of the conduct of the hospital through regular written reports. The chief executive officer must be allowed sufficient freedom from other responsibilities to provide adequate attention to the administration and management of the hospital. 4. The governing body shall ensure, in accordance with hospital policy, that: (a) Each patient is under the care of at least one of the following persons: (1) A doctor of medicine or osteopathy. (2) A doctor of dental surgery or dental medicine who is licensed to practice dentistry in this State and who is acting within the scope of his or her license. (3) A doctor of podiatric medicine, but only with respect to those functions which he or she is licensed to perform in this State. (4) A doctor of optometry who is licensed to practice optometry in this State. (5) A chiropractic physician who is licensed to provide chiropractic services in this State, but only with respect to the treatment of the spine by means of manual manipulation to correct a subluxation which is demonstrated by X-ray to exist. (b) A doctor of medicine or osteopathy is on duty or on call at all times. (c) A doctor of medicine or osteopathy is responsible for the care of each patient with respect to any medical or psychiatric problem that: (1) Is present when the patient is admitted into the hospital or develops after the patient is admitted; and (2) Is not specifically within the scope of practice of a doctor of dental surgery, dental medicine, podiatric medicine or optometry, or of a chiropractic physician, as that scope of practice is defined by the bylaws, rules and regulations of the medical staff. 5. To identify potential organ donors, a hospital shall have written protocols that: (a) Ensure that the family of each potential donor knows of its option to donate organs or tissues, or both, or to decline to make such a donation; and (b) Encourage discretion and sensitivity with respect to the circumstances, views and beliefs of the families of potential donors. 6. A hospital in which organ transplants are performed: (a) Must be a member of the Organ Procurement and Transplantation Network established and operated in accordance with section 372 of the Public Health Service Act, 42 U.S.C. § 274; and (b) Shall abide by the rules and regulations of the Organ Procurement and Transplantation Network. 7. A hospital shall have an overall institutional plan which includes an annual operating budget that is prepared according to generally accepted accounting principles. The annual operating budget must include anticipated income and expenses, except that the hospital is not required to identify item-by-item the components of each anticipated income or expense. 8. The governing body is responsible for the services furnished in the hospital, regardless of whether the services are furnished by staff or pursuant to contracts. The hospital shall maintain a list of contracted services which includes the scope and nature of the services provided. [Bd. of Health, Health Facilities Reg. Part III Ch. I § 1, eff. 10-9-69; A 8-26-74; ch. II § I, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.314 Quality of care; scope of services. ( NRS 449.0302 ) 1. A hospital must be administered in a manner that enables the hospital to use its resources effectively and efficiently to meet the needs of and provide quality care to its patients. The governing body of a hospital shall develop and provide services for the care of its patients based on the identified needs of those patients. 2. The scope of services provided by each department, unit or service within a hospital must be defined in writing and must be approved by the administration and the medical staff of the hospital. Each department, unit or service within a hospital shall provide patient care in accordance with its scope of services. The policies and procedures of a hospital and of each department, unit or service within the hospital must, to the extent necessary, be integrated with the policies and procedures of the other departments, units and services within the hospital. 3. The governing body of a hospital shall: (a) Ensure that the competence of all members of the hospital staff is assessed, maintained, demonstrated and improved; (b) Provide an orientation process for persons hired to work at the hospital that includes initial job training and information; and (c) Assess the ability of the members of the hospital staff to fulfill their specified responsibilities. 4. A hospital shall ensure that it is staffed by a sufficient number of personnel, whose qualifications are consistent with their job responsibilities, to provide care to the patients of the hospital. 5. The chief executive officer of a hospital is responsible for operating the hospital in accordance with the authority conferred on him or her by the governing body. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.3152 Quality improvement program. ( NRS 449.0302 ) 1. The governing body of a hospital shall ensure that the hospital has an effective, comprehensive quality improvement program to evaluate the provision of care to its patients. 2. The quality improvement program must: (a) Be ongoing; (b) Include a written plan for carrying out the program; and (c) Provide for the creation of a committee to oversee the program. 3. All services related to patient care, including services furnished by a contractor, must be evaluated by the committee. 4. Nosocomial infections, medication therapy and deaths occurring in the hospital must be evaluated by the committee. 5. All medical and surgical services performed in the hospital must be evaluated by the committee as those services relate to the appropriateness of the diagnosis and treatment. 6. The committee shall initiate an assessment of a service or the provision of care when any statistical analysis detects an undesirable variation in performance. 7. The committee shall take and document appropriate remedial action to address deficiencies found through the quality improvement program. The committee shall document the outcome of any remedial action taken. 8. When the findings of an assessment relate to the performance of an individual licensed practitioner, the medical staff shall determine how such a finding will be used in any peer review, ongoing monitoring and periodic evaluations of the competence of the practitioner. If the findings of the assessment relate to the performance of a person who is not a licensed practitioner, the director of the department, unit or service in which that person works shall determine how the finding will be used in evaluating the competence of the person. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.3154 Construction, remodeling, maintenance and change of use: General requirements; prerequisites to approval of licensure. ( NRS 439.200 , 449.0302 ) 1. Except as otherwise provided in this section, a hospital shall comply with the provisions of NFPA 101: Life Safety Code , adopted by reference pursuant to NAC 449.0105 . 2. Except as otherwise provided in this section, any new construction, remodeling or change in the use of a hospital must comply with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 , unless the remodeling is limited to refurbishing an area of the hospital, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area and replacing window or wall coverings in the area. 3. Except as otherwise provided in subsection 4, a hospital shall meet all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Life safety, environmental, health, fire and local building codes, Ê related to the construction and maintenance of the hospital. If there are any differences between the state and local codes, the more restrictive standards apply. 4. A hospital which is inspected and approved by the State Public Works Division of the Department of Administration in accordance with the provisions set forth in chapter 341 of NRS and chapter 341 of NAC is not required to comply with any applicable local building codes related to the construction and maintenance of the hospital. 5. A complete copy of the building plans for new construction and remodeling of a hospital, drawn to scale, must be submitted to the entity designated to review such plans by the Division of Public and Behavioral Health pursuant to the provisions of NAC 449.0115 . Before the construction or remodeling may begin, plans for the construction or remodeling must be approved by the Division of Public and Behavioral Health. 6. The Bureau shall not approve the licensure of a hospital until all construction has been completed and a survey is conducted at the site. The plan review is only advisory and does not constitute prelicensing approval. 7. Notwithstanding any provision of this section to the contrary, a hospital which was licensed on January 1, 1999, shall be deemed to be in compliance with this section if the use of the physical space in the hospital does not change and the existing construction of the hospital does not have any deficiencies which are likely to cause serious injury, serious harm or impairment to public health and welfare. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R076-01, 10-18-2001; R068-04, 8-4-2004; R122-16, 9-21-2017; R048-22, 12-29-2022) NAC 449.3156 Compliance with certain guidelines for design and construction; correction of deficiencies. ( NRS 439.200 , 449.0302 ) 1. Notwithstanding any provision of NAC 449.3154 to the contrary, a hospital shall be deemed to be in compliance with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 , if: (a) The hospital submitted architectural plans to the Bureau on or before February 1, 1999; (b) The hospital began construction on or before August 1, 1999; (c) The plans were determined by the Bureau to be in compliance with the provisions of NAC 449.002 to 449.99939 , inclusive, that were in effect on December 1, 1998; (d) The hospital is built in accordance with those provisions; (e) The use of the physical space in the hospital has not changed; and (f) There are no deficiencies in the construction of the hospital which are likely to cause serious injury, serious harm or impairment to public health and welfare. 2. If there are deficiencies that are likely to cause serious injury, serious harm or impairment to public health and welfare, the hospital shall take immediate action to correct the deficiencies or the hospital will not be allowed to continue to operate. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R068-04, 8-4-2004; R122-16, 9-21-2017; R048-22, 12-29-2022) Policies and Procedures for Operation of Hospital NAC 449.316 Physical environment: Safety and well-being of patients; plan for emergency preparedness; safety management. ( NRS 449.0302 ) 1. The buildings of a hospital must be solidly constructed with adequate space and safeguards for each patient. The condition of the physical plant and the overall hospital environment must be developed and maintained in a manner so that the safety and well-being of patients are ensured. 2. A hospital shall develop and carry out a comprehensive plan for emergency preparedness which: (a) Addresses internal and external emergencies, both local and widespread; and (b) Is based on current standards for disaster management and fire safety. 3. A hospital shall ensure that the hospital staff and patients are adequately protected from fire and other disasters. To ensure that it has adequate fire protection, a hospital shall provide for the installation of extinguishers, sprinkling devices, fire barriers and the elimination of fire hazards. 4. The governing body shall analyze identified issues relating to safety management within the environment of care and develop or approve recommendations for addressing those issues. The governing body shall carry out and monitor the effectiveness of the recommendations. [Bd. of Health, Health Facilities Reg. Part III Ch. I § II part subsec. A & subsec. E, eff. 10-9-69; A 8-26-74; Ch. II part § II, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.317 Risk management. ( NRS 449.0302 ) Each hospital shall have in effect a comprehensive program for risk management and shall designate one person to be responsible for the implementation and maintenance of the program for risk management. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.318 Accreditation by national accrediting organization required; exceptions; submission of proof of accreditation to Division. ( NRS 439.200 , 449.0302 ) 1. A hospital must be accredited by an approved national accrediting organization unless the hospital: (a) Is a psychiatric hospital or rural hospital; (b) Has been certified as a critical access hospital by the Secretary of Health and Human Services pursuant to 42 U.S.C. § 1395i-4(e); (c) Contains a distinct part skilled nursing facility or a nursing facility, as defined in 42 C.F.R. § 483.5; (d) Is a hospital described in 42 U.S.C. § 1395ww(d)(1)(B)(iv) and accepts payment through Medicare; (e) Is owned by this State or a political subdivision thereof; (f) Is licensed only for rehabilitation beds; or (g) Was initially licensed before December 19, 2018, and has been licensed continually after that date. 2. A hospital that is required to comply with the requirements of subsection 1 shall submit to the Division proof of such compliance: (a) Not later than 12 months after obtaining an initial license; (b) With each application for renewal submitted pursuant to NAC 449.0116 ; and (c) As required by NAC 449.0108 . 3. As used in this section, “approved national accrediting organization” means a national accrediting organization, as defined in 42 C.F.R. § 488.1, that has been approved by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services pursuant to 42 C.F.R. § 488.5. (Added to NAC by Bd. of Health by R133-18, eff. 12-19-2018; A by R048-22, 12-29-2022) NAC 449.319 Requirements for personal needs of patients. ( NRS 449.0302 ) 1. A hospital shall provide patients access to their belongings as is appropriate based on the needs of the patients and the phase of treatment of the patients. 2. A hospital shall communicate and enforce a nonsmoking policy throughout the hospital. 3. A hospital shall provide a clean and comfortable bed and mattress for each patient. Bed linen, blankets, pillows, washcloths and towels that are clean and in good condition must be provided to each patient. A hospital shall have such systems as are necessary to ensure that an adequate supply of clean linen is provided to each patient. 4. A hospital shall provide each inpatient with necessary bedside equipment and supplies based on the needs of the inpatient. The necessary equipment and supplies must include, without limitation, a water pitcher and equipment for personal hygiene. The equipment and supplies must be maintained in a sanitary manner. 5. In public areas and in areas in which patient care is provided, a hospital shall: (a) Provide adequate and comfortable lighting levels; (b) Provide comfortable and safe temperature levels; and (c) Maintain comfortable sound levels. [Bd. of Health, Health Facilities Reg. Part III Ch. I § II part subsec. A, eff. 10-9-69; A 8-26-74; Ch. II part § II, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.321 Requirement to be primarily engaged in providing certain services; determination of whether requirement is met; exemption for certain hospitals. ( NRS 439.200 , 449.0302 ) 1. A hospital must be primarily engaged in providing the services described in 42 U.S.C. § 1395x(e)(1) to inpatients, unless the hospital: (a) Is a psychiatric hospital or rural hospital; (b) Has been certified as a critical access hospital by the Secretary of Health and Human Services pursuant to 42 U.S.C. § 1395i-4(e); or (c) Contains a distinct part skilled nursing facility or nursing facility, as defined in 42 C.F.R. § 483.5. 2. Except as otherwise provided in subsections 3 and 4, the Division shall determine whether a hospital meets the requirements of subsection 1 based on a totality of the circumstances. 3. Except as otherwise provided in subsection 4, the Division shall deem a hospital to be in compliance with subsection 1 if the hospital: (a) Has 20 or fewer inpatient beds; (b) Has been licensed and operating for less than 12 months; and (c) Contains a number of inpatient beds that is equal to or greater than the capacity for patients in the emergency room at the hospital. 4. The provisions of subsection 3 do not apply to a hospital that was initially licensed on or before December 19, 2018, and has been licensed continually after that date. 5. The Division shall determine that a hospital does not meet the requirements of subsection 1 if the hospital did not maintain: (a) A minimum average daily census of at least two inpatients, as determined pursuant to subsection 6; and (b) An average length of stay of at least 2 days during the 12 months immediately preceding the date on which the Division evaluates the hospital, as determined pursuant to subsection 6. 6. For the purposes of this section: (a) Average daily census must be calculated by dividing the sum for the evaluation period of the number of inpatients in the hospital at midnight of each day of the evaluation period by the number of days in the evaluation period. (b) Average length of stay must be calculated by dividing the total number of inpatient hospital days in an evaluation period by the number of discharges from the hospital in the evaluation period. As used in this paragraph, “inpatient hospital day” means: (1) The day on which a patient is admitted to a hospital; (2) The day on which a patient is discharged from a hospital, including, without limitation, the day on which a patient dies; and (3) Each day after the day on which a patient is admitted to a hospital and before the patient is discharged. (Added to NAC by Bd. of Health by R133-18, eff. 12-19-2018) NAC 449.322 Housekeeping and laundry services. ( NRS 449.0302 ) 1. A hospital shall establish organized housekeeping services planned, operated and maintained to provide a pleasant, safe and sanitary environment. Adequate personnel, using accepted practices and procedures, shall keep the hospital free from offensive odors, accumulations of dirt, rubbish, dust and safety hazards. 2. Suitable equipment and supplies must be provided for cleaning all surfaces. The equipment must be maintained in a safe, sanitary condition. Storage areas, attics and cellars must be kept safe and free from accumulations of extraneous materials such as refuse, discarded furniture and equipment, and old newspapers. Combustibles such as cleaning rags and compounds and hazardous substances must be labeled properly and stored in safe places. Paper towels, tissues and similar supplies must be stored in a manner to prevent their contamination before use. 3. Cleaning must be performed in a manner to minimize the spread of pathogenic organisms. Floors must be cleaned regularly. Polishes on floors must provide a nonslip finish. Throw or scatter rugs must not be used except for nonslip entrance mats. 4. Housekeeping personnel must receive adequate supervision. Continuous in-service training programs must be established for housekeeping personnel. 5. A hospital shall develop and carry out standards and systems for the operation of laundry services. Laundry services, whether owned by the hospital or provided pursuant to a contract, must: (a) Maintain standards for a safe work environment for employees; (b) Address issues relating to the control of infections; and (c) Be operated in a manner that does not disrupt the patient care provided by the hospital. 6. A hospital shall develop and carry out: (a) Standards and systems for the storage and handling of clean linen and soiled linen; and (b) Written policies relating to the handling, storage, transportation and processing of its linen. [Bd. of Health, Health Facilities Reg. Part III Ch. I § II part subsec. A, eff. 10-9-69; A 8-26-74; Ch. II part § II, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.325 Prevention, control and investigation of infections and communicable diseases. ( NRS 449.0302 ) 1. A hospital shall: (a) Provide a sanitary environment to avoid sources and transmission of infections and communicable diseases; and (b) Develop and carry out an active program for the prevention, control and investigation of infections and communicable diseases. 2. A hospital shall designate at least one person as an infection control officer, who shall develop and carry out policies governing the control of infections and communicable diseases. 3. The infection control officer of a hospital shall: (a) Develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel of the hospital; and (b) Maintain a record of incidents within the hospital related to infection and communicable disease. 4. The chief executive officer, the medical staff and the chief administrative nurse of a hospital: (a) Shall ensure that the quality improvement program established pursuant to NAC 449.3152 and the training program for the entire hospital address those problems identified by the infection control officer of the hospital; and (b) Are responsible for the implementation of successful corrective plans of action in affected problem areas. [Bd. of Health, Health Facilities Reg. Part III Ch. I § II part subsec. A & subsec. D, eff. 10-9-69; A 8-26-74; Ch. II part § II, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.327 Preparation, sterilization, storage and distribution of sterile supplies and medical and surgical equipment. ( NRS 449.0302 ) 1. To meet the ongoing needs of its patients, a hospital shall: (a) Provide a designated area for the preparation, sterilization and storage of sufficient sterile supplies and medical and surgical equipment; and (b) Dispense the sterile supplies and equipment to all departments, units and services within the hospital. 2. A hospital which prepares, sterilizes and stores its supplies and equipment directly shall develop systems and standards that are consistent with: (a) The standards for the control of infection established by the infection control officer of the hospital; (b) The standards developed by the Occupational Safety and Health Administration for the preparation, sterilization and storage of such supplies and equipment; and (c) When applicable, the manufacturer’s guidelines for the use and maintenance of the equipment. 3. If the supplies and equipment are sterilized on the premises of a hospital, the process of sterilization must be supervised by a person who has received specialized training in the operation of the process of sterilization, including training in methods of testing the process to verify the efficiency of the process of sterilization. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.329 Admission of patients. ( NRS 449.0302 ) A hospital shall: 1. Develop and carry out policies and procedures for admitting patients to the appropriate levels of care; and 2. Ensure that each patient, or the parent, guardian or other person legally responsible for the patient, receives information about the proposed care of the patient. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.331 Provision of emergency services and medical care; transfer agreements with long-term care facilities; attestation of compliance. ( NRS 439.200 , 449.0302 ) 1. A hospital shall develop and carry out policies and procedures to ensure that emergency services and medical care are provided in accordance with NRS 439B.410 and 450B.790 and 42 C.F.R. § 489.24 and to ensure compliance with the provisions of NRS 450B.795 . 2. All hospitals not having their own long-term facility shall have transfer agreements with long-term care facilities. Transfer agreements between facilities must be in writing and on file at each facility concerned. The agreements must provide for: (a) The transfer of patients between facilities whenever the need for transfer is medically determined; and (b) The exchange of appropriate medical and administrative information between facilities. 3. In addition to the application required by NAC 449.011 or 449.0116 , as applicable, a hospital applying for initial licensure or the renewal of its license shall submit to the Division an attestation under penalty of perjury that the hospital is in compliance with the requirements of this section. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XVI subsecs. A, B & D, eff. 10-9-69; Ch. II part § XI, eff. 10-9-69]—(NAC A by R050-99, 9-27-99; R138-07, 1-30-2008; R133-18, 12-19-2018; R048-22, 12-29-2022) NAC 449.332 Discharge planning. ( NRS 439.200 , 449.0302 ) 1. A hospital shall: (a) Have a process for discharge planning that applies to all inpatients; and (b) Develop and carry out policies and procedures regarding the process for discharge planning. 2. The process for discharge planning must include the participation of registered nurses, social workers or other personnel qualified, through education or experience, to perform discharge planning. 3. A hospital shall, at the earliest possible stage of hospitalization, identify each patient who is likely to suffer adverse health consequences upon discharge if the patient does not receive adequate discharge planning. The hospital shall provide for an evaluation of the needs related to discharge planning of each patient so identified. 4. An evaluation of the needs of a patient relating to discharge planning must include, without limitation, consideration of: (a) The needs of the patient for postoperative services and the availability of those services; (b) The capacity of the patient for self-care; and (c) The possibility of returning the patient to a previous care setting or making another appropriate placement of the patient after discharge. 5. If the evaluation of a patient relating to discharge planning indicates a need for a discharge plan, a discharge plan must be developed under the supervision of a registered nurse, social worker or other person qualified to perform discharge planning. 6. An evaluation of a patient relating to discharge planning and a discharge plan for the patient may be requested by the patient, a physician, a member of the family of the patient or the guardian of the patient, if any. 7. If a hospital finds that a patient does not need a discharge plan, the attending physician may still request a discharge plan for the patient. If the attending physician makes such a request, the physician shall collaborate as much as necessary with the hospital staff in the development of the discharge plan. 8. Activities related to discharge planning must be conducted in a manner that does not contribute to delays in the discharge of the patient. 9. The evaluation of the needs of a patient relating to discharge planning and the discharge plan for the patient, if any, must be documented in his or her medical record. 10. The discharge plan must be discussed with the patient or the person acting on behalf of the patient. 11. The patient, members of the family of the patient and any other person involved in caring for the patient must be provided with such information as is necessary to prepare them for the posthospital care of the patient. 12. If, during the course of a patient’s hospitalization, factors arise that may affect the needs of the patient relating to his or her continuing care or current discharge plan, the needs of the patient must be reassessed and the plan, if any, must be adjusted accordingly. 13. A hospital shall arrange for the initial implementation of the discharge plans of its patients. 14. If identified in a discharge plan, referral of a patient to outpatient services or transfer of the patient to another facility must be accomplished in a manner that meets the identified needs of the patient, including, without limitation: (a) Upon the referral or transfer, necessary sharing of administrative and medical information about the patient with the receiving service or other facility or making such information available to the service or other facility; and (b) Providing for the security of and accountability for the personal effects of the patient. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R133-18, 12-19-2018) NAC 449.337 Dietary services: General requirements. ( NRS 449.0302 ) 1. A hospital shall provide each patient with a nourishing, palatable, well-balanced diet that meets the daily nutritional and dietary needs of the patient. 2. The menu for a patient must meet the nutritional needs of the patient in accordance with: (a) Recognized dietary practices; and (b) The orders of the practitioners responsible for the care of the patient. 3. A hospital shall ensure that not less than three meals are served daily to patients and not more than 15 hours elapse between the evening meal and breakfast served the following day. 4. Nourishment and feeding between meals must be provided as required by diet prescription and must be available to each patient unless otherwise ordered by the physician of the patient. 5. Except as otherwise provided in this subsection, menus must be followed. A meal may vary from the planned menu if the change is noted in writing in the records maintained by the dietary services. 6. A hospital shall ensure that the food and religious preferences of a patient are respected to the extent practicable and that substitute food is available through the use of a selective menu or substitutes from appropriate food groups. 7. A hospital shall ensure that persons who are responsible for therapeutic diets have sufficient knowledge of food values to make appropriate substitutions when necessary. [Bd. of Health, Health Facilities Reg. Part III Ch. I § V, eff. 10-9-69; Ch. II § V, eff. 10-9-69]—(NAC A by R035-97, 10-30-97; R050-99, 9-27-99) NAC 449.338 Dietary services: Provision for needs of patients; facilities; standards; permits; records. ( NRS 449.0302 ) 1. A hospital shall provide for the general dietary needs of its patients, including the preparation of modified special diets. 2. Adequate space for the preparation and service of food must be provided. Equipment for the preparation and service of food must be placed to provide aisles of sufficient width to permit easy movement of personnel, mobile equipment and supplies. 3. Well-ventilated food storage areas of adequate size must be provided. 4. Adequate space must be maintained to accommodate equipment, personnel and procedures necessary for the proper cleaning and sanitizing of dishes and other utensils. 5. Office or other suitable space must be provided for the dietitian and dietetic service supervisor. 6. In providing for the preparation and serving of food, a hospital shall: (a) Comply with the standards prescribed in chapter 446 of NRS and the regulations adopted pursuant thereto; (b) Obtain the necessary permits from the Division; (c) Maintain a report of each inspection concerning the sanitation of the hospital for at least 1 year after the date of the inspection; and (d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R068-04, 8-4-2004; R155-10, 12-16-2010) NAC 449.3385 Dietary services: Personnel. ( NRS 449.0302 ) 1. A hospital shall maintain an organized dietary service that is staffed by an adequate number of personnel. The hospital shall ensure that personnel are on duty to provide dietary services for at least 12 hours each day and that the personnel are competent to perform their duties as outlined in their job descriptions. The dietary service must be integrated with the other departments, units and services within the hospital. 2. The dietary service must be under the direction of a licensed dietitian or other professional person who: (a) Is qualified in the field of institutional management, nutritional sciences or hotel restaurant management; (b) Has completed an academic program in culinary arts; or (c) Is certified as a dietary manager by the Association of Nutrition & Foodservice Professionals and has additional work experience with medical and therapeutic diets. 3. The director of the dietary service may be employed on a full-time or part-time basis, or as a consultant. 4. A hospital shall have on staff a licensed dietitian or a consultant who is licensed as a dietitian who shall provide in-service training for all dietetic service personnel and maintain a record of the in-service training provided which includes a description of the subjects covered by the training, the date that the training was given, the duration of the training and a list of the persons who attended the training. 5. Personnel of the dietary service must: (a) Be trained in basic techniques of food sanitation; (b) While working in the dietary service, be clean and wear clean clothing, including a cap or hairnet, or both; and (c) Be excluded from duty when affected by a skin infection or communicable disease. 6. If an employee of the dietary service has a beard or moustache, or both, which is not closely cropped, the employee shall cover the beard or moustache, or both, while on duty. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R068-04, 8-4-2004; R090-12, 12-20-2012) NAC 449.339 Dietary services: Nutritional status of patients. ( NRS 449.0302 ) 1. A hospital shall carry out a program for the systematic nutritional risk-screening of its patients to detect actual and potential malnutrition at an early stage. 2. A hospital shall ensure that each patient maintains acceptable parameters of nutritional status, including, without limitation, body weight and protein levels, unless the patient’s clinical condition demonstrates that the maintenance of those parameters is not possible. 3. A patient who is fed by an enteral feeding system must receive the appropriate treatment and services to prevent complications to the extent possible. 4. Parenteral nutrition support must be used to nourish a patient who meets clinical guidelines that are developed in accordance with nationally recognized standards of practice and approved by the medical staff of the hospital. 5. A patient must receive a therapeutic diet when it is determined that he or she has a nutritional problem. 6. The director of the dietary service shall develop and carry out policies and procedures for nutritional care and dietetic services. The policies and procedures must be readily available to nursing, dietary and medical staff. The director shall evaluate the policies and procedures for nutritional care and services provided by the dietary service on a regular basis and revise those policies and procedures as necessary. 7. If it is determined that the nutritional status of a patient is at risk, nutritional care for that patient must be: (a) Planned and provided based on an assessment of his or her nutritional status by a licensed dietitian or the attending physician, or both; and (b) Integrated into his or her plan of care. Ê The response of the patient must be monitored and reassessed as needed. 8. Pertinent dietary information must be included in a patient’s transfer records or discharge records, or both, to ensure continuity of nutritional care. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R090-12, 12-20-2012) NAC 449.3395 Dietary services: Sanitary conditions; supplies. ( NRS 449.0302 ) 1. A hospital shall store, prepare, distribute and serve food under sanitary conditions. 2. A hospital shall maintain on its premises at least a 1-week supply of staple foods and at least a 2-day supply of perishable foods. The supplies must be appropriate to meet the requirements of the menu. All food must be of good quality and procured from sources approved or considered satisfactory by federal, state and local authorities. Food that is contained in a container or can that: (a) Is unlabeled, if the contents of the container or can are not readily identifiable without opening the container or can; (b) Is rusty, leaking or broken; or (c) Has dents or swelling, Ê is not acceptable and must not be maintained. 3. All kitchens and kitchen areas in a hospital must be kept clean, kept free from litter and rubbish, and protected from rodents, roaches, flies and other insects. The hospital shall take such measures as are necessary for preventive pest control. All utensils, counters, shelves and equipment must be kept clean, maintained in good repair, and free from breaks, corrosions, open seams, cracks and chipped areas. Plastic ware, china and glassware that is unsightly, unsanitary or hazardous because of chips, cracks or loss of glaze must be discarded. 4. After each use, utensils used for eating or drinking or used in the preparation of food or drink must be cleaned and disinfected, or discarded. 5. Kitchen sinks must not be used for washing hands. Separate facilities for washing hands, which includes soap, running water and individual towels, must be provided. 6. Kitchen wastes that are not disposed of by mechanical means must be: (a) Kept in containers which: (1) Are leak proof; (2) Are made of nonabsorbent materials; and (3) Can be tightly closed; and (b) Disposed of as frequently as necessary to prevent a nuisance or unsightliness. 7. Ice which is used in connection with food or drink must be from a sanitary source and must be handled and dispensed in a sanitary manner. 8. A person other than personnel of the dietary service may not be in the kitchen area unless the person is required to be there in the performance of his or her duties. 9. Equipment of the type and in the amount necessary for the proper preparation, service and storage of food and for proper dishwashing must be provided and maintained in good working order. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.340 Pharmaceutical services. ( NRS 449.0302 ) 1. A hospital shall have a pharmacy directed by a registered pharmacist, who may be a full-time, part-time or consulting pharmacist, or a drug room supervised by no less than a currently licensed professional nurse. If a hospital has an organized pharmaceutical service, the full-time, part-time or consulting pharmacist shall develop, supervise and coordinate all the activities of the service. 2. The pharmacy and area for drug storage must be administered in accordance with all applicable state and federal laws. 3. Except as otherwise provided in this subsection, the medical staff shall develop policies and procedures to minimize errors in the administration of the drugs. The medical staff may designate the organized pharmaceutical service of the hospital to develop the policies and procedures required by this subsection. 4. The pharmaceutical service of a hospital shall have an adequate number of personnel to ensure quality pharmaceutical services, including emergency services. 5. Drugs and biologicals must be controlled and distributed in a manner which is consistent with applicable state and federal laws. 6. When a pharmacist is not available, drugs and biologicals may be removed from the pharmacy or storage area only by personnel designated by the policies of the medical staff and pharmaceutical service, which must be established in accordance with all applicable state and federal laws, to remove the drug or biological. 7. Errors in administering a drug to a patient, adverse reactions by a patient to a drug and incompatibilities between a drug and patient must be immediately reported to the attending physician of the patient and, if appropriate, to the committee that oversees the quality improvement program established pursuant to NAC 449.3152 . 8. Misuses and losses of controlled substances must be reported, in accordance with all applicable state and federal laws, to the person responsible for the pharmaceutical service and the chief executive officer of the hospital. 9. Information relating to drug interactions, drug therapy, side effects, toxicology, dosage indications for use and routes of administration must be made available to the professional members of the hospital staff. 10. A formulary system must be established by the medical staff to ensure the provision of quality pharmaceuticals at reasonable costs. [Bd. of Health, Health Facilities Reg. Part III Ch. I § VII subsecs. A-C, eff. 10-9-69; Ch. II part § VII, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.343 Orders for medication and biologicals. ( NRS 449.0302 ) 1. Except as otherwise provided in this section, an order for medication or biologicals for a patient must be in writing and signed by the practitioner, or other appropriate professional person authorized by state or federal law to order the medication or biological, who is responsible for the care of the patient. 2. When a telephone or verbal order is used to order medications or biologicals, the order must be: (a) Accepted only by a person who is authorized by the policies and procedures of the medical staff, which must be consistent with state law, to accept such an order; and (b) Signed or initialed by the prescribing practitioner in accordance with hospital policy. 3. An order for a medication or a biological must include the name of the medication or biological and the dosage, time or frequency of administration and route of administration of the medication or biological. 4. Medication and biologicals that are not specifically prescribed as to time or number of doses must be automatically stopped after a reasonable time that has been predetermined by the medical staff for that medication or biological. 5. Emergency medications approved by the medical staff or advisory physician must be kept readily available in the pharmacy or drug room and in compliance with all federal, state and local laws. [Bd. of Health, Health Facilities Reg. Part III Ch. I § VII subsecs. D-H, eff. 10-9-69; Ch. II part § VII, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.344 Administration of medication; security. ( NRS 449.0302 ) 1. Only members of the hospital staff who are legally authorized to administer medications may do so. 2. Security of all medications must be maintained in accordance with applicable state law. 3. The quality improvement program established pursuant to NAC 449.3152 must include a system of security to monitor and improve the process of administering medications. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.346 Rehabilitative services. ( NRS 449.0302 ) 1. Rehabilitative services are those activities used in restoring, maintaining and improving the physical and mental well-being of a patient. A hospital shall provide rehabilitative services consistent with its overall role in the treatment of a patient by or under the supervision of persons professionally licensed in this State to render such services. 2. If a hospital provides rehabilitative services, including, without limitation, physical therapy, occupational therapy, audiology or speech-language pathology, the services must be organized and staffed to ensure the health and safety of the patients. The organization of the services must be appropriate to the scope of the services offered. 3. The director of the rehabilitative services must have the necessary knowledge, experience and capabilities to supervise and administer properly the services provided. 4. Rehabilitative services provided by a hospital in accordance with this section must be provided by persons who meet the qualifications specified by the medical staff. 5. Rehabilitative services must be furnished to each patient in accordance with his or her written plan of treatment. The services must be provided pursuant to the order of a practitioner who is authorized by the medical staff to order such services, and those orders must be incorporated into the record of the patient. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XII, eff. 10-9-69; Ch. II § VIII, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.349 Emergency services. ( NRS 449.0302 ) 1. A hospital shall meet the emergency needs of its patients in accordance with nationally recognized standards of practice. 2. If a hospital does not have an emergency department on-site, the policies and procedures for meeting the emergency needs of patients must be under the direction of a qualified member of the medical staff. 3. If a hospital provides emergency services through an emergency department: (a) The services must be organized under the direct supervision of a qualified member of the medical staff; (b) The services must be integrated with the other departments, units and services within the hospital; and (c) The policies and procedures governing the provision of medical care in the emergency department must be established by and are the continuing responsibility of the medical staff. 4. A hospital shall have sufficient medical and nursing personnel who are qualified in emergency medical care to carry out the written emergency procedures of, and to meet the emergency needs anticipated by, the hospital. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XIV, eff. 10-9-69; Ch. II § IX, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.352 Social services. ( NRS 449.0302 ) 1. A hospital shall have effective written policies and procedures for the provision of social services by the hospital staff. 2. Social services must be provided or supervised in accordance with chapter 641B of NRS by a professional, qualified social worker who is appropriately trained and has adequate experience to meet the social and emotional needs of the patients and their families. If the social worker does not have the educational and experiential requirements of a qualified social worker, an ongoing plan for consultation between the social worker and a qualified social worker must be developed. 3. A hospital shall provide to each patient access to related social services based on the assessed needs of the patient. 4. As used in this section, “qualified social worker” means a licensed social worker who has had at least 1 year of actual work experience in a hospital setting. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XV, eff. 10-9-69; Ch. II § X, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.358 Medical staff. ( NRS 449.0302 ) 1. A hospital shall have a well-organized medical staff that operates in accordance with the bylaws approved by the governing body. 2. The medical staff must be appointed by the governing body and be composed of: (a) Doctors of medicine or osteopathy; and (b) To the extent authorized by state law, other practitioners. 3. The medical staff shall periodically conduct appraisals of its members. 4. The members of the medical staff shall examine the credentials of candidates for membership to the medical staff and make recommendations to the governing body on the appointment of those candidates to the medical staff. 5. The medical staff is accountable to the governing body for the quality of the medical care provided to the patients of the hospital. 6. If the medical staff has an executive committee, a majority of the members of the executive committee must be doctors of medicine or osteopathy. 7. The responsibility for the organization and conduct of the medical staff must be assigned only to a doctor of medicine or osteopathy. 8. The medical staff shall adopt and enforce bylaws to carry out its responsibilities. The bylaws must: (a) Be approved by the governing body of the hospital. (b) Include a statement of the duties and privileges for each category of the medical staff, including, without limitation, active status and courtesy privileges. (c) Describe the organization of the medical staff. (d) Describe the qualifications that a candidate for membership to the medical staff must have before the medical staff will consider the recommendation of the candidate for membership. (e) Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to persons requesting privileges. (f) Include a requirement that a physical examination and medical history be done on each patient not more than 7 days before or more than 48 hours after the patient is admitted into the hospital by a member of the medical staff who is a doctor of medicine or osteopathy. 9. The medical staff shall attempt to secure autopsies in all cases in which the death of the patient is unusual or is of legal, medical or educational interest. The medical staff shall: (a) Specifically define a mechanism for documenting permission to perform an autopsy; (b) Establish a system for notifying the members of the medical staff and the attending physician when an autopsy is to be performed; and (c) Ensure that all autopsies performed in the hospital are authorized pursuant to NRS 451.010 . [Bd. of Health, Health Facilities Reg. Part III Ch. I § III, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.361 Nursing services. ( NRS 449.0302 ) 1. A hospital shall have a well-organized plan that provides for 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. 2. The governing body and the hospital shall ensure that the nursing services provided at the hospital are provided in accordance with all applicable federal and state laws and regulations. 3. The nursing service shall have a sufficient number of licensed registered nurses, licensed practical nurses and other personnel to provide nursing care to all patients as needed. A sufficient number of registered nurses and other members of the nursing staff must be on duty at all times to ensure that proper care is provided to each patient. A person who is not a registered nurse may be assigned to care for a patient, if: (a) The extent of care provided by the person is consistent with his or her education and experience and is within his or her scope of practice; and (b) The person is supervised by a registered nurse while providing that care. 4. A hospital shall have a system for determining the nursing needs of each patient. The system must include assessments made by a registered nurse of the needs of each patient and the provision of staffing based on those assessments. 5. The plan for providing nursing services must include a plan of administrative authority and a delineation of responsibilities for patient care. 6. A hospital shall ensure that the nursing staff develops and keeps current a plan for nursing care for each inpatient. 7. The nursing services must be under the direct supervision of a chief administrative nurse. The chief administrative nurse must be knowledgeable, skilled and competent in clinical practice and nursing management. The chief administrative nurse shall direct and supervise the nursing services in compliance with chapter 632 of NRS and nationally recognized professional standards for organized nursing services. 8. The chief administrative nurse shall define the policies, procedures and standards relating to the provision of nursing services and shall ensure that the members of the nursing staff carry out those policies, procedures and standards. The policies, procedures and standards must be documented and accessible to each member of the nursing staff in written or electronic form. The chief administrative nurse must approve each element of the policies, procedures and standards before the element may be used or put into effect. 9. A hospital shall ensure that its patients receive proper treatment and care provided by its nursing services in accordance with nationally recognized standards of practice and physicians’ orders. [Bd. of Health, Health Facilities Reg. Part III Ch. I § IV, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.3622 Appropriate care of patients. ( NRS 449.0302 ) 1. Each patient must receive, and the hospital shall provide or arrange for, individualized care, treatment and rehabilitation based on the assessment of the patient that is appropriate to the needs of the patient and the severity of the disease, condition, impairment or disability from which the patient is suffering. 2. The governing body shall ensure that each person’s role in providing care to a patient is determined by: (a) The professional skills, competence and credentials of the person providing care; (b) The care or rehabilitation to be provided to the patient; (c) The policies of the hospital; and (d) The relevant required licensure or certification, regulation, privileges, scope of practice and job description of the person. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.3624 Assessment of patients. ( NRS 449.0302 ) 1. To provide a patient with the appropriate care at the time that the care is needed, the needs of the patient must be assessed continually by qualified hospital personnel throughout the patient’s contact with the hospital. The assessment must be comprehensive and accurate as related to the condition of the patient. 2. Each patient must be reassessed according to hospital policy: (a) When there is a significant change in the patient’s condition; (b) When there is a significant change in the patient’s diagnosis; or (c) To determine the patient’s response to the care that he or she is receiving. 3. The hospital shall ensure that the hospital staff develop and keep current a plan of care for each inpatient based on the assessed needs of the inpatient. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.3626 Rights of patients. ( NRS 449.0302 ) A governing body shall develop and carry out policies and procedures that protect and support the rights of patients as set forth in NRS 449A.100 to 449A.118 , inclusive. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.3628 Protection of patients; use of physical restraints. ( NRS 449.0302 ) 1. A governing body shall develop and carry out policies and procedures that prevent and prohibit: (a) Verbal, sexual, physical and mental abuse of patients; and (b) The involuntary seclusion of a patient without clinical justification for that seclusion. 2. The governing body shall develop and carry out policies and procedures that prevent and prohibit neglect and misappropriation of the personal property of a patient. 3. The governing body shall develop policies and procedures for the identification and investigation of neglect and abuse of patients. 4. The governing body shall develop and carry out organizational policies and procedures that limit the use of physical restraints on patients to only those situations in which the use of physical restraints is appropriate and for which there is adequate clinical justification. 5. The governing body shall ensure that the use of any physical restraints on a patient is initiated only pursuant to a physician’s order or protocols approved by the medical staff and the hospital administration. 6. If the use of physical restraints is permitted pursuant to approved protocols, the approved protocols must include: (a) A thorough assessment of the patient before the use of physical restraints is initiated; (b) A provision that requires the initiation of the use of the physical restraints by a registered nurse or other authorized person according to hospital policy; (c) A provision for notifying the physician within 12 hours after the use of the physical restraints is initiated; (d) A requirement that a verbal or written order of the physician be obtained and entered into the medical record of the patient; and (e) A requirement that the continued use of physical restraints beyond the first 24 hours be authorized by the physician through the renewal of the original order. The issuance of an order for the continued use of physical restraints on a patient must occur no less often than once each calendar day. 7. Organizational policies and procedures, protocols, physician’s orders and the individual needs of a patient must be used to establish the frequency, nature and extent of monitoring of a patient upon whom physical restraints are being used. 8. The hospital shall have a process for quality improvement to identify appropriate opportunities for reducing the use of physical restraints. The process for quality improvement must include areas for measurement and assessment to identify opportunities to reduce the risks associated with the use of physical restraints through the introduction of preventive strategies, innovative alternatives to the use of physical restraints and improvements to the process of using physical restraints. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.363 Personnel policies concerning employment, licensing and certification; training of employees who provide care to victims of sexual assault or attempted sexual assault. ( NRS 439.200 , 449.0302 ) 1. A hospital shall have written policies concerning the qualifications, responsibilities and conditions of employment for each type of hospital personnel, including the licensure and certification of each employee when required by law. 2. The written policies must be reviewed and updated as needed and must be made available to the members of the hospital staff. 3. Personnel policies must provide for: (a) The orientation of all health personnel to the policies and objectives of the hospital; and (b) The maintenance of records of current employees which confirm that the personnel policies are being followed. 4. The hospital shall have evidence of a current license or certification on file at the hospital for each person employed by the hospital, or under contract with the hospital, who is required to be licensed or certified by law to perform his or her job. 5. The hospital shall ensure that the health records of its employees contain documented evidence of surveillance and testing of those employees for tuberculosis in accordance with chapter 441A of NAC. 6. A hospital shall: (a) Provide training to each employee who provides care to victims of sexual assault or attempted sexual assault not later than 60 days after the date on which the employee commenced his or her employment and at least biennially thereafter. Such training must include, without limitation, providing the employee with access to the most current version of the document developed pursuant to paragraph (a) of subsection 1 of NRS 449.1885 and reviewing the document with the employee. (b) Not later than 30 days after providing the training required by paragraph (a) to an employee, evaluate the competency of the employee in providing information concerning emergency contraception and prophylactic antibiotics, including, without limitation, possible side effects of using those medications, and provide additional training if the employee is not competent to provide such information. (c) Maintain evidence of compliance with the requirements of paragraphs (a) and (b) in the personnel file for each employee who is subject to those requirements. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99; A by R048-22, 12-29-2022) NAC 449.364 Obstetrical services: Administration; staffing and equipment. ( NRS 449.0302 ) 1. If a hospital provides obstetric services, the obstetric services must be provided through an obstetric department which is well-organized and sufficiently staffed to ensure the health and safety of the patients. 2. The obstetric department must be under the direction and supervision of a qualified member of the medical staff. The director of the obstetric department is responsible for the quality of medical care provided to patients by the obstetric department and for the review of the professional practices of the medical staff within the obstetric department, including, without limitation: (a) The delineation of the privileges accorded to members of the medical staff and members of allied health professional persons in the obstetric department; and (b) The reappraisal and appointment of each such member. 3. A roster of the privileges relating to the provision of obstetric services of each member of the medical staff must be kept in the files of the obstetric department. The roster must specify the privileges awarded to each member. 4. A hospital shall ensure that the obstetric department has adequate staffing and equipment, including, without limitation: (a) A sufficient number of registered nurses, trained in perinatal care of a maternal patient and in newborn care, who are on duty at all times to ensure that proper care is provided to each patient; (b) Appropriate equipment maintained in good working order; (c) Drugs and oxygen necessary to provide obstetric care to a maternal patient and a newborn; (d) Appropriate clinical laboratory services available to provide safe obstetric care according to the needs of the patient and medical staff of the department; and (e) Sufficient personnel on the premises and immediately available for each delivery of a newborn who: (1) Are trained and experienced in performing cardiopulmonary resuscitation on adults and newborns; and (2) Have successfully completed the Neonatal Resuscitation Program endorsed by the American Academy of Pediatrics and the American Heart Association. 5. A hospital shall ensure that the obstetric department has the capability of providing: (a) Initial evaluation of the risk-status of each patient needing obstetric services, including the appropriateness of admitting the patient; and (b) Support of patients in labor. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. D pars. 1-8, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.3645 Obstetrical services: Labor rooms; delivery rooms; utility rooms; area for cleaning instruments. ( NRS 449.0302 ) 1. Each hospital which has an organized obstetric service shall have at least one labor room, with the need for additional labor rooms to be determined by the amount of use of the labor room. 2. Each hospital shall have at least one properly equipped delivery room, with the need for additional delivery rooms to be determined by the amount of use of the delivery room. The delivery room must have: (a) An emergency call system that is operable without the use of hands and an adequate signal system. (b) Emergency sterilizing facilities to support the delivery area. (c) A heated bassinet and warmer, and resuscitation equipment for newborns which is readily available. (d) A device for easy, positive identification of a newborn before the newborn is removed from the delivery room. (e) Adequate storage space for sterile supplies and equipment. (f) Sinks and dispensers which are equipped with foot, knee or elbow controls or an alternative method of control. 3. A hospital shall have a clean utility room with adequate storage for cleaning supplies and other cleaning equipment needed for the delivery and labor rooms. 4. Major cleaning of instruments and other utensils used in the delivery or labor room must take place in a specified cleanup area or holding area for soiled materials. (Added to NAC by Bd. Health by R050-99, eff. 9-27-99) NAC 449.365 Obstetrical services: Required services. ( NRS 449.0302 ) 1. An obstetric department of a hospital shall provide services for labor, delivery, newborn care and recovery care, and shall maintain the areas in which these services are provided in a safe and clean manner. 2. The obstetric department must be equipped with those items needed to provide obstetrical care and emergency procedures in life-threatening situations to a mother or her baby. (Added to NAC by Bd. Health by R050-99, eff. 9-27-99) NAC 449.3655 Obstetrical services: Transfer or discharge of patient. ( NRS 449.0302 ) 1. No person may be transferred or discharged from an obstetric department of a hospital unless: (a) The transfer or discharge is appropriate based on a risk assessment of the patient; (b) A physician determines that the patient is not in active labor; or (c) A physician determines that the medical needs of the patient exceed the capability of the obstetric department. 2. The criteria for the transfer of a patient must be in writing and included in the manual for policies and procedures of the obstetric department. 3. A patient in the obstetric department may be transferred only to a hospital capable of providing a higher level of obstetrical and neonatal care and for which there are written documents which verify that the receiving hospital agrees to accept emergency patients without regard to their ability to pay. 4. The obstetric department shall establish written protocols for the discharge of patients from the hospital, which include, without limitation: (a) The provision of instructions to the mother regarding the care and feeding of her newborn; (b) Plans for the examination of the mother and newborn after discharge; (c) The provision of instructions to the mother regarding the availability of consultation services by telephone or home visit, as needed or requested by the mother; and (d) The criteria and conditions under which a patient or newborn should be considered for transfer. Such a determination must be made by a qualified member of the medical staff and the criteria and conditions must be included in the written policies and procedures of clinical practices for the obstetric department. The written policies must be reviewed periodically by a qualified member of the medical staff and a review of all such transfers must be included in the quality improvement program established pursuant to NAC 449.3152 . (Added to NAC by Bd. Health by R050-99, eff. 9-27-99) NAC 449.367 Obstetrical services: Nurseries. ( NRS 449.0302 ) 1. An obstetric department shall have a nursery which is organized under the direction of a qualified member of the medical staff. 2. Nurseries must be completely equipped for any neonatal emergencies. 3. The total number of bassinets in a nursery service must be at least equal to the number of beds for postpartum patients. 4. A separate storage room must be available to support the requirements of the entire nursery. 5. The following must be made available for each unit for infants: (a) A bassinet for each infant with storage space for the infant’s supplies, such as diapers, shirts and thermometers. (b) Incubators for infants needing supplemental oxygen, heat or humidity and for all infants with a low birth weight. (c) A scale for weighing babies. (d) Oxygen. 6. If a nursery for premature infants exists, it must be designed to provide for maximum observation and supervision and must include: (a) An electrical outlet for each incubator located in the nursery; and (b) Oxygen for every incubator. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. D pars. 9-13, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.370 Outpatient services. ( NRS 449.0302 ) 1. If a hospital provides outpatient services, the services must meet the needs of the patients in accordance with nationally recognized standards of practice. 2. A hospital shall ensure that its outpatient unit is appropriately organized and integrated with inpatient services. 3. A hospital which provides outpatient services shall: (a) Assign a person to be responsible for the outpatient unit; (b) Have sufficient numbers of professional and nonprofessional personnel available to provide the outpatient services; and (c) Ensure that nursing services provided in the outpatient unit are provided under the direction of a registered nurse. 4. Equipment and supplies necessary to meet the anticipated needs of the outpatients must be readily available and in good working order. 5. The outpatient unit shall have a sufficient number of examination and treatment rooms for the outpatient service based on the volume and nature of work performed. 6. Laboratory, radiology and pharmaceutical services must be readily available to the outpatient unit. 7. If outpatient surgery is performed in the outpatient unit, the basic facilities that must be available to perform the surgery include, without limitation: (a) A fully equipped and staffed operating room and postanesthesia recovery area; (b) Means of control against hazards of infection, electrical or mechanical fire, and explosion; (c) Sterile supplies that are readily available to meet the needs of the outpatients; and (d) Equipment and instrumentation for anesthesia and emergency cardiopulmonary resuscitation. 8. If beds are provided in an outpatient unit, the number of outpatient beds must not be included in the licensed bed capacity of the hospital. Inpatients may not occupy an outpatient bed. An outpatient shall not remain in an outpatient bed for more than 48 consecutive hours. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XIII, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.371 Intensive care services. ( NRS 449.0302 ) 1. If a hospital provides intensive care services, the services must be well-organized and provided in accordance with nationally recognized standards of practice. 2. An intensive care unit must be under the direction of a qualified member of the medical staff. 3. Written policies and procedures must be developed and maintained by the director of the intensive care unit, in consultation with other appropriate health-care professionals and the administration of the hospital. The administration and medical staff of the hospital must approve procedures to be used by the intensive care unit when approval of such procedures is appropriate. 4. The responsibility and the accountability of the intensive care unit to the medical staff and administration must be set forth in writing by the director of the intensive care unit. 5. Whenever a patient is present in the intensive care unit, a registered nurse, with training and experience in intensive care nursing, shall supervise the nursing care and nursing management of the intensive care service. 6. All licensed nurses working in an intensive care unit must: (a) Have training and experience in intensive care nursing; or (b) Work under the direct supervision of a registered nurse who has training and experience in intensive care nursing. 7. The hospital shall establish a system for determining the nursing needs of each patient in the intensive care unit that includes an assessment made by a registered nurse trained in critical care of the patient’s needs and the provision of staffing based on that assessment. 8. The hospital shall follow the written policies for the plans for nurse staffing, which are dependent upon the acuity level of the patients in the intensive care unit, to ensure that the needs of the patients are met. 9. A respiratory therapist or respiratory technician, physical therapist and other supportive personnel must be available depending upon the requirements of the intensive care unit. 10. The equipment and supplies for the intensive care unit must be adequate to meet the needs of the patients in the intensive care unit. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.373 Laboratory services; pathology services; blood and blood products. ( NRS 449.0302 ) 1. Each hospital shall maintain or have available adequate laboratory services to meet the needs of its patients and medical staff. Each hospital shall ensure that all laboratory services provided to its patients are provided by a medical laboratory licensed pursuant to chapter 652 of NRS. 2. Laboratory services must be available 24 hours a day, 7 days a week, including holidays. 3. While a patient is under the care of a hospital, all laboratory testing must be performed: (a) In the laboratories of the hospital; (b) By a reference laboratory that is certified pursuant to 42 U.S.C. § 263a; or (c) In accordance with NRS 652.217 . 4. The director of a laboratory that provides laboratory services to a hospital shall establish procedures to ensure that patients who have been transfused with blood or blood products which have tested positive for the human immunodeficiency virus are promptly notified of that fact. 5. Each laboratory which provides laboratory services to a hospital shall provide for the proper receipt and reporting of tissue specimens. All reports of tissue specimens must be signed by a pathologist. The medical staff of the hospital and a pathologist shall determine which tissue specimens require a macroscopic (gross) examination and which require both macroscopic and microscopic examinations. 6. If provided in a hospital, pathology services must be under the supervision of a pathologist in a full-time, regular part-time or regular consultative basis and he or she shall participate in staff, departmental and clinicopathologic conferences. 7. Facilities for the procurement, safekeeping and transfusion of blood and blood products must be provided in each hospital, or readily available, with adequate control and supervision by an authorized physician. The refrigerator for the storage of blood must have an adequate recording thermograph and temperature alarm system, must be regularly inspected and must be otherwise safe and adequate to prevent the deterioration of the blood and blood products. 8. If the hospital depends on outside blood banks, there must be an agreement governing the procurement, transfer and availability of blood which is reviewed and approved by the medical staff, administration and governing body. Provision must be made for prompt blood typing, cross-matching and investigation of transfusion reactions. A committee of the medical staff, or its equivalent, shall review all transfusions of blood or blood derivatives, and blood or blood derivative reactions, occurring in the hospital and make recommendations concerning policies governing these practices. [Bd. of Health, Health Facilities Reg. Part III Ch. I § VIII, eff. 10-9-69]—(NAC A 10-22-93; R050-99, 9-27-99) NAC 449.3735 Transfusions of blood. ( NRS 449.0302 ) 1. To perform a transfusion of blood safely and efficiently, hospital personnel shall follow the policies and procedures developed by the hospital, with input from the medical staff, for performing a transfusion of blood. 2. Hospital personnel may administer blood only within the scope of their practice and after they have been trained to administer blood. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.374 Nuclear medicine services. ( NRS 449.0302 ) 1. If a hospital provides nuclear medicine services, those services must meet the needs of the patients receiving those services in accordance with nationally recognized standards of practice. 2. The nuclear medicine services must be under the supervision of a doctor of medicine or osteopathy who is qualified in nuclear medicine. The director of the nuclear medicine services is responsible for the medical direction of those services. 3. The qualifications, training, functions and responsibilities of the personnel of the nuclear medicine services must be specified by the administration of the hospital and approved by the medical staff. 4. Radioactive materials used in providing nuclear medicine services must be prepared, labeled, used, transported, stored and disposed of in accordance with nationally recognized standards of practice. 5. In-house preparation of radiopharmaceuticals must be made by, or under the direct supervision of, an appropriately trained registered pharmacist or a doctor of medicine or osteopathy. 6. A radionuclide must be stored, used and disposed of in accordance with the requirements set forth in chapter 459 of NAC. 7. If laboratory tests are performed in the nuclear medicine services, the services must meet the applicable requirements for laboratory services specified in 42 C.F.R. § 482.27. 8. Equipment and supplies used for the nuclear medicine services must be appropriate for the types of nuclear medicine services offered by the hospital and must be maintained for safe and efficient performance. The equipment must be: (a) Maintained in safe operating condition; and (b) Inspected, tested and calibrated at least annually by persons who are qualified to do such inspections, tests and calibrations. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.375 Records for nuclear medicine services; authorization. ( NRS 449.0302 ) 1. A hospital shall maintain signed and dated reports of nuclear medicine interpretations, consultations and procedures. 2. The hospital shall maintain nuclear medicine reports, or copies thereof, for at least 5 years after the date on which the report was made. 3. A practitioner approved by the medical staff to interpret diagnostic procedures must sign and date his or her interpretation of the tests. 4. The hospital shall maintain records of the receipt and disposition of radiopharmaceuticals. 5. Nuclear medicine services may be ordered only by a practitioner whose scope of licensure and defined staff privileges authorize the practitioner to make such orders. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.376 Radiological services. ( NRS 449.0302 ) 1. A hospital shall have diagnostic radiological facilities available. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications. 2. The hospital shall maintain or have available radiological services according to the needs of the patients. 3. Radiological services, particularly ionizing radiological procedures, must be conducted in a manner that monitors and controls hazards so that safety is maintained for patients and personnel. 4. Proper safety precautions must be maintained against radiation hazards, including, without limitation: (a) Adequate shielding for patients, personnel and facilities; and (b) Appropriate storage, use and disposal of radioactive materials. 5. Equipment used for providing radiological services must be periodically inspected, and any hazards identified in the inspection must be promptly corrected. 6. Radiological technicians and other persons who work with radiation must be checked periodically by the use of exposure meters or badge tests for the amount, if any, of radiation exposure. 7. Radiological services must be provided only upon the order of: (a) A practitioner who has clinical privileges or is authorized by state law to order such services; or (b) Other practitioners authorized by the medical staff and governing body to order such services. 8. A qualified full-time, part-time or consulting radiologist shall supervise the ionizing radiological services and shall interpret only those radiological tests that are determined by the medical staff to require the specialized knowledge of the radiologist. 9. Only personnel designated as qualified personnel by the medical staff may use radiologic equipment and administer radiological procedures. 10. Records of radiology services provided to patients must be maintained. 11. A radiologist or other practitioner who performs radiology services shall sign any report of his or her interpretation. 12. A hospital shall maintain the following information for at least 5 years: (a) Copies of reports and printouts of radiology services; and (b) Films, scans and other image records of radiology services that have been provided. 13. As used in this section, “radiologist” means a doctor of medicine or osteopathy who is qualified by education and experience in radiology. [Bd. of Health, Health Facilities Reg. Part III Ch. I § IX, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.377 Radiological therapeutic services. ( NRS 449.0302 ) 1. If a hospital provides radiological therapeutic services, the services must meet professionally nationally recognized standards for safety and personnel qualifications. 2. A radiological therapeutic department must be under the direction of a physician who is: (a) Certified or eligible for certification in therapeutic radiology by the American Board of Radiology; or (b) Certified or eligible for certification in radiology by the American Board of Radiology and has 2 years of full-time experience in radiation therapy. 3. Other personnel who may provide radiological therapeutic services, on a full-time, part-time or consultative basis, depending on the activity of the department, include: (a) A radiological physicist who is certified in radiological physics or in therapeutic radiological physics by the American Board of Radiology; (b) A dosimetrist, or treatment plan technologist, who is a qualified and experienced radiation therapy technologist and who has at least 1 year of additional clinical training in dosimetry; (c) A certified therapeutic radiological technologist; and (d) Appropriate support personnel, including licensed nurses, as required by the patient load. 4. Written policies and procedures must be developed and maintained by the director of the department in consultation with other appropriate health professional persons and the administration of the hospital. 5. Radiation therapy must be given only under the direction of a radiation therapist. 6. All cancer patients accepted for curative radiation must have adequate histological substantiation of diagnosis, unless convincing alternative evidence for diagnosis is presented. 7. Documentation of the initial evaluation and treatment plan of each patient, and dosimetry, clinical, technical and follow-up notes on each patient, must be maintained. 8. Adequate communication must be maintained between the department and the referring physicians, including periodic review of case management, complications and treatment results. 9. Calibration and operation of equipment for radiation therapy must meet the requirements specified in chapter 459 of NAC. 10. Radiation protection for patients and staff must comply with the requirements specified in chapter 459 of NAC. 11. Periodic follow-ups of a patient following the completion of his or her treatment must be coordinated with the physician who referred the patient. 12. Equipment and supplies for the radiological therapeutic services must conform to the requirements specified in chapter 459 of NAC. 13. The rooms in which radiation therapy machines are used must be of adequate size to permit the easy use of the machines by patients on stretchers. Shielding of those rooms must meet the requirements specified in chapter 459 of NAC. 14. Sufficient examination rooms must be available to accommodate all patients receiving the therapeutic services. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.379 Medical records. ( NRS 449.0302 ) 1. A hospital shall maintain a medical record for each person evaluated or treated in the hospital. 2. The organization of the medical records service at the hospital must be appropriate to the scope and complexity of the services performed at the hospital. A hospital shall employ adequate personnel to ensure prompt completion, filing and retrieval of the medical records. 3. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. A hospital shall use a system for author identification and record maintenance that ensures the integrity of the authentication of the record and protects the security of all entries to a medical record. 4. Except as otherwise provided in this subsection, medical records must be retained in their original form or in a legally reproduced form for at least 5 years. The medical staff may identify specific items in a medical record that must be kept for at least 10 years. The hospital shall have a system for coding and indexing its medical records. The system must allow for the timely retrieval of information by diagnosis and procedure to support studies evaluating the medical care provided at the hospital. 5. A hospital must have a procedure for ensuring the confidentiality of the medical records of its patients. Information from or copies of medical records may be released only to authorized persons, and the hospital shall ensure that unauthorized persons cannot gain access to or alter the medical records of its patients. Original medical records may be released by the hospital only in accordance with state or federal law, court orders or subpoenas. 6. A medical record must include information: (a) Demonstrating the justification for the admission and continued hospitalization of a patient; (b) Supporting the diagnosis of the patient; and (c) Describing the progress of the patient and his or her response to the medications and services received during his or her hospitalization. 7. All entries to a medical record must be legible and complete, and authenticated and dated promptly by the person who is responsible for ordering, providing or evaluating the service provided. In authenticating a medical record, the person shall include his or her name and discipline. Authentication may include the signature or written initials of the person or a computer entry by the person. 8. All medical records must document the following information, as appropriate: (a) Evidence that a physical examination, including a history of the health of the patient, was performed on the patient not more than 7 days before or more than 48 hours after his or her admission into the hospital. (b) The diagnosis of the patient at the time of admission. (c) The results of all consultative evaluations of the patient and the appropriate findings by clinical and other staff involved in caring for the patient. (d) Documentation of any complications suffered by the patient, infections acquired by the patient while in the hospital and unfavorable reactions by the patient to drugs and anesthesia administered to the patient. (e) Properly executed informed consent for all procedures and treatments specified by the medical staff, or federal or state law, as requiring written patient consent. (f) All orders of practitioners, nursing notes, reports of treatment, records of medication, radiology and laboratory reports, vital signs and other information necessary to monitor the condition of the patient. (g) A discharge summary that includes a description of the outcome of the hospitalization, disposition of the case and the provisions for follow-up care that have been provided to the patient. (h) The final diagnosis of the patient. 9. The medical record of a patient must be completed not later than 30 days after the date on which he or she is discharged. [Bd. of Health, Health Facilities Reg. Part III Ch. I § VI, eff. 10-9-69; A 8-26-74]—(NAC A by R050-99, 9-27-99) NAC 449.382 Medical library. ( NRS 449.0302 ) A hospital shall have a medical library to meet the requirements of the facility, with access to current periodicals on clinical services which are offered. [Bd. of Health, Health Facilities Reg. Part III Ch. I § X, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.385 Surgical services. ( NRS 449.0302 ) 1. If a hospital provides surgical services, the services must be well-organized and provided in accordance with nationally recognized standards of practice. If outpatient surgical services are offered, the services must be consistent in quality, in accordance with the complexity of the services, with similar services provided to inpatients. 2. The operating rooms must be supervised by an experienced registered nurse or a doctor of medicine or osteopathy. 3. A licensed practical nurse or a surgical or operating room technician may act as a scrub nurse or scrub technician only under the direct supervision of a registered nurse. 4. Circulating duties in an operating room must be performed by a qualified registered nurse, who shall not perform circulating duties in more than one operating room at a time. 5. Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competency of each practitioner. A hospital shall maintain a roster of practitioners that specifies the surgical privileges accorded to each practitioner. 6. Policies governing surgical care must be designed by the medical staff to ensure the achievement and maintenance of high standards of medical practice and patient care. 7. Except in emergency cases and except as otherwise provided in this subsection, a complete history and physical work-up must be completed and placed in a patient’s chart before the patient undergoes surgery. A patient may undergo surgery before his or her complete history or physical work-up is placed in his or her chart if the complete history or physical work-up has been dictated but not yet recorded and a statement of that fact and an admission note have been placed in the patient’s chart by the practitioner who admitted the patient. 8. Except in emergency cases, an informed consent form properly executed by a patient for the surgery must be placed in his or her chart before the surgery is performed. 9. Each surgical suite must have readily available and in good working condition: (a) A call system; (b) A cardiac monitor; (c) A resuscitator; (d) A defibrillator; (e) An aspirator; and (f) A tracheotomy set. 10. A hospital shall make adequate provision for immediate postoperative care. 11. The operating room register must be complete and up-to-date at all times. 12. Immediately following surgery on a patient, the surgeon shall write or dictate an operative report, which must be included in the medical record of the patient, describing the techniques used, findings and tissues removed or altered. The surgeon shall sign the report. 13. The medical staff shall define which surgeries require the presence of a first assistant. A list of the surgeries that require the presence of a first assistant must be readily available to the surgical staff of the hospital. 14. A registered nurse or operating room technician may serve as a first assistant if: (a) The medical staff has not otherwise required that the first assistant in a surgery be a physician; and (b) The medical staff has designated the nurse or technician as having sufficient training to assist in the procedure adequately and properly. 15. A hospital shall establish and carry out policies and procedures relating to the cleaning and sanitation of a surgical suite. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. A, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.388 Anesthesia services. ( NRS 449.0302 ) 1. If a hospital furnishes anesthesia services, the services must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital. 2. The organization of the anesthesia service must be appropriate to the scope of the services offered by the hospital. Anesthesia may only be administered by: (a) A qualified anesthesiologist; (b) A doctor of medicine or osteopathy, other than an anesthesiologist; (c) A dentist, oral surgeon or podiatrist who is legally authorized, under state law, to administer anesthesia; or (d) A certified registered nurse anesthetist who is under the direction of the operating practitioner or of an anesthesiologist who is immediately available if needed. This paragraph does not affect the requirements for qualification as a certified registered nurse anesthetist as specified in chapter 632 of NRS, and any regulations adopted pursuant thereto. 3. Anesthesia services must be consistent with the needs and resources of the hospital. Policies on anesthesia procedures must include the delineation of preanesthesia and postanesthesia responsibilities. The policies must ensure that each patient receives: (a) A preanesthesia evaluation by a person qualified to administer anesthesia, as set forth in subsection 2, that must be performed within 48 hours before surgery. (b) An intraoperative anesthesia record. (c) For inpatients, a postanesthesia follow-up report by the person who administered the anesthesia. The follow-up report must be written not later than 48 hours after the surgery. (d) For outpatients, a postanesthesia evaluation for proper anesthesia recovery, performed in accordance with the policies and procedures approved by the medical staff. 4. If the hospital does not have a department of anesthesia, the department of surgery is responsible for the organization and implementation of the policies and procedures relating to the provision of anesthesia services. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. B, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.389 Respiratory care services. ( NRS 449.0302 ) A hospital shall meet the needs relating to respiratory care of its patients in accordance with nationally recognized standards of practice. If the hospital has a unit to provide respiratory care services: 1. The director of the unit must be a doctor of medicine or osteopathy who has the knowledge, experience and capabilities to supervise and administer the respiratory care services properly. The director may serve on a full-time or part-time basis. 2. The hospital shall ensure that there are an adequate number of respiratory therapists, respiratory therapy technicians and other personnel who meet the qualifications, which must be consistent with state law, specified by the medical staff to provide respiratory care services. 3. Personnel qualified to perform specific procedures relating to the provision of respiratory care services and the amount of supervision required for such personnel to carry out specific procedures must be designated in writing. 4. If blood gases or other clinical laboratory tests are performed in the respiratory care unit, the unit must meet the requirements for clinical laboratories with respect to management, adequacy of facilities, proficiency testing and quality control. 5. Respiratory care services must be provided only upon and in accordance with the orders of a doctor of medicine or osteopathy. 6. Diagnostic studies and treatment modalities relating to respiratory care must be recorded in the patient’s medical record, including, without limitation: (a) The type of diagnostic or therapeutic procedures used; (b) The dates and times of the use of such procedures; and (c) The effects of such procedures, including adverse reactions. 7. The unit shall have sufficient types and quantities of equipment to provide for the appropriate inhalation of the several gases, aerosols and such other modalities required for the anticipated nature and variety of procedures that will be performed in the unit. Equipment must be calibrated in accordance with the manufacturer’s instructions and records of such calibrations must be maintained. 8. The unit shall have sufficient space for: (a) The storage of necessary equipment; (b) Work areas for: (1) Cleaning, sterilizing and repairing equipment; and (2) Performing studies of pulmonary function and blood analyses, if such studies and analyses are performed in the unit; and (c) Office space for the personnel of the unit. 9. The unit shall establish and carry out procedures for the safe handling and storage of medical gas cylinders. Only certified persons and persons trained by the hospital may transfer gas from one cylinder to another. Such a transfer must be completed in accordance with safety protocols. (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99) NAC 449.391 Dental services. ( NRS 449.0302 ) 1. If a hospital provides dental services, the services must be well-organized and provided in accordance with nationally recognized standards of practice. 2. The dental service must be under the direct supervision of a dentist, who has overall responsibilities for the dental service. 3. Dental hygienists, dental assistants or dental laboratory technicians may be employed by the hospital if the dental hygienist, assistant or laboratory technician works under the direct supervision of a dentist. 4. Members of the dental staff must be currently licensed in this State for the positions to which they are appointed. 5. Patients admitted for dental services must be admitted by the dentist, either to the department of dentistry or, if there is no department, to an organized clinical service. 6. Equipment and supplies necessary to meet the anticipated dental needs of patients must be available. 7. Equipment for the sterilization of instruments and supplies must be provided directly in the dental service or through another department, unit or service within the hospital. 8. If the dental service offers primary dental care, the dental service must: (a) Have adequate space to provide that care; and (b) Facilities for dental radiography. 9. There must be specific bylaws concerning the dental staff written in combination with the bylaws of the medical staff or as separate dental bylaws. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. C, eff. 10-9-69]—(NAC A by R050-99, 9-27-99) NAC 449.394 Psychiatric services. ( NRS 439.200 , 449.0302 ) 1. A hospital which has a designated area set aside for use on a continuous basis for the treatment and care of psychiatric patients is deemed to operate a psychiatric service and shall comply with the requirements in this section. 2. A licensed physician may render psychiatric care in any licensed hospital on a short term or emergency basis. 3. A hospital shall develop and carry out policies and procedures for the provision of psychiatric treatment and behavioral management services that are consistent with NRS 449A.200 to 449A.263 , inclusive, to ensure that the treatment and services are safely and appropriately used. The hospital shall ensure that the policies and procedures protect the safety and rights of the patient. 4. The medical direction of the psychiatric unit and the psychiatric services provided by the hospital must be under the direct supervision of a qualified member of the medical staff. 5. All nursing services provided with regard to the provision of psychiatric care must be provided under the direction of a registered nurse. 6. A consulting medical staff composed of qualified persons in appropriate specialties must be available at all times to the patients in the psychiatric unit. [Bd. of Health, Health Facilities Reg. Part III Ch. I § XI subsec. E, eff. 10-9-69]—(NAC A by R050-99, 9-27-99; R048-22, 12-29-2022) INTERMEDIARY SERVICE ORGANIZATIONS REVISER’S NOTE. NAC 449.395 to 449.39561 , inclusive, have been codified in chapter 449 of NAC in accordance with section 38 of chapter 41, Statutes of Nevada 2013, at page 146 , which authorized the related provisions of chapter 427A of NAC to be renumbered and moved to chapter 449 of NAC. General Provisions NAC 449.395 Definitions. ( NRS 439.200 , 449.4308 , 449.4309 , 449.4311 , 449.4327 ) As used in NAC 449.395 to 449.39561 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.39501 to 449.39508 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008; A by R109-18, 1-30-2019)—(Substituted in revision for NAC 427A.800) NAC 449.39501 “Certificate” defined. ( NRS 449.4308 , 449.4311 , 449.4327 ) “Certificate” means a certificate to operate an intermediary service organization issued by the Division pursuant to the provisions of NRS 449.4304 to 449.4339 , inclusive, and NAC 449.395 to 449.39524 , inclusive. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.803) NAC 449.39502 “Client” defined. ( NRS 449.4308 , 449.4311 , 449.4327 ) “Client” means a person with a disability who seeks or receives personal assistance in his or her home or other location where a person with a disability receives personal assistance, including, without limitation, a place of employment of the person with a disability, or other responsible person who seeks or obtains such assistance on behalf of a person with a disability. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.804) NAC 449.39503 “Intermediary service organization” defined. ( NRS 449.4308 , 449.4311 , 449.4327 ) 1. “Intermediary service organization” has the meaning ascribed to it in NRS 449.4304 . 2. The term does not include an organized group of persons composed of the family and friends of a person needing personal assistance that employs or contracts with persons to provide such assistance if: (a) The organization of the group of persons is set forth in a written document that is made available for review by the Division upon request; and (b) The personal assistance is provided to only one person or to members of a family who reside at the same residence. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.806) NAC 449.39504 “Managing employer” defined. ( NRS 449.4308 , 449.4311 , 449.4327 ) “Managing employer” means the person who selects, sets the schedule for and directs the training of a personal assistant. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.807) NAC 449.39505 “Other responsible person” defined. ( NRS 449.4308 , 449.4311 , 449.4327 ) “Other responsible person” has the meaning ascribed to it in NRS 449.4308 . (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.808) NAC 449.39506 “Personal assistance” defined. ( NRS 449.4308 , 449.4327 ) “Personal assistance” has the meaning ascribed to it in NRS 449.4308 . (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.809) NAC 449.39507 “Personal assistant” defined. ( NRS 449.4308 , 449.4327 ) “Personal assistant” has the meaning ascribed to it in NRS 449.4308 . (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.810) NAC 449.39508 “Guardian” interpreted. ( NRS 449.4308 , 449.4327 ) As used in subparagraph (2) of paragraph (a) of subsection 2 of NRS 449.4308 , the Division will interpret the term “guardian” to include, without limitation, any person who is legally responsible for a person with a disability who suffers from a cognitive impairment. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.813) Certification NAC 449.3951 Form of application; written verification for submission of fingerprints. ( NRS 449.4311 , 449.4321 , 449.4327 ) 1. The Division will prescribe the form for an application to apply for a certificate. 2. An applicant for a certificate must submit with his or her application written verification, on a form prescribed by the Division, stating that the fingerprints of the applicant were taken and directly forwarded electronically or by another means to the Central Repository for Nevada Records of Criminal History and that the applicant has given written permission to the law enforcement agency or other authorized entity taking the fingerprints to submit the fingerprints to the Central Repository for submission to the Federal Bureau of Investigation for a report on the applicant’s background and to such other law enforcement agencies as the Division deems necessary. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008; A by Aging & Disability Services Div. by R015-12, 9-14-2012)—(Substituted in revision for NAC 427A.815) NAC 449.39511 Application for certificate and renewal: Fees. ( NRS 449.4311 , 449.4314 , 449.4319 ) 1. An applicant for a certificate must pay to the Division, at the time of application, a nonrefundable fee of $2,748. 2. An applicant for the renewal of a certificate must pay to the Division, at the time of application for renewal, a nonrefundable fee of $1,374. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.816) NAC 449.39512 Application for certificate and renewal: Proof of insurance coverage. ( NRS 449.4311 , 449.4327 ) An applicant for a certificate and for the renewal of a certificate must provide to the Division with the initial application for a certificate, with the application for renewal of a certificate and at such other times upon request of the Division, proof that the intermediary service organization maintains adequate insurance coverage against liabilities resulting from claims incurred in the course of operation. Such insurance coverage must include, without limitation: 1. Workers’ compensation insurance pursuant to chapters 616A to 617 , inclusive, of NRS for each personal assistant employed by the intermediary service organization; 2. Commercial general liability insurance in an amount not less than $2,000,000 in general aggregate coverage and not less than $1,000,000 per claim; and 3. Insurance coverage for employee dishonesty in an amount not less than $25,000 per claim. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.817) NAC 449.39513 Applicability of certificate; specification of primary location; records. ( NRS 449.4311 , 449.4318 , 449.4327 ) 1. Each certificate must be separate and issued to a specific person or persons to operate the intermediary service organization. The name of the person responsible for the operation of an intermediary service organization must appear on the face of the certificate. 2. Each certificate must specify the primary location for the operation of an intermediary service organization, but a separate certificate is not required for each location where the intermediary service organization conducts business. 3. If an intermediary service organization conducts business at more than one location, all records required to be maintained by the intermediary service organization, including, without limitation, records of each client, personnel files and operational records, must be maintained at the primary location specified on the certificate. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.818) NAC 449.39514 Issuance of provisional certificate. ( NRS 449.4324 ) 1. The Division may issue a provisional certificate to an intermediary service organization pursuant to NRS 449.4324 if the Division determines that the intermediary service organization is substantially, but not fully, in compliance with NRS 449.4304 to 449.4339 , inclusive, and NAC 449.395 to 449.39561 , inclusive. 2. A provisional certificate issued pursuant to subsection 1: (a) Expires 90 days after its issuance unless, within the 90-day period, the Division issues a nonprovisional certificate to the intermediary service organization. (b) Is nonrenewable. 3. The Division will provide in writing to each intermediary service organization which is issued a provisional certificate pursuant to subsection 1 the conditions that the intermediary service organization must meet before the Division will issue a nonprovisional certificate. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.819) Authorized Activities and General Requirements for Operation NAC 449.39515 Operation of intermediary service organization and agency to provide personal care services in the home. ( NRS 449.4308 , 449.4327 ) 1. A person may operate an intermediary service organization and an agency to provide personal care services in the home if the person: (a) Maintains separate records and clients for the intermediary service organization and the agency to provide personal care services in the home; and (b) Distinguishes between the services to be provided by the intermediary service organization and the personal care services provided by the agency to provide personal care services in the home. 2. As used in this section, “agency to provide personal care services in the home” has the meaning ascribed to it in NRS 449.0021 . (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.820) NAC 449.39516 Duties and responsibilities. ( NRS 449.4308 , 449.4327 ) 1. An intermediary service organization shall ensure that each client of the intermediary service organization and personal assistant employed by the intermediary service organization is aware of and understands: (a) The rights and responsibilities of the client; (b) The ethical responsibilities of the personal assistant, including, without limitation, any responsibilities concerning the confidentiality of client information; (c) The training requirements for the personal assistant as set forth in NAC 449.39519 ; (d) The policies and procedures to be used by the personal assistant for the control of infections, including, without limitation, the policies and procedures of the intermediary service organization and the universal precautions as defined in NAC 441A.195 ; (e) The respective responsibilities of the personal assistant and the client to properly document the needs of the person with a disability and to properly document the provision of personal assistance to that person; (f) The procedures that the personal assistant will follow when responding to medical and nonmedical emergencies of the person with a disability; (g) The provisions of NRS 629.091 and the appropriate procedures that must be followed when providing assistance to a person with a disability pursuant to that section; and (h) The procedures for a client to appeal the termination, reduction or suspension of services by the intermediary service organization. 2. An intermediary service organization shall: (a) Remain open for operation during regular business hours; (b) Maintain a telephone line at the location of the intermediary service organization that is listed on its certificate, which must be published in a public telephone directory; (c) Have a federal taxpayer identification number; (d) Maintain all business licenses required by state and local law; (e) Maintain a written policy concerning the manner in which complaints from clients will be documented and resolved and a log which lists all complaints filed by clients; and (f) Maintain a written policy concerning the procedures for a client to appeal the termination, reduction or suspension of services by the intermediary service organization. 3. If an intermediary service organization withholds any money from a personal assistant which must be forwarded to another person, including, without limitation, insurance premiums, fees required to be paid by the intermediary service organization pursuant to state or federal law on behalf of the personal assistant or money withheld at the request of the personal assistant, the intermediary service organization must transfer such money to the person designated for receipt of the money by the date required for such transfer. 4. An intermediary service organization may: (a) Employ personal assistants to provide specific medical, nursing or home health care services for a person with a disability pursuant to NRS 629.091 ; and (b) At the request of a client, assist in the development of a plan of care for a person with a disability. 5. An intermediary service organization shall not serve as the managing employer of a personal assistant. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.821) NAC 449.39517 Personal assistants: Qualifications; maintenance and availability of personnel files. ( NRS 449.4308 , 449.4327 , 449.4329 , 449.433 ) 1. Each personal assistant employed by an intermediary service organization must: (a) Be at least 18 years of age; (b) Demonstrate the ability to meet the needs of the person with a disability as outlined by the client; (c) Demonstrate the ability to communicate effectively with the client; (d) Obtain certification to perform first aid and cardiopulmonary resuscitation within 120 days after the date on which the personal assistant begins employment with the intermediary service organization; (e) Be in good health as certified by a physician and must not be infected with any communicable disease that may be contagious; and (f) If the personal assistant transports a person with a disability in a motor vehicle, maintain motor vehicle liability insurance. 2. An intermediary service organization shall serve as the employer of record for and shall maintain a personnel file for each personal assistant employed by the intermediary service organization. Each personnel file must include, without limitation: (a) The name, address and telephone number of the personal assistant; (b) The date on which the personal assistant began employment with the intermediary service organization; (c) Proof that the personal assistant meets the qualifications set forth in subsection 1; (d) Evidence that the intermediary service organization has submitted the personal assistant’s fingerprints to the Central Repository for Nevada Records of Criminal History or the results of the criminal history report prepared by the Central Repository, as applicable; and (e) Documentation submitted by the client pursuant to NAC 449.39519 of the training received by the personal assistant as required pursuant to that section. 3. An intermediary service organization shall, upon the request of the Division, make available to the Division all personnel files, including, without limitation, any personnel files that are maintained electronically. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.822) NAC 449.39518 Personal assistants: Results of reports on criminal history. ( NRS 449.4308 , 449.4327 , 449.4329 ) Upon receiving a report concerning any records of criminal history of a personal assistant from the Central Repository for Nevada Records of Criminal History pursuant to subsection 4 of NRS 449.4329 , an intermediary service organization shall provide to the client who selected the personal assistant the results of the report on the criminal history of the personal assistant. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.823) NAC 449.395185 Personal assistants: Performance of certain tasks. ( NRS 439.200 , 449.4308 , 449.4309 , 449.4327 ) 1. A personal assistant may perform a task described in NRS 449.4309 if the personal assistant: (a) Before performing the task, annually thereafter and when any device used for performing the task is changed: (1) Receives training concerning the task that meets the requirements of subsections 6 and 7; and (2) Demonstrates an understanding of the task; (b) Follows the manufacturer’s instructions when operating any device used for performing the task; (c) Performs the task in conformance with the Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, 42 U.S.C. § 263a, if applicable, and any other applicable federal law or regulation; and (d) Complies with the requirements of subsection 3 or 4, if applicable. 2. If a person with diabetes who is a client of an intermediary service organization does not have the physical or mental capacity to perform a blood glucose test on himself or herself and a personal assistant performs a blood glucose test on the client, the Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, 42 U.S.C. § 263a, shall be deemed to be applicable for the purposes of paragraph (c) of subsection 1. 3. In addition to satisfying the requirements of subsection 1, a personal assistant who conducts a blood glucose test must ensure that the device for monitoring blood glucose is not used on more than one person. 4. A personal assistant may assist a client in the administration of insulin prescribed to the client for his or her diabetes and furnished by a registered pharmacist through an auto-injection device approved by the United States Food and Drug Administration for use in the home in accordance with the requirements of subsection 1 if: (a) A physician, physician assistant or advanced practice registered nurse has determined that the client’s physical and mental condition is stable and following a predictable course; and (b) The amount of the insulin prescribed to the client is at a maintenance level and does not require a daily assessment, including, without limitation, the use of a sliding scale. 5. A personal assistant may weigh a client of an intermediary service organization only if: (a) The personal assistant has received training on the manner in which to weigh a person that meets the requirements of subsections 6 and 7; and (b) The client has consented to being weighed by the personal assistant. 6. The training described in this section must be provided by: (a) A physician, physician assistant or licensed nurse; (b) For the training described in paragraph (b) or (c) of subsection 1 of NRS 449.4309 , a registered pharmacist; or (c) An employee of the residential facility who has: (1) Received training pursuant to paragraph (a) of subsection 1 or paragraph (a) of subsection 5, as applicable, from a physician, a physician assistant, a licensed nurse or, if applicable, a registered pharmacist; (2) At least 1 year of experience performing the task for which he or she is providing training; and (3) Demonstrated competency in performing the task for which he or she is providing training. 7. Any training described in this section must include, without limitation: (a) Instruction concerning how to accurately perform the task for which the personal assistant is being trained in conformance with nationally recognized infection control guidelines which may include, without limitation, guidelines published by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services; (b) Instruction concerning how to accurately interpret the information obtained from performing the task; and (c) A description of any action, including, without limitation, notifying a physician, that must be taken based on such information. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.39519 Client to serve as managing employer and provide training to personal assistant; reporting of training to organization. ( NRS 449.4308 , 449.4327 ) 1. The client of an intermediary service organization must serve as the managing employer of the personal assistant and must be responsible for the selection and termination of the personal assistant. 2. Each client shall ensure that: (a) The personal assistant selected to provide services to the person with a disability under the direction of the client completes the training required pursuant to this section; and (b) The personal assistant is able to safely perform the services required to meet the needs of the person with a disability. 3. Each client shall ensure that the personal assistant: (a) Receives instruction from the client or a person designated by the client at the location where the personal assistant will provide services to the person with a disability; (b) Within 120 days after being employed by the intermediary service organization, receives not less than 16 hours of training which must include, without limitation: (1) The rights of a client, including, without limitation, confidentiality of client information and state and federal laws relating to confidentiality; (2) First aid and cardiopulmonary resuscitation; (3) Universal precautions, as defined in NAC 441A.195 , and the control of infection, including, without limitation, information on bloodborne pathogens and infection control procedures; (4) Body mechanics, transferring and mobility, including, without limitation, typical body movements, range of motion, prevention of back injury and potential fall hazards; (5) Household safety and accident prevention, including, without limitation, the preparation of a home for safety and accident prevention; (6) Basic communication skills, including, without limitation, techniques for sharing information with persons who require alternative modes of communication; (7) Information concerning advance directives as defined in NRS 449A.703 ; (8) General awareness of issues relating to aging and disabilities, sensory, physical and cognitive disabilities, behavioral interventions targeted to specific populations, and the philosophy and principles of independent living; and (9) The prevention of abuse, neglect and exploitation of a person with a disability, including, without limitation, identifying and reporting the full range of serious occurrences, and reporting of suspected cases of abuse, neglect or exploitation in the manner prescribed in NRS 200.5093 , 200.50935 and 632.472 ; and (c) Receives not less than 8 hours of training during each year of employment thereafter concerning such topics as determined by the client. 4. The client shall submit to the intermediary service organization documentation which includes, without limitation: (a) The content of the training provided to the personal assistant pursuant to this section; (b) The date on which the training was completed; (c) The number of hours of training provided to the personal assistant; and (d) A certificate indicating successful completion of the training. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.824) NAC 449.3952 Additional training to be provided by intermediary service organization. ( NRS 439.200 , 449.4308 , 449.4309 , 449.4327 ) An intermediary service organization shall make available to a personal assistant employed by the intermediary service organization all training required pursuant to NAC 449.39519 and, at the request of a client, such additional training for a personal assistant as necessary to support the plan of care for the person with a disability, including, without limitation: 1. General training for the personal assistant; 2. Protocols for a personal assistant, including, without limitation, the rights and responsibilities of a client and of a personal assistant; 3. The manner in which to groom and dress the person with a disability; 4. Procedures for bathing and maintaining proper hygiene for a person with a disability, including, without limitation, bed-bath and tub-bath techniques; 5. Caring for the bowel, bladder and skin of a person with a disability, including, without limitation, information concerning caring for a catheter, the identification and control of infection, common bowel problems, the early recognition of skin problems, the prevention of pressure sores and the routine inspection of skin; 6. Assistive technology, including, without limitation, examples of assistive technology, how assistive technology can be used by the personal assistant and resources from which assistive technology may be obtained; 7. Nutrition and food preparation, including, without limitation, information about preparing balanced meals, addressing special dietary needs or restrictions, guidelines for hydration and the proper handling and storage of food; 8. The manner in which to maintain health records, including, without limitation, illustrations of how information should be conveyed in a written or dictated form to assure confidentiality and a means to ensure that the person with a disability receives services as outlined in the plan of care; and 9. Training described in NAC 449.395185 . (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008; A by R109-18, 1-30-2019)—(Substituted in revision for NAC 427A.825) NAC 449.39521 Visits and telephone interviews with clients. ( NRS 449.4308 , 449.4327 ) 1. Except as otherwise provided in subsection 3, an intermediary service organization shall, not less than once every 6 months, conduct a visit of the residence of the person with a disability or perform a telephone interview with the client to monitor the quality of care received by the person with a disability. 2. The intermediary service organization shall document each visit or telephone interview conducted pursuant to subsection 1. Such documentation must include, without limitation: (a) The date of the visit or telephone interview; (b) Whether the plan of care is meeting the needs of the person with a disability; (c) Whether the personal assistant has received sufficient training to provide the services for the person with a disability; and (d) Whether there have been changes in the health status of the person with a disability. 3. A client may decline to receive a visit or a telephone interview pursuant to subsection 1 by providing to the intermediary service organization a written waiver declining the visit or telephone interview. An intermediary service organization shall retain a copy of a written waiver in the record of the client. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.826) NAC 449.39522 Written statement of services provided to clients. ( NRS 449.4308 , 449.4327 ) 1. An intermediary service organization shall provide to each client for his or her signature a written statement which contains a description of the services provided by the intermediary service organization. The statement must include, without limitation: (a) An easily understandable statement that it is not within the scope of services provided by the intermediary service organization to manage the medical and health conditions of a person with a disability; (b) The qualifications and required training for personal assistants; (c) The amount that will be charged for the services provided by the intermediary service organization; (d) A description of billing methods, acceptable payment methods and due dates for payments, and the policy for notifying the client of any increase in the amount that will be charged for the services provided by the intermediary service organization; (e) Criteria, circumstances or conditions which may result in the termination of services by the intermediary service organization, the procedures for notifying the client of such termination and the procedures for appealing such termination; (f) The manner in which the intermediary service organization may be contacted during all hours when services are being provided to a person with a disability; and (g) Information about the rights of a client of the intermediary service organization and the procedures for filing a grievance. 2. A copy of the signed statement must be maintained by the intermediary service organization in the records of the client maintained by the intermediary service organization. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.827) NAC 449.39523 Discussion of services provided to clients. ( NRS 449.4308 , 449.4327 ) 1. An intermediary service organization shall discuss with each potential client before providing services: (a) The planned training to be provided by the intermediary service organization to the personal assistant; (b) The responsibilities of the intermediary service organization; and (c) A contingency plan in the event that a personal assistant fails to report for a scheduled visit with the person with a disability. 2. The information discussed pursuant to subsection 1 and the result of that discussion must be documented and maintained in the records of the client maintained by the intermediary service organization. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.828) NAC 449.39524 Rights of person with a disability receiving services. ( NRS 449.4308 , 449.4327 ) 1. An intermediary service organization shall ensure that a person with a disability who receives services from the intermediary service organization or, as applicable, other responsible person acting on his or her behalf: (a) Has the right to select the personal assistant of his or her choice; (b) Has the right to choose community-based care or institutional care; (c) Receives services from the intermediary service organization without regard to race, color, creed, national origin, sex or disability; (d) Is treated with respect, receives recognition of his or her individuality and is free from physical, verbal or psychological abuse; (e) Is allowed to make informed decisions regarding the care of the person with a disability and to participate in the development of a plan of care; (f) Receives a description of advance directives, as defined in NRS 449A.703 , and information on how to obtain an advance directive; (g) Has the right to appeal any termination, reduction or suspension of services by the intermediary service organization and to receive a written explanation of decisions of the intermediary service organization relating to the provision of services; (h) Receives confidential treatment of personal, medical and financial information; (i) Has access to any records maintained by the intermediary service organization relating to the care of the person with a disability; (j) Is informed of the primary contact person for the intermediary service organization, the person with whom a grievance may be filed with the intermediary service organization and the process to follow when filing a grievance with the intermediary service organization; and (k) Receives timely responses to a concern expressed to the intermediary service organization regarding the provision of services by the intermediary service organization. 2. Each person with a disability who receives services from the intermediary service organization or, as applicable, other responsible person acting on his or her behalf must be provided with a written list of the rights set forth in subsection 1. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.829) Administrative Review and Hearings NAC 449.39525 Request for administrative review of complaint. ( NRS 449.4337 ) 1. An applicant for a certificate to operate an intermediary service organization or a person who is certified to operate an intermediary service organization may submit a written request to the Administrator or the Administrator’s designee for an administrative review of a complaint if the complainant: (a) Has a legitimate grievance with any action of the Division in the certification process; and (b) Has not resolved the grievance through informal negotiations with an officer of the Division. 2. Not later than 30 days after the occurrence of the action that is the cause of the grievance of the complainant, a request for an administrative review must be mailed by registered or certified mail, return receipt requested, to the Administrator or the Administrator’s designee. 3. A request for an administrative review must include: (a) The date of the occurrence of the action which is the cause of the grievance of the complainant; (b) A statement of the complaint, including each issue that the complainant considers relevant to the complaint; (c) A statement of each resolution of the complaint offered by the complainant; (d) Citations to the statutes or regulations, if any, which pertain to the complaint; (e) A statement which supports the position of the complainant; (f) The mailing address and telephone number of the complainant; and (g) The signature of the complainant and the date of the signature. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.830) NAC 449.39526 Scheduling of administrative review. ( NRS 449.4337 ) The Administrator or the Administrator’s designee shall conduct an administrative review at a time and place which is reasonable for the parties. Unless otherwise scheduled to accommodate the complainant, the Administrator or the designee shall conduct an administrative review within 10 days after the Administrator or the designee receives a request for an administrative review pursuant to NAC 449.39525 . (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.831) NAC 449.39527 Conduct of administrative review. ( NRS 449.4337 ) An administrative review must be: 1. Conducted informally without attorneys or witnesses. 2. Based on the record available, except that the complainant may, upon the complainant’s request, appear and present additional facts. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.832) NAC 449.39528 Issuance of written decision following administrative review. ( NRS 449.4337 ) 1. Not later than 15 days after an administrative review, the Administrator or the Administrator’s designee shall issue a written decision, including the findings of fact and conclusions of law concerning the complaint and any appropriate orders. 2. The Division will mail the written decision to the complainant by registered or certified mail, return receipt requested, or a representative of the Division may personally deliver the decision to the complainant and read it to the complainant. If the decision is personally delivered to the complainant, the complainant shall date and sign a copy of the decision as an acknowledgment of the receipt. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.833) NAC 449.39529 Request for hearing. ( NRS 449.4337 ) 1. Not later than 15 days after receipt of a written decision on a complaint, a complainant may submit a written request to the Administrator for a hearing on the complaint. The request must be mailed to the Administrator by certified or registered mail, return receipt requested. 2. The written request for a hearing must include a copy of the original complaint filed by the complainant. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.834) NAC 449.395295 Hearings: Scheduling; notice. ( NRS 449.4337 ) 1. Not later than 30 days after the Administrator receives a written request for a hearing, a hearing officer appointed by the senior hearing officer of the Hearings Division of the Department of Administration shall conduct a hearing at a time and location that is reasonable for the parties. The hearing officer must not have any personal involvement in the complaint. 2. Not less than 10 days before the date of the hearing, the Division of Public and Behavioral Health will, in accordance with NRS 233B.121 , provide to all parties notice of the time, date and place of the hearing. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.835) NAC 449.3953 Hearings: Representation; evidence; rights of parties. ( NRS 449.4337 ) 1. The complainant may be represented at the hearing by an attorney or another person designated by the complainant. 2. The hearing officer is not bound by the technical rules of evidence. Decisions concerning the admissibility of evidence must be made in accordance with NRS 233B.123 . 3. Each party must be granted the opportunity to present the party’s case, examine and cross-examine witnesses, and rebut evidence. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.8355) NAC 449.39531 Resolution of complaint. ( NRS 449.4337 ) Unless otherwise provided by statute, a complaint may be resolved by arbitration, mutual agreement of the parties, settlement, consent decree or default of a party. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.836) NAC 449.39532 Final decision of hearing officer; request for judicial review. ( NRS 449.4337 ) 1. A final decision by a hearing officer on a complaint must be in writing or stated in the record. A final decision must include findings of fact and conclusions of law. Findings of fact must include a statement of the facts which support the findings. 2. Not more than 30 days after a final decision is made, a party may appeal the final decision of the hearing officer and request judicial review pursuant to NRS 233B.130 to 233B.150 , inclusive. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.837) NAC 449.39533 Record of hearing. ( NRS 449.4337 ) The record of the hearing must include: 1. The transcript of the oral testimony provided at the hearing; 2. All pleadings and motions filed by the parties; 3. Any rulings made by the hearing officer, including rulings on offers of proof; 4. Evidence that was admitted; 5. Facts which were officially noticed by the hearing officer; and 6. Any other decision, opinion or report of the hearing officer. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.838) NAC 449.39534 Provision of transcript of oral proceedings of hearing. ( NRS 449.4337 ) Upon request of a party, the Division will provide a transcript of the oral proceedings of the hearing. The Division may require payment of the cost incurred for providing the transcript. (Added to NAC by Aging & Disability Services Div. by R197-09, eff. 7-22-2010)—(Substituted in revision for NAC 427A.839) Administrative Sanctions NAC 449.39535 Definitions. ( NRS 449.4336 ) As used in NAC 449.39535 to 449.39561 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.39536 to 449.39544 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.840) NAC 449.39536 “Ban on enrollment” defined. ( NRS 449.4336 ) “Ban on enrollment” means a prohibition on the provision of services to clients who are newly enrolled. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.841) NAC 449.39537 “Cluster” defined. ( NRS 449.4336 ) “Cluster” means a violation that involves the same or similar kinds of services as one or more other violations. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.842) NAC 449.39538 “Compliance” defined. ( NRS 449.4336 ) “Compliance” means that no major violation is present and that effective steps have been taken to resolve all violations. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.843) NAC 449.39539 “De minimis violation” defined. ( NRS 449.4336 ) “De minimis violation” means a violation rated at a severity level of one or two and at a scope level of one or two. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.844) NAC 449.3954 “Major violation” defined. ( NRS 449.4336 ) “Major violation” means a violation with a severity and scope score of five or more. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.845) NAC 449.39541 “Plan of correction” defined. ( NRS 449.4336 ) “Plan of correction” means a plan developed by the intermediary service organization and approved by the Division that: 1. Describes the actions to be taken by the intermediary service organization to correct one or more violations; and 2. Specifies the date by which those violations will be corrected. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.846) NAC 449.39542 “Resurvey” defined. ( NRS 449.4336 ) “Resurvey” means a survey conducted after the initial survey to evaluate compliance with a plan of correction. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.847) NAC 449.39543 “Severity and scope score” defined. ( NRS 449.4336 ) “Severity and scope score” means the sum of the numerical levels of severity and scope assigned to a violation. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.848) NAC 449.39544 “Subsequent violation” defined. ( NRS 449.4336 ) “Subsequent violation” means a violation found on a resurvey. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.849) NAC 449.39545 Imposition of sanctions generally. ( NRS 449.4336 ) 1. The Division will impose at least one administrative sanction against an intermediary service organization for each violation by the intermediary service organization with a severity level of four and for each violation with a severity and scope score of six or more as determined pursuant to the provisions of NAC 449.39551 to 449.39555 , inclusive. 2. The Division may impose sanctions if violations of a severity level of three or less or a severity and scope score of less than six are identified. 3. The Division will minimize the time between identification of a violation and the imposition of a sanction for the violation. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.855) NAC 449.39546 Minimum sanction to be imposed. ( NRS 449.4336 ) The Division will impose at least one sanction upon any intermediary service organization that has a violation with a severity level of four or a severity and scope score of six or more as determined pursuant to the provisions of NAC 449.39551 to 449.39555 , inclusive. More than one of these sanctions may be imposed at the discretion of the Division. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.856) NAC 449.39547 Available sanctions. ( NRS 449.4321 , 449.4335 , 449.4336 ) 1. The Division may apply one or more sanctions as provided in NRS 449.4335 , including, without limitation: (a) The imposition of a plan of correction as directed by the Division; (b) The imposition of a ban on enrollment; (c) Monitoring of the intermediary service organization by the Division; (d) The assessment of monetary penalties in an amount set forth in NAC 449.39561 ; (e) The requirement that the intermediary service organization be managed temporarily by a person appointed by the Division; and (f) The denial, suspension or revocation of the certificate. 2. If the Division chooses to impose a particular sanction, it must be applied according to the severity and scope factors established in NAC 449.39551 to 449.39555 , inclusive. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.857) NAC 449.39548 Duration of sanctions. ( NRS 449.4336 ) Sanctions applied pursuant to NAC 449.39535 to 449.39561 , inclusive, may be imposed until substantial compliance is achieved or, if compliance is not achieved, until the day before termination of the certificate becomes effective. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.858) NAC 449.39549 Notice of sanction; appointment of temporary manager; ban on enrollment or suspension of certificate authorized in certain circumstances. ( NRS 449.4335 , 449.4336 ) 1. The Division will give notice of a sanction to the holder of a certificate by certified mail as required pursuant to NRS 449.4337 . 2. If there is an immediate and serious threat to the health and safety of any person with a disability served by an intermediary service organization, the Division may appoint a temporary manager to remove the threat. 3. The Division may, in an emergency, impose a ban on enrollment or may suspend a certificate upon transmitting notice of such sanction to the holder of the certificate by certified mail. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.859) NAC 449.3955 Imposition of one or more sanctions; reporting of violations; presumption of de minimis violation. ( NRS 449.4336 ) 1. The Division may apply one or more sanctions on the basis of violations found during surveys or investigations of complaints conducted by the Division. 2. Violations must be reported to the intermediary service organization and any client of the intermediary service organization who may be affected by the violation. The report to the intermediary service organization must specify the violations found and the severity and scope score for each violation determined by the Division pursuant to the provisions of NAC 449.39551 to 449.39555 , inclusive. 3. Any violation for which a severity and scope score is not specified is presumed to be a de minimis violation. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.860) NAC 449.39551 Severity and scope of violations to be considered in determining sanctions to be imposed. ( NRS 449.4336 ) In determining the sanctions to be imposed, the Division will consider the severity and scope of the violations according to the classifications of severity and scope described in NAC 449.39551 to 449.39555 , inclusive. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.861) NAC 449.39552 Scope of violations: Survey of organization; sampling of clients; use of scope relating to one client authorized. ( NRS 449.4336 ) 1. In determining the scope of a violation by an intermediary service organization, a survey of an intermediary service organization must evaluate a representative sample of clients of the intermediary service organization. The sample must consist of at least: Number of clients Minimum number of clients in sample 1 - 9...................................................................................................... All clients 10 - 40...................................................................................................... 10 41 - 75...................................................................................................... 15 76 - 100...................................................................................................... 20 101 - 175...................................................................................................... 25 176 - 250...................................................................................................... 30 251 - 350...................................................................................................... 35 351 - 450...................................................................................................... 40 451 or more...................................................................................................... 50 2. In determining the scope of a violation involving particular kinds of services, the sampling of clients must evaluate a representative sample of clients of the intermediary service organization receiving or requiring the particular kinds of services. 3. The Division may review more than the minimum number of clients and determine the scope based on the number of clients actually reviewed. 4. If the Division investigates a specific complaint relating to a client, the Division may use only that client as the sample. The scope of any violation determined pursuant to this subsection must be a scope level of one. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.862) NAC 449.39553 Scope of violations: Use of scope; basis for assessment. ( NRS 449.4336 ) 1. The scope scale must be used to assess the scope of a particular violation by the intermediary service organization. 2. The basis for the assessment is the actual or potential harm to clients as shown by: (a) The frequency of the violation; (b) The number or percentage of clients affected; (c) The number or percentage of staff involved; and (d) The pattern or lack of pattern of the violations. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.863) NAC 449.39554 Scope of violations: Criteria for evaluation. ( NRS 449.4336 ) 1. The scope of the violations must be evaluated using the criteria prescribed in this section. 2. A violation with a scope level of one consists of one or a few unrelated incidents in the sample surveyed. A violation is of this scope if it involves 20 percent or less of the clients sampled. 3. A violation has a scope level of two if the Division identifies a pattern of incidents involving the intermediary service organization, including, without limitation, any violations involving clients who require particular kinds of services. The number or percentage of clients or staff involved in the violation or the repeated occurrences of the violation in short succession may also establish a pattern by indicating a reasonable degree of predictability of similar incidents. A violation is also of this scope if it involves more than 20 percent but not more than 50 percent of the clients sampled. 4. A violation has a scope level of three if it occurs in a sufficient number or percentage of clients or staff or with sufficient regularity over time that it may be considered systemic or pervasive in or by the intermediary service organization. A violation is also of this scope if it involves more than 50 percent of the clients sampled. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.864) NAC 449.39555 Severity of violations: Use of severity scale; basis for assessment; criteria for evaluation. ( NRS 449.4336 ) 1. The severity scale must be used to assess the severity of a particular violation pertaining to the intermediary service organization. The basis for the assessment must be the actual or potential harm to a person with a disability or, as applicable, other responsible person acting on his or her behalf. 2. Violations with a severity level of one concern requirements promulgated primarily for administrative purposes. No harm is likely to occur to a person with a disability. No negative impact has occurred or is likely to occur. The ability of a person with a disability to achieve the highest practicable physical, mental or psychosocial well-being has not been and is not likely to be compromised. 3. Violations with a severity level of two indirectly threaten the health, safety, rights, security, welfare or well-being of a person with a disability or, as applicable, other responsible person acting on his or her behalf. A potential for harm, as yet unrealized, exists. If continued over time: (a) A negative impact on or a violation of one or more rights of a person with a disability or, as applicable, other responsible person acting on his or her behalf would occur or would be likely to occur; or (b) The ability of one or more persons with disabilities to achieve the highest practicable physical, mental or psychosocial well-being would be or would likely be compromised. 4. Violations with a severity level of three create a condition or incident in the operation of an intermediary service organization that directly or indirectly threatens the health, safety, rights, security, welfare or well-being of a person with a disability or, as applicable, other responsible person acting on his or her behalf. A negative impact on the health, safety, rights, security, welfare or well-being of one or more persons with disabilities or, as applicable, other responsible person acting on his or her behalf has occurred or can be predicted with substantial probability to occur, or the ability of persons with disabilities to achieve the highest practicable physical, mental or psychosocial well-being has been or is about to be compromised and requires intervention and correction of the violation. Violation of a partial or complete ban on enrollment imposed on an intermediary service organization or failure to implement a directed plan of correction is presumed to be a violation of this severity level. 5. Violations with a severity level of four create a condition or incident that has resulted in or can be predicted with substantial probability to result in death or serious harm to a person with a disability. As used in this subsection, “serious harm” includes serious mental harm, serious impairment of bodily functions, serious dysfunction of any bodily organ or part, life-threatening harm or death. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.865) NAC 449.39556 Subsequent violation on resurvey: Rebuttable presumption; imposition of sanction. ( NRS 449.4336 ) If the same violation is found on a resurvey, there is a rebuttable presumption that the violation continued through the period between the survey and resurvey. A sanction may be imposed for a subsequent violation only if the resurvey is made and the violation is again actually found to be present. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.866) NAC 449.39557 Determination of sanctions: Initial assessment. ( NRS 449.4336 ) The Division will initially assess individual violations or clusters of violations according to the following initial factors: 1. The presence or absence of an immediate and serious threat to the health and safety of persons with disabilities who receive services from the intermediary service organization or, as applicable, other responsible person acting on his or her behalf; and 2. The severity of the violation. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.867) NAC 449.39558 Determination of sanctions: Secondary factors to be considered. ( NRS 449.4336 ) After the initial assessment, the Division will consider the following secondary factors in determining the sanction to impose: 1. The relationship of one violation or cluster of violations to other violations; 2. The history of previous compliance by the intermediary service organization generally and specifically with reference to the violations in issue; 3. Whether the violations are directly related to the services received by a person with a disability from the intermediary service organization; and 4. The corrective and long-term compliance outcomes desired. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.868) NAC 449.39559 Determination of sanctions: Basis for selection; restrictions upon service and monetary penalties presumed to be most effective. ( NRS 449.4336 ) The selection of a sanction must be based upon the nature of the violations or cluster of violations and the sanction most likely to correct those violations. Absent evidence to the contrary, restrictions upon service and monetary penalties are presumed to be the most effective sanctions for violations that do not cause an immediate and serious threat to clients. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.869) NAC 449.3956 Plan of correction: Development by intermediary service organization; authority of Division when plan is not acceptable; effect of failure to submit plan. ( NRS 449.4336 ) 1. The intermediary service organization shall develop a plan of correction for each violation and submit the plan to the Division for approval within 10 days after receipt of the notice of violations from the Division pursuant to NAC 449.39549 . The plan of correction must include specific requirements for corrective action, which must include the time within which the violations are to be corrected. 2. If the plan of correction is not acceptable to the Division, the Division may direct the intermediary service organization to resubmit a plan of correction or the Division may develop a directed plan of correction with which the intermediary service organization must comply. 3. Failure to submit the plan of correction to the Division within 10 days after receipt of the notice of violations constitutes a separate violation subject to monetary penalties pursuant to NAC 449.39561 with severity and scope rated at the same levels as the highest violation identified on the notice of violations. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.870) NAC 449.39561 Monetary penalties: Determination of initial penalty; daily penalties; maximum total penalties. ( NRS 449.4335 , 449.4336 ) 1. In determining the amount of an initial monetary penalty, the Division will consider the severity alone if the severity level is four. In determining the amount of the monetary penalty where the severity level is less than four, the severity and scope score must be considered. 2. For initial violations with a severity level of four, an initial monetary penalty of up to $1,000 per violation may be imposed. 3. For initial violations with a severity level of three and a scope level of three, a monetary penalty of up to $800 per violation may be imposed. 4. For initial violations with a severity level of three and a scope level of two or less, an initial monetary penalty of up to $400 per violation may be imposed. 5. For initial violations with a severity level of two and a scope level of three, an initial monetary penalty of up to $200 per violation may be imposed. The payment of this monetary penalty must be suspended if the facility has corrected the violations within the time specified in the plan of correction approved by the Division. 6. Except as otherwise provided in subsection 7, in addition to any monetary penalty imposed pursuant to this section, the Division may impose a monetary penalty of not more than $10 per client per day for each day the violation continues. 7. The total monetary penalties imposed by the Division pursuant to this section must not be more than $1,000 per day for each violation, together with interest thereon at a rate of 10 percent per annum. (Added to NAC by Bd. of Health by R167-07, eff. 1-30-2008)—(Substituted in revision for NAC 427A.871) COMMUNITY HEALTH WORKER POOLS NAC 449.39565 Definitions. ( NRS 449.0302 ) As used in NAC 449.39565 to 449.39591 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.39567 to 449.39575 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39567 “Client” defined. ( NRS 449.0302 ) “Client” means a person who receives the services of a community health worker. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39569 “Continuing education” defined. ( NRS 449.0302 ) “Continuing education” means a course of study or training that is designed to develop and enhance the knowledge, skills and competency of a community health worker with regard to providing the services of a community health worker to a client. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39571 “Representative of the client” defined. ( NRS 449.0302 ) “Representative of the client” means the spouse of a client, a parent or stepparent of a client who is a minor, the legal guardian of a client and any other person required by law to provide medical support to a client. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39573 “Service plan” defined. ( NRS 449.0302 ) “Service plan” means a plan which includes a written description of the needs of a client for the services of a community health worker and which specifies the tasks that a community health worker is authorized to provide for the client. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39575 “Services of a community health worker” defined. ( NRS 449.0302 ) “Services of a community health worker” means the services provided by a community health worker at the direction of a community health worker pool which may include, without limitation, outreach, community education, informal counseling, social support, advocacy and improvement of the social determinants of health. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39577 Location to which license applies; name of administrator to appear on license; liability coverage. ( NRS 449.0302 ) 1. Except as otherwise provided in this subsection, each license issued to operate a community health worker pool is separate and distinct and is issued to a specific person, who is designated on the license, to operate the community health worker pool at a specific location. The person may operate a community health worker pool at multiple work stations if the community health worker pool maintains the records for the clients, community health workers, other members of the staff of the community health worker pool and operations of the community health worker pool at the specific location designated on the license. 2. The name of the administrator of the community health worker pool must appear on the face of the license. 3. Each community health worker pool must retain proof that it is adequately covered against liabilities resulting from claims incurred in the course of operation. 4. The proof of liability coverage required by subsection 3 must be verified at the time the community health worker pool submits its initial application to the Division for a license and upon request by the Division. 5. As used in this section, “work station” means a satellite office of a community health worker pool that is established for the sole purposes of providing a location where copies of records may be sent to a community health worker pool and providing a location from which a community health worker may work to serve a geographic area outside the geographic area in which the community health worker normally works. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39579 Qualifications and duties of administrator; access to records in absence of administrator. ( NRS 449.0302 ) 1. The administrator of a community health worker pool must: (a) Be at least 18 years of age; (b) Have a high school diploma or its equivalent; (c) Be responsible and mature and have the personal qualities which will enable the administrator to understand the problems relating to the prevention and management of chronic disease, the social determinants of health, the field of behavioral health and community services; (d) Understand the provisions of this chapter and chapter 449 of NRS; and (e) Demonstrate the ability to read, write, speak and understand the English language. 2. The administrator of a community health worker pool shall represent the licensee in the daily operation of the community health worker pool and shall appoint a person to exercise his or her authority in the administrator’s absence. The responsibilities of an administrator include, without limitation: (a) Employing qualified personnel and arranging for their training; (b) Ensuring that only trained community health workers are providing the services of a community health worker to a client of the community health worker pool and that such services are provided in accordance with the functional assessment of the client, the service plan established for the client and the policies and procedures of the community health worker pool; (c) Developing and implementing an accounting and reporting system that reflects the fiscal experience and current financial position of the community health worker pool; (d) Negotiating for services provided by contract in accordance with legal requirements and established policies of the community health worker pool; (e) Providing oversight and direction for community health workers and other members of the staff of the community health worker pool as necessary to ensure that the clients of the community health worker pool receive needed services; (f) Developing and implementing policies and procedures for the community health worker pool, including, without limitation, policies and procedures concerning terminating the services of a community health worker provided to a client; (g) Designating one or more employees of the community health worker pool to be in charge of the community health worker pool during those times when the administrator is absent; (h) Demonstrating to the Division upon request that the community health worker pool has sufficient resources and the capability to satisfy the requests of each client of the community health worker pool related to the provision of the services of a community health worker described in the service plan to the client; and (i) Providing an annual report to the Division, on a form prescribed by the Division, on or before January 1 of each year after the initial licensure of the community health worker pool. 3. Except as otherwise provided in this subsection, an employee designated to be in charge of the community health worker pool when the administrator is absent must have access to all records kept at the community health worker pool. Confidential information may be removed from a file to which an employee designated to be in charge of the community health worker pool has access if the confidential information is maintained separately by the administrator. 4. The administrator of a community health worker pool shall ensure that: (a) The clients of the community health worker pool are not abused, neglected, exploited, isolated or abandoned by a community health worker or another member of the staff of the community health worker pool, or by any person who is visiting the client when a community health worker or another member of the staff of the community health worker pool is present; and (b) Suspected cases of abuse, neglect, exploitation, isolation or abandonment of a client are reported in the manner prescribed in NRS 200.5093 , 200.50935 and 632.472 . (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39581 Written policies and procedures. ( NRS 449.0302 ) A community health worker pool shall maintain written policies and procedures concerning the qualifications, responsibilities and conditions of employment for each community health worker and other members of the staff of the community health worker pool. The written policies and procedures must be reviewed and revised as needed. The written policies and procedures must be made available to the community health workers and other members of the staff of the community health worker pool upon hire and whenever revisions are made to those policies and procedures. At a minimum, the policies and procedures must: 1. Provide descriptions of the duties and responsibilities of community health workers; 2. Provide descriptions of any activities that community health workers are prohibited from engaging in, including, without limitation: (a) Making a long distance telephone call that is personal in nature: (1) On a telephone owned by or provided by a client; or (2) While on duty providing the services of a community health worker to a client; (b) Loaning, borrowing or accepting gifts of money or personal items from a client; (c) Accepting or retaining money or gratuities from a client, other than money needed for the purchase of groceries or medication for the client; and (d) Becoming the legal guardian of a client or being named as an attorney-in-fact in a power of attorney executed by the client; 3. Set forth the rights of clients; 4. Set forth any requirements relating to ethics governing community health workers and other members of the staff of the community health worker pool, including, without limitation, any requirements concerning the confidentiality of client information; 5. Provide a description of the services of a community health worker that are provided to clients; 6. Provide a description of the manner in which the community health worker pool assigns community health workers to provide the services of a community health worker to clients and any supervision of those services that will be provided by the community health worker pool; 7. Provide for documentation of the needs of each client and the services of a community health worker that are provided to the client; 8. Set forth the emergency responses of the community health worker pool to both medical and nonmedical situations; 9. Set forth the roles of the community health worker pool and any coordination that the community health worker pool will provide with services provided by other community service agencies; 10. Provide for periodic evaluations of the performance of the community health workers and other members of the staff of the community health worker pool; 11. Provide for the maintenance of current personnel records which confirm that the policies and procedures are being followed; and 12. Set forth any other specific information that is necessary based on the needs of any special populations served by the community health worker pool. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39583 Qualifications of community health worker. ( NRS 449.0302 ) Each community health worker employed or retained pursuant to a contract by a community health worker pool must: 1. Be at least 18 years of age; 2. Demonstrate the ability to provide the services of a community health worker; 3. Understand the provisions of this chapter and chapter 449 of NRS; 4. Demonstrate the ability to read, write, speak and communicate effectively with the clients of the community health worker pool; 5. Provide to the community health worker pool and maintain documentation of either: (a) A certificate of completion evidencing the successful completion of an initial training course for community health workers which is not less than 30 hours and is approved by the Division; or (b) Certification as a community health worker by an accrediting body approved by the Division; 6. Demonstrate the ability to meet the needs of the clients of the community health worker pool; and 7. Receive annually not less than 20 hours of continuing education related to providing for the needs of the clients of the community health worker pool. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39585 Personnel files for community health workers. ( NRS 449.0302 ) 1. A separate personnel file must be kept for each community health worker employed or retained pursuant to a contract by a community health worker pool and must include, without limitation: (a) The name, address and telephone number of the community health worker; (b) The date on which the community health worker began working for the community health worker pool; (c) Documentation satisfactory to the Division that the community health worker has been screened for communicable diseases as described in NAC 441A.375 ; (d) Evidence of compliance with NRS 449.123 by the administrator of the community health worker pool or the person licensed to operate the community health worker pool with respect to the community health worker; (e) Proof that, within 6 months after the community health worker began working for the community health worker pool, the community health worker obtained a certificate in first aid and cardiopulmonary resuscitation issued by the American National Red Cross or an equivalent certificate approved by the Division and proof that such certification has been maintained current; (f) Proof that the community health worker is at least 18 years of age; (g) Proof of possession by the community health worker of at least the minimum liability insurance coverage required by state law if the community health worker will be providing transportation to a client in a motor vehicle; (h) Documentation of each initial training course and continuing education attended by the community health worker; and (i) Documentation of the performance evaluations of the community health worker. 2. The documentation described in paragraph (h) of subsection 1 must include, without limitation, for each initial training course and continuing education attended by the community health worker: (a) The name of the training course or continuing education; (b) The date on which the training course or continuing education was attended; (c) The number of hours of the training course or continuing education; (d) The name of the instructor of the training course or continuing education; and (e) A certificate of completion or another certificate indicating that the training course or continuing education was successfully completed by the community health worker. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39587 Training and evaluation of community health workers. ( NRS 449.0302 ) 1. Each community health worker employed or retained pursuant to a contract by a community health worker pool shall: (a) Obtain a working knowledge of the provisions of this chapter which govern the licensing of community health worker pools before providing the services of a community health worker to the clients of the community health worker pool. The community health worker pool must provide a copy of those provisions to a community health worker before the community health worker may provide the services of a community health worker to the clients of the community health worker pool. (b) Participate in and complete a training program before independently providing the services of a community health worker to the clients of the community health worker pool. The training program must include an opportunity for the community health worker to receive on-the-job instruction provided to clients of the community health worker pool, as long as the administrator of the community health worker pool or the administrator’s designee provides supervision during this instruction to determine whether the community health worker is able to provide the services of a community health worker successfully and independently to the client. (c) Receive training: (1) In the written documentation of: (I) The services provided by the community health worker to the clients of the community health worker pool; and (II) Verification of time records. (2) In the core competencies, roles, values, scope of practice and ethics of a community health worker that are consistent with guidelines of the American Public Health Association or an equivalent association approved by the Division. (3) In the rights of clients, including, without limitation, training in methods to protect client confidentiality pursuant to state and federal regulations. (4) Related to outreach, community education, informal counseling, social support, advocacy and improvement of the social determinants of health. (5) Related to communication skills, including, without limitation, active listening, problem solving, conflict resolution and techniques for communicating through alternative modes with persons with communication or sensory impairments. 2. Each community health worker of a community health worker pool must: (a) Be evaluated and determined to be competent by the community health worker pool in the required areas of training set forth in paragraph (c) of subsection 1. (b) Have evidence of successful completion of a training program that includes the areas of training set forth in paragraph (c) of subsection 1 which precedes the date on which the community health worker first begins providing the services of a community health worker to a client. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39589 Rights of clients: Duties of administrator; provision of written description to clients. ( NRS 449.0302 ) 1. The administrator of a community health worker pool shall ensure that a client is not prohibited from speaking to any person who advocates for the rights of the clients of the community health worker pool. 2. The administrator of a community health worker pool shall establish and enforce a procedure to respond to grievances, incidents and complaints concerning the community health worker pool in accordance with the written policies and procedures of the community health worker pool. The procedure established and enforced by the administrator must include a method for ensuring that the administrator or the administrator’s designee is notified of each grievance, incident or complaint. The administrator or his or her designee shall personally investigate the matter in a timely manner. A client who files a grievance or complaint or reports an incident concerning the community health worker pool must be notified of the action taken in response to the grievance, complaint or report or must be given a reason why no action was taken. 3. The administrator of a community health worker pool shall ensure that the community health worker pool is in compliance with NRS 449A.100 to 449A.118 , inclusive. 4. The community health worker pool shall develop a written description of the rights of clients and provide a copy to each client or a representative of the client upon initiation of the service plan established for the client. A signed and dated copy of the receipt of this information by the client or a representative of the client must be maintained in the record of the client. 5. The written description of the rights of clients developed pursuant to subsection 4 must include, without limitation, a statement that each client has the right: (a) To receive considerate and respectful care that recognizes the inherent worth and dignity of each client; (b) To participate in the development of the service plan established for the client and to receive an explanation of the services of a community health worker that will be provided pursuant to the service plan and a copy of the service plan; (c) To receive the telephone number of the Bureau which may be contacted for complaints; (d) To receive notification of any authority of the Division to examine the records of the client relating to the regulation and evaluation of the community health worker pool by the Division; and (e) To receive from the community health worker pool, within the limits set by the service plan established for the client and within the program criteria, responses to reasonable requests for assistance. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) NAC 449.39591 Initial screening of client. ( NRS 449.0302 ) The administrator of a community health worker pool or the administrator’s designee shall conduct an initial screening to evaluate each prospective client’s requests for the services of a community health worker and to develop a service plan for the client or to accept a service plan established for the client. (Added to NAC by Bd. of Health by R133-15, eff. 12-19-2017) AGENCIES TO PROVIDE PERSONAL CARE SERVICES IN THE HOME General Provisions NAC 449.396 Definitions. ( NRS 439.200 , 449.0302 , 449.0304 ) As used in NAC 449.396 to 449.3982 , inclusive, the words and terms defined in NAC 449.3961 to 449.3968 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008; A by R109-18, 1-30-2019; R048-22, 12-29-2022) NAC 449.3961 “Activities of daily living” defined. ( NRS 449.0302 ) “Activities of daily living” means the activities listed in NRS 449.0021 . (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3962 “Agency” defined. ( NRS 449.0302 ) “Agency” means an agency to provide personal care services in the home as defined in NRS 449.0021 . (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3963 “Attendant” defined. ( NRS 449.0302 ) “Attendant” means a person who is employed by or retained pursuant to a contract by an agency for the purpose of providing personal care services to a client. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3964 “Client” defined. ( NRS 449.0302 ) “Client” means an elderly person or a person with a disability who desires the provision of personal care services in the home in which the person lives. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3965 “Personal care services” defined. ( NRS 449.0302 ) “Personal care services” means the nonmedical services described in NRS 449.0021 . (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3966 “Representative of the client” defined. ( NRS 449.0302 ) “Representative of the client” means the spouse of a client, a parent or stepparent of a client who is a minor, the legal guardian of a client and any other person required by law to provide medical support to a client. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3967 “Service plan” defined. ( NRS 449.0302 ) “Service plan” means a plan which includes a written description of the needs of a client for personal care services and which specifies the tasks that an attendant is authorized to provide for the client. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3968 “Work station” defined. ( NRS 449.0302 ) “Work station” means a satellite office of an agency that is established for the sole purposes of providing a location where copies of records may be sent to an agency and providing a location from which an attendant may work to serve a geographic area outside the geographic area in which the attendant normally works. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) Licensing NAC 449.3972 Location to which license applies; agency to retain proof of liability coverage and compliance with certain statutory provisions. ( NRS 449.0302 ) 1. Except as otherwise provided in this subsection, each license issued to operate an agency is separate and distinct and is issued to a specific person to operate the agency at a specific location. A person may operate an agency at multiple work stations if the agency maintains the records for the clients, attendants, other members of the staff of the agency and operations of the agency at the specific location designated on the license. 2. The name of the person who is designated as responsible for the conduct of the agency must appear on the face of the license. 3. Each agency must retain: (a) Proof that it is adequately covered against liabilities resulting from claims incurred in the course of operation; and (b) Proof of compliance with NRS 449.065 and 449.067 . 4. The proof of liability coverage and compliance with state statute required by subsection 3 must be verified at the time the agency submits its initial application to the Division for a license and upon request by the Division. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) Administration and Personnel NAC 449.3973 Qualifications and duties of administrator; appointment of designee to act in administrator’s absence. ( NRS 439.200 , 449.0302 ) 1. The administrator of an agency must: (a) Be at least 18 years of age; (b) Have a high school diploma or its equivalent; (c) Be responsible and mature and have the personal qualities which will enable the administrator to understand the problems of elderly persons and persons with disabilities; (d) Understand the provisions of this chapter and chapter 449 of NRS; and (e) Demonstrate the ability to read, write, speak and understand the English language. 2. The administrator of an agency shall represent the licensee in the daily operation of the agency and shall appoint a person to exercise his or her authority in the administrator’s absence. The responsibilities of an administrator include, without limitation: (a) Employing qualified personnel and ensuring that such personnel receive all training required by this chapter and chapter 449 of NRS in accordance with NAC 449.39735 ; (b) Ensuring that only trained attendants are providing services to a client of the agency and that such services are provided in accordance with the functional assessment of the client, the service plan established for the client and the policies and procedures of the agency; (c) Developing and implementing an accounting and reporting system that reflects the fiscal experience and current financial position of the agency; (d) Negotiating for services provided by contract in accordance with legal requirements and established policies of the agency; (e) Providing oversight and direction for attendants and other members of the staff of the agency as necessary to ensure that the clients of the agency receive needed services; (f) Developing and implementing policies and procedures for the agency, including, without limitation, policies and procedures concerning terminating the personal care services provided to a client; (g) Designating one or more employees of the agency to be in charge of the agency during those times when the administrator is absent; and (h) Demonstrating to the Division upon request that the agency has sufficient resources and the capability to satisfy the requests of each client of the agency related to the provision of the personal care services described in the service plan to the client. 3. Except as otherwise provided in this subsection and subsection 4 of NAC 449.3976 , an employee designated to be in charge of the agency when the administrator is absent must have access to all records kept at the agency. Confidential information may be removed from a file to which an employee designated to be in charge of the agency has access if the confidential information is maintained separately by the administrator. 4. The administrator of an agency shall ensure that: (a) The clients of the agency are not abused, neglected or exploited by an attendant or another member of the staff of the agency, or by any person who is visiting the client when an attendant or another member of the staff of the agency is present; and (b) Suspected cases of abuse, neglect or exploitation of a client are reported in the manner prescribed in NRS 200.5093 and 632.472 . (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008; A by R048-22, 12-29-2022) NAC 449.39735 Training of employees: Provision or arranging for provision of training; costs; payment of salary or hourly wage; exceptions; documentation. ( NRS 439.200 , 449.0302 ) 1. To comply with the requirements of paragraph (a) of subsection 2 of NAC 449.3973 concerning the training of employees, an agency shall: (a) Provide or arrange for the provision of the training required by that paragraph; (b) Except as otherwise provided in subsection 4, pay any costs associated with attending such training, including, without limitation: (1) The cost of the training; and (2) If the training is not provided at the agency, the costs of travelling to and from the location where the training is provided; and (c) Pay an employee attending such training his or her salary or hourly wage as if the employee were working for: (1) Time spent attending the training; and (2) The time that would ordinarily be required to travel from the agency to the location of the training and back to the agency. 2. An agency that provides training pursuant to paragraph (a) of subsection 2 of NAC 449.3973 on the premises of the agency is not required to arrange or pay the costs of training provided at another location if: (a) The training provided on the premises of the agency meets the applicable requirements of state law and regulations; and (b) The agency pays all costs associated with the training provided on the premises of the agency. 3. An agency may require an employee attending training pursuant to paragraph (a) of subsection 2 of NAC 449.3973 to provide any documentation necessary to verify expenses or time described in paragraph (b) or (c) of subsection 1. Such documentation may include, without limitation, receipts and proof of mileage. 4. An agency is not required to pay the costs described in paragraph (b) of subsection 1 for an employee who attends, but fails to complete, the training described in paragraph (a) of subsection 2 of NAC 449.3973 . 5. An agency shall: (a) Require an employee who completes training pursuant to paragraph (a) of subsection 2 of NAC 449.3973 to provide to the agency documentation of the completion of the training; and (b) Maintain such documentation in the personnel file of the employee. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) NAC 449.3974 Maintenance of policies and procedures concerning qualifications, responsibilities and conditions of employment for staff members. ( NRS 449.0302 ) An agency shall maintain written policies and procedures concerning the qualifications, responsibilities and conditions of employment for each attendant and other members of the staff of the agency. The written policies and procedures must be reviewed and revised as needed. The written policies and procedures must be made available to the attendants and other members of the staff of the agency upon hire and whenever revisions are made to those policies and procedures. At a minimum, the policies and procedures must: 1. Provide descriptions of the duties and responsibilities of attendants; 2. Provide descriptions of any activities that attendants are prohibited from engaging in, including, without limitation: (a) Making a long distance telephone call that is personal in nature: (1) On a telephone owned by or provided by a client; or (2) While on duty providing personal care services to a client; (b) Loaning, borrowing or accepting gifts of money or personal items from a client; (c) Accepting or retaining money or gratuities from a client, other than money needed for the purchase of groceries or medication for the client; and (d) Becoming the legal guardian of a client or being named as an attorney-in-fact in a power of attorney executed by the client; 3. Set forth the rights of clients; 4. Set forth any requirements relating to ethics governing attendants and other members of the staff of the agency, including, without limitation, any requirements concerning the confidentiality of client information; 5. Provide for the prevention, control and investigation of infections and communicable diseases; 6. Provide a description of the personal care services that are provided by the agency to clients; 7. Provide a description of the manner in which the agency assigns attendants to provide personal care services to clients and any supervision of those services that will be provided by the agency; 8. Provide for documentation of the needs of each client and the personal care services that are provided to the client; 9. Set forth the emergency responses of the agency to both medical and nonmedical situations; 10. Set forth the roles of the agency and any coordination that the agency will provide with services provided by other community service agencies; 11. Provide for periodic evaluations of the performance of attendants and other members of the staff of the agency; 12. Provide for the maintenance of current personnel records which confirm that the policies and procedures are being followed; and 13. Set forth any other specific information that is necessary based on the needs of any special populations served by the agency. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3975 Attendants: Qualifications; annual training. ( NRS 449.0302 ) Each attendant of an agency must: 1. Be at least 18 years of age; 2. Be responsible and mature and have the personal qualities which will enable the attendant to understand the problems of elderly persons and persons with disabilities; 3. Understand the provisions of this chapter and chapter 449 of NRS; 4. Demonstrate the ability to read, write, speak and communicate effectively with the clients of the agency; 5. Demonstrate the ability to meet the needs of the clients of the agency; and 6. Receive annually not less than 8 hours of training related to providing for the needs of the clients of the agency. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3976 Attendants: Maintenance of personnel file; evaluation of competency. ( NRS 449.0302 ) 1. A separate personnel file must be kept for each attendant of an agency and must include, without limitation: (a) The name, address and telephone number of the attendant; (b) The date on which the attendant began working for the agency; (c) Documentation that the attendant has had the tests or obtained the certificates required by NAC 441A.375 ; (d) Evidence that the references supplied by the attendant were checked by the agency; (e) Evidence of compliance with NRS 449.123 by the administrator of the agency or the person licensed to operate the agency with respect to the attendant; (f) Proof that, within 6 months after the attendant began working for the agency, the attendant obtained a certificate in first aid and cardiopulmonary resuscitation issued by the American National Red Cross or an equivalent certificate approved by the Division; (g) Proof that the attendant is at least 18 years of age; (h) Proof of possession by the attendant of at least the minimum liability insurance coverage required by state law if the attendant will be providing transportation to a client in a motor vehicle; and (i) Documentation of all training attended by and performance evaluations of the attendant. 2. The documentation described in paragraph (i) of subsection 1 must include, without limitation, for each training course attended by the attendant: (a) A description of the content of the training course; (b) The date on which the training course was attended; (c) The number of hours of the training course; (d) The name and signature of the instructor of the training course; and (e) A certificate indicating that the training course was successfully completed by the attendant. 3. The administrator or the administrator’s designee shall evaluate the competency of an attendant in each competency area required by the agency if the attendant provides written proof of his or her current or previous training in that competency area. After the initial evaluation, any additional training provided to the attendant may be limited to areas in which the attendant needs to improve his or her competency. 4. The administrator may keep the personnel files of the agency in a locked cabinet and may, except as otherwise provided in this subsection, restrict access to this cabinet by attendants and other members of the staff of the agency. The administrator shall make the personnel files, including, without limitation, any electronic files, available for review by the Division upon request. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3977 Attendants: Required knowledge and training. ( NRS 449.0302 ) 1. Each attendant of an agency shall: (a) Obtain a working knowledge of the provisions of this chapter which govern the licensing of agencies before providing personal care services to the clients of the agency. The agency must provide a copy of those provisions to an attendant before the attendant may provide personal care services to the clients of the agency. (b) Participate in and complete a training program before independently providing personal care services to the clients of the agency. The training program must include an opportunity for the attendant to receive on-the-job instruction provided to clients of the agency, as long as the administrator of the agency or the administrator’s designee provides supervision during this instruction to determine whether the attendant is able to provide personal care services successfully and independently to the client. (c) Receive training: (1) In the written documentation of: (I) Personal care services provided to the clients of the agency; and (II) Verification of time records. (2) In the rights of clients, including, without limitation, training in methods to protect client confidentiality pursuant to state and federal regulations. (3) Related to the special needs of elderly persons and persons with disabilities, including, without limitation, training in the sensory, physical and cognitive changes related to the aging process. (4) Related to communication skills, including, without limitation, active listening, problem solving, conflict resolution and techniques for communicating through alternative modes with persons with communication or sensory impairments. (5) In first aid and cardiopulmonary resuscitation. A certificate in first aid and cardiopulmonary resuscitation issued by the American National Red Cross or an equivalent certificate will be accepted as proof of that training. (6) That is specifically related to the personal care services provided by the agency, including, as applicable, training in the following topics: (I) Duties and responsibilities of attendants and the appropriate techniques for providing personal care services; (II) Recognizing and responding to emergencies, including, without limitation, fires and medical emergencies; (III) Dealing with adverse behaviors; (IV) Nutrition and hydration, including, without limitation, special diets and meal preparation and service; (V) Bowel and bladder care, including, without limitation, routine care associated with toileting, routine maintenance of an indwelling catheter drainage system such as emptying the bag and positioning, routine care of colostomies such as emptying and changing the bag, signs and symptoms of urinary tract infections, and common bowel problems, including, without limitation, constipation and diarrhea; (VI) Skin care, including, without limitation, interventions that prevent pressure sores, routine inspections of the skin and reporting skin redness, discoloration or breakdown to the client or a representative of the client and to the administrator of the agency or the administrator’s designee; (VII) Methods and techniques to prevent skin breakdown, contractures and falls; (VIII) Hand washing and infection control; (IX) Body mechanics, mobility and transfer techniques, including, without limitation, simple nonprescribed range of motion; and (X) Maintenance of a clean and safe environment. 2. Each attendant of an agency must be evaluated and determined to be competent by the agency in the required areas of training set forth in paragraph (c) of subsection 1. 3. Each attendant of an agency must have evidence of successful completion of a training program that includes the areas of training set forth in paragraph (c) of subsection 1 within the 12 months immediately preceding the date on which the attendant first begins providing care to a client. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.39775 Attendants: Performance of certain tasks. ( NRS 439.200 , 449.0302 , 449.0304 ) 1. An attendant may perform a task described in NRS 449.0304 if the attendant: (a) Before performing the task, annually thereafter and when any device used for performing the task is changed: (1) Receives training concerning the task that meets the requirements of subsections 6 and 7; and (2) Demonstrates an understanding of the task; (b) Follows the manufacturer’s instructions when operating any device used for performing the task; (c) Performs the task in conformance with the Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, 42 U.S.C. § 263a, if applicable, and any other applicable federal law or regulation; and (d) Complies with the requirements of subsection 3 or 4, if applicable. 2. If a person with diabetes who is a client of an agency does not have the physical or mental capacity to perform a blood glucose test on himself or herself and an attendant performs a blood glucose test on the client, the Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, 42 U.S.C. § 263a, shall be deemed to be applicable for the purposes of paragraph (c) of subsection 1. 3. In addition to satisfying the requirements of subsection 1, an attendant who conducts a blood glucose test must ensure that the device for monitoring blood glucose is not used on more than one person. 4. An attendant may assist a client in the administration of insulin prescribed to the client for his or her diabetes and furnished by a registered pharmacist through an auto-injection device approved by the United States Food and Drug Administration for use in the home in accordance with the requirements of subsection 1 if: (a) A physician, physician assistant or advanced practice registered nurse has determined that the client’s physical and mental condition is stable and following a predictable course; and (b) The amount of the insulin prescribed to the client is at a maintenance level and does not require a daily assessment, including, without limitation, the use of a sliding scale. 5. An attendant may weigh a client of an agency only if: (a) The attendant has received training on how to accurately weigh persons that meets the requirements of subsections 6 and 7; and (b) The client has consented to being weighed by the attendant. 6. The training described in this section must be provided by: (a) A physician, physician assistant or licensed nurse; (b) For the training described in paragraph (b) or (c) of subsection 1 of NRS 449.0304 , a registered pharmacist; or (c) An employee of the residential facility who has: (1) Received training pursuant to paragraph (a) of subsection 1 or paragraph (a) of subsection 5, as applicable, from a physician, a physician assistant, a licensed nurse or, if applicable, a registered pharmacist; (2) At least 1 year of experience performing the task for which he or she is providing training; and (3) Demonstrated competency in performing the task for which he or she is providing training. 7. Any training described in this section must include, without limitation: (a) Instruction concerning how to accurately perform the task for which the attendant is being trained in conformance with nationally recognized infection control guidelines which may include, without limitation, guidelines published by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services; (b) Instruction concerning how to accurately interpret the information obtained from performing the task; and (c) A description of any action, including, without limitation, notifying a physician, that must be taken based on such information. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.3978 Attendants: Prohibition on provision of certain types of services to clients. ( NRS 439.200 , 449.0302 , 449.0304 ) 1. The administrator of an agency shall ensure that each attendant working for the agency is working within the attendant’s scope of service and conducts himself or herself in a professional manner. An attendant is prohibited from providing any of the services listed in subsection 2 to a client. 2. The services an attendant must not provide to a client include, without limitation: (a) Insertion or irrigation of a catheter; (b) Irrigation of any body cavity, including, without limitation, irrigation of the ear, insertion of an enema or a vaginal douche; (c) Application of a dressing involving prescription medication or aseptic techniques, including, without limitation, the treatment of moderate or severe conditions of the skin; (d) Except as authorized by NAC 449.39775 , administration of injections of fluids into veins, muscles or the skin; (e) Except as authorized by NAC 449.39775 , administration of medication, including, without limitation, the insertion of rectal suppositories, the application of a prescribed topical lotion for the skin and the administration of drops in the eyes; (f) Performing physical assessments; (g) Using specialized feeding techniques; (h) Performing a digital rectal examination; (i) Trimming or cutting toenails; (j) Massage; (k) Providing specialized services to increase the range of motion of a client; (l) Providing medical case management, including, without limitation, accompanying a client to the office of a physician to provide medical information to the physician concerning the client or to receive medical information from the physician concerning the client; and (m) Any task identified in chapter 632 of NRS and the regulations adopted by the State Board of Nursing as requiring skilled nursing care, except any services that are within the scope and practice of a certified nursing assistant. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008; A by R109-18, 1-30-2019) Provision of Services NAC 449.3979 Provision of written disclosure statement to client upon acceptance for services by agency. ( NRS 449.0302 ) 1. When a person is accepted as a client by an agency, the agency shall: (a) Provide a written disclosure statement to the client; (b) Require the client or a representative of the client to sign the written disclosure statement; and (c) Ensure that a copy of the written disclosure statement is incorporated into the record of the client. 2. The written disclosure statement must include a description of and information concerning the personal care services offered by the agency, including, without limitation: (a) A statement which is easily understandable to the client indicating that it is not within the scope of the license of the agency to manage the medical and health conditions of clients should the conditions become unstable or unpredictable; (b) The qualifications and training requirements for the attendants who provide personal care services to the clients of the agency; (c) The charges for the personal care services provided by the agency; (d) A description of billing methods, payment systems, due dates for bills for personal care services and the policy for notifying clients of increases in the costs of personal care services provided by the agency; (e) The criteria, circumstances or conditions which may result in the termination of personal care services by the agency and the policy for notifying clients of such termination of personal care services; (f) Procedures for contacting the administrator of the agency or the administrator’s designee during all hours in which personal care services are provided and the on-call policy of the agency; and (g) Information concerning the rights of clients and the grievance procedure of the agency. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.398 Rights of clients: Duties of administrator; provision of written description to clients. ( NRS 449.0302 ) 1. The administrator of an agency shall ensure that a client is not prohibited from speaking to any person who advocates for the rights of the clients of the agency. 2. The administrator of an agency shall establish and enforce a procedure to respond to grievances, incidents and complaints concerning the agency in accordance with the written policies and procedures of the agency. The procedure established and enforced by the administrator must include a method for ensuring that the administrator or the administrator’s designee is notified of each grievance, incident or complaint. The administrator or his or her designee shall personally investigate the matter in a timely manner. A client who files a grievance or complaint or reports an incident concerning the agency must be notified of the action taken in response to the grievance, complaint or report or must be given a reason why no action was taken. 3. The administrator of an agency shall ensure that the agency is in compliance with NRS 449A.100 to 449A.118 , inclusive. 4. The agency shall develop a written description of the rights of clients and provide a copy to each client or a representative of the client upon initiation of the service plan established for the client. A signed and dated copy of the receipt of this information by the client or a representative of the client must be maintained in the record of the client. 5. The written description of the rights of clients developed pursuant to subsection 4 must include, without limitation, a statement that each client has the right: (a) To receive considerate and respectful care that recognizes the inherent worth and dignity of each client; (b) To participate in the development of the service plan established for the client and to receive an explanation of the personal care services provided pursuant to the service plan and a copy of the service plan; (c) To receive the telephone number of the Bureau which may be contacted for complaints; (d) To receive notification of any authority of the Division to examine the records of the client as related to the regulation and evaluation of the agency by the Division; (e) To receive from the agency, within the limits set by the service plan established for the client and within the program criteria, responses to reasonable requests for assistance; and (f) To receive information, upon request, concerning the policies and procedures of the agency, including, without limitation, the policies and procedures of the agency relating to charges, reimbursements and determinations concerning service plans. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3981 Initial screening of client and development or acceptance of service plan; requirements before providing personal care to client. ( NRS 449.0302 ) 1. The administrator of an agency or the administrator’s designee shall conduct an initial screening to evaluate each prospective client’s requests for personal care services and to develop a service plan for the client or to accept a service plan established for the client. 2. The initial screening and the development or acceptance of a service plan must be documented. The documentation must be dated and signed by the person who conducted the initial screening and developed or accepted the service plan. 3. The agency shall complete the following tasks before providing the personal care services outlined in the service plan established for the client and as often as necessary if the service plan is revised: (a) Evaluate whether the agency has sufficient resources and the capability to satisfy the requests of the client and to provide the client with the personal care services described in the service plan; (b) Review the service plan with the client, including, without limitation, the schedule for the provision of personal care services to the client, the procedure to follow if an attendant fails to provide personal care services in accordance with the service plan, the hiring and training policies of the agency, the responsibilities of the agency, the procedure for filing a grievance or complaint and any personal care services that an attendant is prohibited from providing pursuant to NAC 449.3978 ; (c) Review the procedure to be followed if an attendant does not appear for a scheduled visit and the procedure to be followed if an additional visit from an attendant is required; (d) Ensure that the personal care services requested by the client are services which assist the client with the activities of daily living; and (e) Ensure that the agency is coordinating the personal care services that it will be providing to the client with the care and services available to the client from other organizations and persons. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) NAC 449.3982 Supervisory home visits or telephone calls required to ensure quality of care provided; documentation of evaluation. ( NRS 449.0302 ) 1. The administrator of an agency or the administrator’s designee shall conduct supervisory home visits or telephone calls to the home of each client of the agency to ensure that quality personal care services are provided to the client. 2. Each supervisory visit and each telephone call must be documented. The documentation must be dated and signed by the administrator or the administrator’s designee. Each supervisory visit and each telephone call must consist of an evaluation of whether: (a) Appropriate and safe techniques have been used in the provision of personal care services to the client; (b) The service plan established for the client has been followed; (c) The service plan established for the client is meeting the personal care needs of the client; (d) The attendant providing personal care services to the client has received sufficient training relating to the personal care services that the attendant is providing to the client; and (e) It is necessary for the administrator or the administrator’s designee to follow up with the attendant or client concerning any problems in the personal care services being provided to the client or the service plan established for the client that are identified as the result of the supervisory visit or telephone call. (Added to NAC by Bd. of Health by R182-07, eff. 1-30-2008) FACILITIES FOR CARE OF ADULTS DURING THE DAY General Provisions NAC 449.4061 Definitions. ( NRS 439.200 , 449.0302 , 449.0304 ) As used in NAC 449.4061 to 449.4089 , inclusive, unless the context otherwise requires: 1. “Division” means the Division of Public and Behavioral Health of the Department of Health and Human Services. 2. “Facility” means a facility for the care of adults during the day as defined in NRS 449.004 . (Added to NAC by Bd. of Health, eff. 6-23-86; A by R109-18, 1-30-2019) Licensing NAC 449.4063 Design, construction, equipment and maintenance of facility: General requirements; prerequisites to approval for licensure. ( NRS 449.0302 ) 1. A facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the clients and personnel of the facility and members of the general public. 2. A facility shall comply with all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Environmental, health, fire and local building codes, Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply. 3. Except as otherwise provided in subsection 5, before any new construction of a facility or any remodeling of an existing facility is begun: (a) The facility must submit building plans for the new construction or remodeling to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 . The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the facility. (b) The building plans for the construction or remodeling must be approved by the Division. 4. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility. 5. The provisions of subsection 3 do not apply to plans for remodeling a facility if the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area, and replacing window or wall coverings in the area. (Added to NAC by Bd. of Health, eff. 6-23-86; A by R076-01, 10-18-2001; R074-04, 8-4-2004) NAC 449.4065 Consultation with representative of Division; notice of nonconformity. ( NRS 449.0302 ) 1. A representative of the Division will be available upon request for consultation to assure compliance with applicable regulations. 2. If a licensed facility does not conform to any requirement for licensing, the Division will issue a written notice specifying the nature of the nonconformity and set a time within which the facility must conform. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4067 Operation in combination with other medical facility or facility for the dependent. ( NRS 449.0302 ) A facility must not be operated in combination with any other medical facility or facility for the dependent unless it is licensed as a separate and distinct unit. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4069 Insurance. ( NRS 449.0302 ) 1. A facility must maintain a contract of insurance for protection against liability to third persons in amounts appropriate for the protection of clients, employees, volunteers and visitors to the facility. 2. A certificate of insurance must be furnished to the Division as evidence that a contract is in force, and a license will not be issued until that certificate is furnished. 3. Each contract of insurance must contain an endorsement providing for a notice of 30 days to the Division before the effective date of a cancellation or nonrenewal of the policy. (Added to NAC by Bd. of Health, eff. 6-23-86) Operation of Facility NAC 449.407 Advertising and promotional materials. ( NRS 449.0302 ) Advertising and promotional materials for the facility must be accurate and represent the accommodations, programs or other services actually offered by the facility. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4071 Policies and procedures; accounting. ( NRS 449.0302 ) 1. Every facility must have a written policy concerning: (a) Admission, discharge and care of clients; (b) Employees of the facility; and (c) Fiscal and administrative procedures for the facility, Ê which must be evaluated at least once a year. 2. The system of accounting and financial reporting used by a facility must reflect the fiscal experience and current financial position of the facility. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4072 Director and employees: Qualifications and duties; physical and mental health; personnel files. ( NRS 449.0302 ) 1. Each facility must have the number and kind of employees required by the physical characteristics of the facility, the number of clients and the services provided. 2. The director of a facility: (a) Must be responsible and mature and have the personal qualities which will enable him or her to understand the problems of aged and infirm adults. (b) Must be at least 21 years of age. (c) Must have a high school diploma or its equivalent. (d) Shall designate an acting director, who is similarly qualified, to act when the director is absent from the facility. 3. Every employee of the facility must be in good physical and mental health. 4. The facility shall keep a separate personnel file for each employee of the facility that must include, without limitation, documentation that the employee has had the tests or obtained the certificates required by NAC 441A.375 . (Added to NAC by Bd. of Health, eff. 6-23-86; A by R022-14, 6-26-2015) NAC 449.40723 Supervision of clients; volunteers. ( NRS 449.0302 ) 1. A client must be supervised by an employee of the facility at all times during the operating hours of the facility. The employee shall report a change in any physical, mental, emotional or social function of the client to the director of the facility. These reports must be included in the client’s file. 2. The facility may use volunteers or outside consultants or services to meet the needs of its clients. 3. A volunteer shall conform to the same standards and requirements as a paid employee who performs a similar function, except that a volunteer is only required to provide the results of a tuberculin test and not the results of a complete physical examination. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.40725 Orientation and training of employees and volunteers. ( NRS 449.0302 ) All employees and volunteers at the facility: 1. Shall participate in a program of general orientation to inform them of the programs, policies and services of the facility; 2. Must receive a copy of the facility’s policies and procedures; and 3. Must receive training at the facility on a regular basis, but not less than 12 hours per year. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4073 Files concerning employees. ( NRS 449.0302 ) A separate file must be maintained and kept current on each employee. The file must include the following: 1. The employee’s: (a) Name, address and telephone number; (b) Social security number; (c) Date of birth; (d) Date of employment; (e) Educational qualifications; and (f) Application for employment. 2. The name of a person to notify in case of an emergency. 3. Records of the employee’s experience related to his or her work. 4. Reports of periodic evaluations of the employee. 5. All required health certificates. 6. A record of any communicable illness which caused the employee to be absent from work. 7. Records of all accidents at the facility involving the employee. 8. The date of termination of employment and the reason for the employee’s discharge or resignation. 9. Records of the employee’s training at the facility. 10. Verification of any license held by the employee. 11. Proof that the employee received the required orientation at the facility. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4074 Requirements of facility; health and sanitation; medications; exits. ( NRS 449.0302 ) 1. The facility must: (a) Provide proper access for each client to all activities and services; (b) Have furniture and equipment appropriate for use by the clients; (c) Have free local telephone service available for use by clients; (d) Have sufficient space to accommodate a full range of activities and services; (e) Provide for each client at least 40 square feet of space inside the facility excluding areas for maintenance of the facility; (f) Contain offices sufficient to permit employees to work effectively and without interruption; (g) Provide adequate space for storage of supplies; (h) Provide at least one toilet for every 10 clients; (i) Have sufficient areas for parking and the safe delivery and pick-up of clients; and (j) Provide secure space for the temporary storage of the property of clients. 2. The facility and its grounds must be safe, clean and accessible to all clients. 3. Medications and prescriptions must be stored in an appropriate, locked container or area. 4. Each facility must have at least two well-identified exits. 5. Stairs, ramps and interior floors must have surfaces or carpets which inhibit falling or slipping. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4075 Preparations for fires and other emergencies; reporting of fire or disaster. ( NRS 449.0302 ) 1. Each facility must have a plan in case of a fire or other emergency. The plan must be: (a) Understood by all employees; (b) Posted in a conspicuous place; and (c) Reviewed at least once a year. 2. A drill for evacuation must be conducted at least once each month. Each facility shall retain a written record of the drill on file at the facility for not less than 12 months after the drill is conducted. Fire extinguishers must be inspected periodically, and training must be provided for employees of the facility in procedures to be followed in case of a fire or other emergency. 3. A facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster. (Added to NAC by Bd. of Health, eff. 6-23-86; A by R074-04, 8-4-2004) NAC 449.4076 First aid. ( NRS 449.0302 ) A first-aid kit must be available at the facility. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4077 Policy for admissions; retention of signed copy. ( NRS 449.0302 ) 1. A facility’s written policy on admissions must include: (a) A statement of nondiscrimination regarding admission to the facility and treatment after admission; and (b) The requirements for eligibility as a client. 2. A copy of the policy must be signed by the director of the facility and the client and retained in the client’s file. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4078 Requirements for admission; designation of physician. ( NRS 449.0302 ) 1. Each client shall, before being admitted to the facility, provide the facility with: (a) The results of a physical examination conducted by a physician, physician assistant or advanced practice registered nurse within the preceding 6 months; (b) A summary of the client’s medical history prepared by a physician, physician assistant or registered nurse, within the preceding 6 months; (c) A statement from the client’s physician which indicates that the facility is an appropriate setting for the client; and (d) Any special dietary requirements. 2. Each client shall designate a physician to be called in case of emergency. The facility must make all necessary arrangements to secure the services of a licensed physician for a client if his or her own physician is not available. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4079 Required services. ( NRS 449.0302 ) The facility must: 1. Provide each client with such assistance as necessary for the activities of daily living; 2. Provide activities for a client which are suited to his or her interests and capacities; 3. Observe the health of the client and notify his or her next of kin, guardian, or other person responsible for the client of any significant change in his or her physical or mental condition; 4. Establish procedures for the administration of medication to clients, either directly by the client or by an employee at the facility; 5. Provide fluids to clients as necessary to prevent dehydration; 6. Have at least one employee on the premises at all times who is trained to administer first aid and cardiopulmonary resuscitation; 7. Provide information to a client about other local, state and federal agencies in the area that may be able to assist the client and his or her family; and 8. Prepare a monthly calendar of activities at the facility and distribute the calendar to clients and their families. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.408 Housekeeping and maintenance. ( NRS 449.0302 ) Each facility must have adequate and regular services for housekeeping and the maintenance of the facility. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4081 Administration of medication; notification of accidents, injuries or illnesses; treatment with dignity; use of restraints or sedatives. ( NRS 439.200 , 449.0302 , 449.0304 ) 1. Except as otherwise authorized by NAC 449.40815 , if the facility accepts a client who cannot administer his or her own medication, an employee licensed to administer medications must administer the medication to the client. 2. The next of kin or guardian or other person responsible for the client must be notified immediately in case of any accident, injury or illness involving the client. 3. Each client must be treated with dignity and respect and not subjected to verbal or physical abuse of any kind. 4. Restraints or sedatives in lieu of restraints may not be used or given to any client, except by a physician’s order. (Added to NAC by Bd. of Health, eff. 6-23-86; A by R109-18, 1-30-2019) NAC 449.40815 Performance of certain tasks by employee. ( NRS 439.200 , 449.0302 , 449.0304 ) 1. An employee of a facility may perform a task described in NRS 449.0304 if the employee: (a) Before performing the task, annually thereafter and when any device used for performing the task is changed: (1) Receives training concerning the task that meets the requirements of subsections 6 and 7; and (2) Demonstrates an understanding of the task; (b) Follows the manufacturer’s instructions when operating any device used for performing the task; (c) Performs the task in conformance with the Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, 42 U.S.C. § 263a, if applicable, and any other applicable federal law or regulation; and (d) Complies with the requirements of subsection 3 or 4, if applicable. 2. If a person with diabetes who is a client of a facility does not have the physical or mental capacity to perform a blood glucose test on himself or herself and an employee of the facility performs a blood glucose test on the client, the Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, 42 U.S.C. § 263a, shall be deemed to be applicable for the purposes of paragraph (c) of subsection 1. 3. In addition to satisfying the requirements of subsection 1, an employee of a facility who conducts a blood glucose test must ensure that the device for monitoring blood glucose is not used on more than one person. 4. An employee of a facility may assist a client in the administration of insulin prescribed to the client for his or her diabetes and furnished by a registered pharmacist through an auto-injection device approved by the United States Food and Drug Administration for use in the home in accordance with the requirements of subsection 1 if: (a) A physician, physician assistant or advanced practice registered nurse has determined that the client’s physical and mental condition is stable and following a predictable course; and (b) The amount of the insulin prescribed to the client is at a maintenance level and does not require a daily assessment, including, without limitation, the use of a sliding scale. 5. An employee of a facility may weigh a client of the facility only if: (a) The employee has received training on how to accurately weigh persons that meets the requirements of subsections 6 and 7; and (b) The client has consented to being weighed by the employee. 6. The training described in this section must be provided by: (a) A physician, physician assistant or licensed nurse; (b) For the training described in paragraph (b) or (c) of subsection 1 of NRS 449.0304 , a registered pharmacist; or (c) An employee of the residential facility who has: (1) Received training pursuant to paragraph (a) of subsection 1 or paragraph (a) of subsection 5, as applicable, from a physician, a physician assistant, a licensed nurse or, if applicable, a registered pharmacist; (2) At least 1 year of experience performing the task for which he or she is providing training; and (3) Demonstrated competency in performing the task for which he or she is providing training. 7. Any training described in this section must include, without limitation: (a) Instruction concerning how to accurately perform the task for which the employee is being trained in conformance with nationally recognized infection control guidelines which may include, without limitation, guidelines published by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services; (b) Instruction concerning how to accurately interpret the information obtained from performing the task; and (c) A description of any action, including, without limitation, notifying a physician, that must be taken based on such information. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.4082 Service of food; dietary consultants. ( NRS 449.0302 ) 1. Adequate facilities and equipment for the preparation, service and storage of food must be provided and meet the standards of the Division. 2. The dining area must be separated from the area used to prepare food. 3. Tables and chairs must be of proper height and of sufficient number to provide seating for the number of clients authorized for the facility. They must be sturdy and have easily washable surfaces. Chairs must be constructed so that they do not overturn easily. Tables must be designed to accommodate persons in wheelchairs. 4. Meals must be served by employees who have received training in the sanitary preparation and handling of food. 5. Each meal must provide one-third of the daily nutritional allowances recommended by the Food and Nutrition Board of the Institute of Medicine of the National Academies. 6. Any client who is in the facility for 5 hours or more a day must be served a meal. If he or she is in the facility for more than 6 hours in any day, additional nourishment must be provided. 7. Meals must be served in a manner suitable for the client and prepared with regard for individual preferences and religious requirements. Special diets and nourishment must be provided as ordered by the client’s physician. If meals are prepared within the facility, the facility must consult with a licensed dietitian for at least 4 hours each month on the planning and serving of meals. If meals are prepared outside of and delivered to the facility, the facility shall develop and provide an alternative for any client on a special diet. The facility shall not accept a client who requires a special diet if it cannot develop an alternative which conforms to the client’s prescribed diet. (Added to NAC by Bd. of Health, eff. 6-23-86; A by R090-12, 12-20-2012) NAC 449.40833 Summary of client’s care; referrals. ( NRS 449.0302 ) When a client permanently discontinues his or her use of a facility, the client must receive a: 1. Written summary of his or her care at the facility, including any recommendations for care in the future; and 2. Referral to any other agency in the community for service, as appropriate. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.40835 Records. ( NRS 449.0302 ) 1. Each facility must have a written policy regarding the records of clients. The policy must include a description of the procedures governing the use and removal of records and the release of information contained in the records. 2. An individual file must be maintained for each client and retained for 5 years after the client permanently discontinues his or her use of the facility. Each such file must be kept in a locked place which is resistant to fire and must be available only to authorized persons. The file must contain all records, letters and other information related to the client, including: (a) The client’s forms for application and enrollment; (b) The client’s medical information; (c) The client’s full name, address, race, religion, occupation, date of birth and social security number; (d) The telephone number of the client’s physician and home address and telephone number of his or her next of kin or guardian or other person responsible for him or her; and (e) Any signed authorizations for medical treatment for the client or the release of his or her medical information. 3. All records and reports in the client’s file must be typewritten or legibly written in ink and dated and signed by the person responsible for the files. (Added to NAC by Bd. of Health, eff. 6-23-86) Medical and Ancillary Services NAC 449.4084 Contract for provision by another person. ( NRS 449.0302 ) 1. A medical or ancillary service not directly provided by the facility may be provided by another person pursuant to a contract. 2. The contract must: (a) Be in writing; (b) Designate the service provided, the manner in which it will be provided and the geographical area to be served; (c) Describe the manner in which the person providing the service will be supervised; (d) Describe how the service will be coordinated with other services at the facility; (e) Require the person providing the service to furnish his or her clinical notes and observations of a client for the file of the client; (f) Specify the method of determining charges for the service and the method for reimbursement by the facility; (g) Specify the period of the contract and how frequently it is to be reviewed; and (h) Assure that the service and any person providing the service meet the same qualifications as required for employees of and services provided by a facility. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4085 Provision by facility authorized. ( NRS 449.0302 ) A facility which otherwise meets the requirements of NAC 449.4061 to 449.4084 , inclusive, may provide medical or ancillary services if the requirements of NAC 449.4086 to 449.4089 , inclusive, are met. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4086 Evaluation of programs and policies. ( NRS 449.0302 ) 1. Every facility must have a written plan for the annual evaluation of its programs and policies. The plan must describe the: (a) Schedule for the annual evaluation; (b) Subjects covered by the evaluation; and (c) Methods to be used in conducting the evaluation. 2. The evaluation must include an assessment of the: (a) Success of the programs offered at the facility; (b) Efficiency and effectiveness of the facility’s programs, including the extent to which a program is economical in terms of tangible benefits produced by the money spent; and (c) Relation of the facility’s programs to other services in the community and the availability of long-term care. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4087 Written assessments of clients. ( NRS 449.0302 ) Upon admission, an initial written assessment must be made of any person admitted to the facility. Within 30 days after admission, another written assessment must be completed which must include: 1. An evaluation of the client’s physical and mental health; 2. A history of the client’s social development; 3. A list of formal and informal systems for emotional support which are available to the client; 4. An evaluation of the tasks required for daily living that can be performed by the client; 5. A list of programs for financial assistance which are available to the client; and 6. The plan for care of the client. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4088 Plan of care; periodic assessment. ( NRS 449.0302 ) 1. A written plan of care must be prepared for each client that provides a balance of activities to meet the client’s needs and interests. The client, his or her next of kin or guardian or other person responsible for the client and other providers of service to him or her may contribute to the development and carrying out of the plan. A copy of the plan must be included in the client’s file. 2. Each plan must include: (a) An evaluation of the client’s strengths and needs; (b) The objectives of the plan for care; (c) The activities recommended to achieve those objectives; (d) Any recommendations for therapy or referrals to other providers of services; (e) A schedule for achieving the objectives of the plan with provisions for review of the plan; and (f) An evaluation of the client’s nutritional requirements. 3. An assessment of each client’s needs in relation to his or her plan of care must be conducted at least once every 3 months and included in the client’s file. (Added to NAC by Bd. of Health, eff. 6-23-86) NAC 449.4089 Menus. ( NRS 449.0302 ) Menus for meals served must be in writing, planned a week in advance, dated, posted and kept in the files for 6 months. Any substitutions must be noted on the written menu so that the menu in the file reflects what was actually served. (Added to NAC by Bd. of Health, eff. 6-23-86) PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES General Provisions NAC 449.410 Definitions. ( NRS 449.0302 , 449.0303 ) As used in NAC 449.410 to 449.4495 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.4105 , 449.411 and 449.4115 have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.4105 “Administrator” defined. ( NRS 449.0302 , 449.0303 ) “Administrator” means the person who is appointed by a psychiatric residential treatment facility to have primary responsibility for the operations of the overall program of the facility. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.411 “Psychiatric residential treatment facility” defined. ( NRS 449.0302 , 449.0303 ) “Psychiatric residential treatment facility” means a facility, other than a hospital, that provides a range of psychiatric services to treat residents under the age of 21 years on an inpatient basis under the direction of a physician. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.4115 “Resident” defined. ( NRS 449.0302 , 449.0303 ) “Resident” means a person who resides in a psychiatric residential treatment facility and receives psychiatric services at the facility. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) Licensing NAC 449.414 License required to operate facility. ( NRS 449.0302 , 449.0303 ) A person or a public or private facility shall not operate or provide the services of a psychiatric residential treatment facility or represent that the person or the public or private entity operates or provides the services of a psychiatric residential treatment facility, unless the person or the public or private facility is licensed by the Division pursuant to NAC 449.410 to 449.4495 , inclusive, to operate the psychiatric residential treatment facility. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.4145 Application for accreditation required; recognition as accrediting organization by Board; failure of facility to attain or maintain accreditation. ( NRS 449.0302 , 449.0303 ) 1. If a person or a public or private facility wants to operate a psychiatric residential treatment facility, the person or the public or private facility must: (a) File with the Division an application for a license pursuant to NAC 449.011 ; (b) Include with the application proof that the applicant has applied for accreditation by: (1) The Joint Commission; (2) The Commission on Accreditation of Rehabilitation Facilities; (3) The Council on Accreditation; or (4) Any other accrediting organization with comparable standards that is approved by the Board pursuant to subsection 2; and (c) Demonstrate that the proposed psychiatric residential treatment facility is able to comply with the requirements set forth in NAC 449.410 to 449.4495 , inclusive. 2. An organization which accredits psychiatric residential treatment facilities that wishes to be recognized by the Board as an accrediting organization for the purposes of this section must submit to the Division an application on a form prescribed by the Division. The Division shall review each application received pursuant to this subsection and shall forward to the Board each application, including the recommendation of the Division whether to approve or deny the application. The recommendation of the Division must be based upon whether the applicant requires a psychiatric residential treatment facility to meet minimum requirements necessary to ensure a high level of quality. The Board may approve or deny an application submitted pursuant to this subsection. 3. If a psychiatric residential treatment facility fails to obtain the accreditation described in paragraph (b) of subsection 1 within 6 months after obtaining a license or fails to maintain current accreditation, or if the accreditation is revoked or otherwise no longer valid, the psychiatric residential treatment facility shall, as soon as practicable, cease to operate. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.416 Prelicensure investigation and site inspection. ( NRS 449.0302 , 449.0303 ) After it receives a properly completed application, accompanied by the appropriate fee, the Division shall conduct an investigation of the applicant and inspect the proposed psychiatric residential treatment facility. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.417 Issuance of license. ( NRS 449.0302 , 449.0303 ) The Division shall issue a license to operate a psychiatric residential treatment facility to the applicant if, after investigation, the Division finds that the applicant is in substantial compliance with the provisions of NAC 449.410 to 449.4495 , inclusive. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.419 Personnel: Written policies required; evidence of licensure or certification and tuberculosis testing required. ( NRS 449.0302 , 449.0303 ) 1. A psychiatric residential treatment facility shall have written policies concerning the qualifications, responsibilities and conditions of employment for each type of personnel employed by the psychiatric residential treatment facility, including the licensure and certification of each employee when required by law. 2. The written policies must provide for the orientation of all employees to the policies and objectives of the psychiatric residential treatment facility. 3. The psychiatric residential treatment facility shall have evidence of a current license or certification on file at the psychiatric residential treatment facility for each person employed by the psychiatric residential treatment facility, or under contract with the psychiatric residential treatment facility, who is required to be licensed or certified by law to perform his or her job. 4. The psychiatric residential treatment facility shall ensure that the health records of its employees contain documented evidence of surveillance and testing of those employees for tuberculosis in accordance with chapter 441A of NAC. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.420 Compliance with state, federal and local laws, regulations and ordinances; failure to comply is ground for suspension or revocation of license. ( NRS 449.0302 , 449.0303 ) 1. During the term of a license to operate a psychiatric residential treatment facility, the licensee shall continuously maintain the psychiatric residential treatment facility in conformance with the provisions of NAC 449.410 to 449.4495 , inclusive. 2. Each psychiatric residential treatment facility shall comply with the requirements set forth in 42 C.F.R. §§ 441.150 to 441.156, inclusive, and 483.350 to 483.376, inclusive. 3. In addition to the requirements of subsections 1 and 2, each psychiatric residential treatment facility shall comply with all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Environmental, life safety, fire, health and local building codes. 4. Any violation of this section may result in the suspension or revocation of the license to operate the psychiatric residential treatment facility. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.421 Suspension, revocation or cancellation of license; provisional license. ( NRS 449.0302 , 449.0303 ) The Division may suspend or revoke a license issued pursuant to NAC 449.410 to 449.4495 , inclusive, or cancel such a license and issue a provisional license based upon any grounds for such action set forth in NAC 449.002 to 449.99939 , inclusive, or chapter 449 of NRS. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) Administration and Operation NAC 449.423 Written scope of services; policies and procedures; responsibilities and duties of administrator. ( NRS 449.0302 , 449.0303 ) 1. A psychiatric residential treatment facility must be administered in a manner that enables the psychiatric residential treatment facility to use its resources effectively and efficiently to meet the needs of and provide quality care to its residents. The psychiatric residential treatment facility shall develop and provide services for the care of its residents based on the identified needs of those residents. 2. A psychiatric residential treatment facility must define in writing the scope of services provided by each department, unit or service within the psychiatric residential treatment facility. The written scope of services must be approved by the administration and the medical staff of the psychiatric residential treatment facility. Each department, unit or service within a psychiatric residential treatment facility shall provide residents care in accordance with its scope of services. The policies and procedures of a psychiatric residential treatment facility and of each department, unit or service within the psychiatric residential treatment facility must, to the extent necessary, be integrated with the policies and procedures of the other departments, units and services within the psychiatric residential treatment facility. 3. The administrator shall: (a) Ensure that the competence of all members of the staff of the psychiatric residential treatment facility is assessed, maintained, demonstrated and improved; (b) Provide an orientation process for persons hired to work at the psychiatric residential treatment facility that includes initial job training and information; and (c) Assess the ability of the members of the staff of the psychiatric residential treatment facility to fulfill their specified responsibilities. 4. The administrator shall ensure that the psychiatric residential treatment facility is staffed by a sufficient number of personnel, whose qualifications are consistent with their job responsibilities, to provide care to the residents of the psychiatric residential treatment facility. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.424 Quality improvement program. ( NRS 449.0302 , 449.0303 ) 1. The administrator shall ensure that the psychiatric residential treatment facility has an effective, comprehensive quality improvement program to evaluate the provision of care to its residents. 2. The quality improvement program must: (a) Be ongoing; (b) Include a written plan for carrying out the program; and (c) Provide for the creation of a committee to oversee the program. 3. The committee to oversee the program shall: (a) Take and document appropriate remedial action to address deficiencies found through the quality improvement program; (b) Document the outcome of any remedial action taken; and (c) Initiate any assessments required by the quality improvement program. 4. When the findings of an assessment relate to the performance of an individual licensed practitioner, the medical staff shall determine how such a finding will be used in any peer review, ongoing monitoring and periodic evaluations of the competence of the practitioner. If the findings of the assessment relate to the performance of a person who is not a licensed practitioner, the director of the department, unit or service in which that person works shall determine how the finding will be used in evaluating the competence of the person. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.426 Construction and maintenance of facility; plan for emergency preparedness; safety from fire and other disasters. ( NRS 449.0302 , 449.0303 ) 1. The buildings of a psychiatric residential treatment facility must be solidly constructed with adequate space and safeguards for each resident. The condition of the physical plant and the overall environment of the psychiatric residential treatment facility must be developed and maintained in a manner that ensures the safety and well-being of residents. 2. A psychiatric residential treatment facility shall develop and carry out a comprehensive plan for emergency preparedness which: (a) Addresses internal and external emergencies, both local and widespread; and (b) Is based on current standards for disaster management and fire safety. 3. A psychiatric residential treatment facility shall ensure that the staff and residents of the psychiatric residential treatment facility are adequately protected from fire and other disasters. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.427 Limitation on number of residents. ( NRS 449.0302 , 449.0303 ) A psychiatric residential treatment facility shall not have more residents than the number of beds for which it is licensed. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.428 Access of residents to their belongings; accommodations, equipment and supplies for residents; lighting and temperature levels. ( NRS 449.0302 , 449.0303 ) 1. A psychiatric residential treatment facility shall provide residents access to their belongings as is appropriate based on the needs of the residents and the phase of treatment of the residents. 2. A psychiatric residential treatment facility shall provide a clean and comfortable bed and mattress for each resident. Bed linens, blankets, pillows, washcloths and towels that are clean and in good condition must be provided to each resident. A psychiatric residential treatment facility shall have such systems as are necessary to ensure that an adequate supply of clean linens is provided to each resident. 3. A psychiatric residential treatment facility shall provide each resident with necessary bedside equipment and supplies based on the needs of the resident. The necessary equipment and supplies must include, without limitation, equipment for personal hygiene. The equipment and supplies must be maintained in a sanitary manner. 4. A psychiatric residential treatment facility shall provide: (a) Adequate lighting levels; and (b) Comfortable and safe temperature levels. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.429 Housekeeping services; cleaning and laundry requirements. ( NRS 449.0302 , 449.0303 ) 1. A psychiatric residential treatment facility shall establish organized housekeeping services planned, operated and maintained to provide a pleasant, safe and sanitary environment. Adequate personnel, using accepted practices and procedures, shall keep the psychiatric residential treatment facility free from offensive odors, accumulations of dirt, rubbish and dust and safety hazards. 2. The psychiatric residential treatment facility shall ensure that cleaning is performed in a manner that minimizes the spread of pathogenic organisms. 3. A psychiatric residential treatment facility shall develop and carry out standards and systems for the operation of laundry services. Laundry services, whether owned by the psychiatric residential treatment facility or provided pursuant to a contract, must: (a) Meet standards for a safe work environment for employees; and (b) Address issues relating to the control of infections. 4. A psychiatric residential treatment facility shall develop and carry out written policies relating to the handling, storage, transportation and processing of its linens. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.430 Prevention, control and investigation of infections and communicable diseases. ( NRS 449.0302 , 449.0303 ) A psychiatric residential treatment facility shall: 1. Provide a sanitary environment to avoid sources and transmission of infections and communicable diseases; 2. Develop and carry out an active program for the prevention, control and investigation of infections and communicable diseases; 3. Develop a system for identifying, reporting, investigating and controlling infections and communicable diseases of residents and personnel of the psychiatric residential treatment facility; and 4. Maintain a record of incidents within the psychiatric residential treatment facility related to infections and communicable diseases. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.432 Administration of medication; security. ( NRS 449.0302 , 449.0303 ) 1. Only members of the staff of the psychiatric residential treatment facility who are legally authorized to administer medications may do so. 2. Security of all medications must be maintained in accordance with applicable state law. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.4325 Orders for medication and biologicals. ( NRS 449.0302 , 449.0303 ) 1. Except as otherwise provided in this section, an order for a medication or biological for a resident must be in writing and signed by the practitioner, or other appropriate professional person authorized by state or federal law to order the medication or biological, who is responsible for the care of the resident. 2. When a telephone or verbal order is used to order a medication or biological, the order must be: (a) Accepted only by a person who is authorized by the policies and procedures of the psychiatric residential treatment facility, which must be consistent with state law, to accept such an order; and (b) Signed or initialed by the prescribing practitioner in accordance with the policies and procedures of the psychiatric residential treatment facility. 3. An order for a medication or biological must include the name of the medication or biological and the dosage, time or frequency of administration and route of administration of the medication or biological. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.433 Reporting of problems concerning administration of drug to resident and misuses and losses of controlled substances; information concerning drugs must be available to professional members of staff. ( NRS 449.0302 , 449.0303 ) 1. Errors in administering a drug to a resident, adverse reactions by a resident to a drug and incompatibilities between a drug and a resident must be immediately reported to the attending physician of the resident and, if appropriate, to the committee that oversees the quality improvement program established pursuant to NAC 449.424 . 2. Misuses and losses of controlled substances must be reported, in accordance with all applicable state and federal laws, to the person responsible for the pharmaceutical service and the administrator. 3. Information relating to drug interactions, drug therapy, side effects, toxicology, dosage indications for use and routes of administration must be made available to the professional members of the staff of the psychiatric residential treatment facility. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.435 Dietary services: General requirements. ( NRS 449.0302 , 449.0303 ) A psychiatric residential treatment facility shall: 1. Provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and dietary needs of the resident. 2. Ensure that the menu for a resident meets the nutritional needs of the resident in accordance with: (a) Recognized dietary practices; and (b) The orders of the practitioners responsible for the care of the resident. 3. Ensure that not fewer than three meals are served daily to residents and not more than 15 hours elapse between the evening meal and breakfast served the following day. 4. Ensure that nourishment is provided between meals as required by diet prescription and is available to each resident unless otherwise ordered by the physician of the resident. 5. Except as otherwise provided in this subsection, ensure that menus are followed. A meal may vary from the planned menu if the change is noted in writing in the records maintained by the dietary service. 6. Ensure that persons who are responsible for therapeutic diets have sufficient knowledge of food values to make appropriate substitutions when necessary. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.436 Dietary services: Facilities; standards; permits. ( NRS 449.0302 , 449.0303 ) A psychiatric residential treatment facility shall ensure that: 1. Adequate space for the preparation and service of food is provided; 2. Adequate space is maintained to accommodate equipment, personnel and procedures necessary for the proper cleaning and sanitizing of dishes and other utensils; and 3. In providing for the preparation and serving of food, the facility: (a) Complies with the standards prescribed in chapter 446 of NRS and chapter 446 of NAC; and (b) Obtains the necessary permits from the Division. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.438 Dietary services: Sanitary conditions required; supplies. ( NRS 449.0302 , 449.0303 ) 1. A psychiatric residential treatment facility shall store, prepare, distribute and serve food under sanitary conditions. 2. A psychiatric residential treatment facility shall maintain on its premises at least a 1-week supply of staple foods and at least a 2-day supply of perishable foods. The supplies must be appropriate to meet the requirements of the menu. All food must be of good quality and procured from sources approved or considered satisfactory by federal, state and local authorities. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.439 Dietary services: Therapeutic diets. ( NRS 449.0302 , 449.0303 ) A psychiatric residential treatment facility shall ensure that a resident receives a therapeutic diet when it is determined that he or she has a nutritional problem. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.441 Dietary services: Personnel. ( NRS 449.0302 , 449.0303 ) 1. A psychiatric residential treatment facility shall maintain an organized dietary service that is staffed by an adequate number of personnel. The dietary service must be integrated with the other departments, units and services within the psychiatric residential treatment facility. 2. The psychiatric residential treatment facility shall ensure that the personnel who provide the dietary service are trained in basic techniques of food sanitation. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) Provision of Services NAC 449.442 Policies and procedures for protection of rights of residents; duties of employee or independent contractor who believes resident has been abused or neglected. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A psychiatric residential treatment facility shall develop and carry out policies and procedures that protect and support the rights of residents in the same manner as set forth for medical facilities and facilities for the dependent in NRS 449A.100 to 449A.118 , inclusive. 2. If an employee or independent contractor of a psychiatric residential treatment facility has reasonable cause to believe that another employee or independent contractor of the facility has abused or neglected a resident: (a) The employee or independent contractor with knowledge of the abuse or neglect shall report the abuse or neglect as required by NRS 200.5093 or 432B.220 , if applicable; (b) The facility shall prevent the alleged perpetrator of the abuse or neglect from having further direct contact with any resident; and (c) The facility shall notify the parent of or other person legally responsible for the alleged victim of the abuse or neglect and ensure that the alleged victim receives appropriate medical assessment and treatment. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014; A by R048-22, 12-29-2022) NAC 449.445 Policies and procedures for admission of residents; provision of certain information to resident or person legally responsible for resident. ( NRS 449.0302 , 449.0303 ) A psychiatric residential treatment facility shall: 1. Develop and carry out policies and procedures for admitting residents; and 2. Ensure that each resident, or the parent, guardian or other person legally responsible for the resident, receives information about the proposed care of the resident. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.447 Records of residents. ( NRS 449.0302 , 449.0303 ) A psychiatric residential treatment facility shall: 1. Maintain a record for each resident evaluated or treated in the psychiatric residential treatment facility. 2. Ensure that each record is accurately written, promptly completed, properly filed and retained and accessible. A psychiatric residential treatment facility shall use a system for identification and record maintenance that ensures the integrity of the authentication of the record and protects the security of all entries to the record. 3. Ensure that the record of a resident is retained in accordance with the provisions of NRS 629.051 . 4. Ensure that each record of a resident includes information: (a) Demonstrating the justification for the admission of the resident; (b) Supporting the diagnosis of the resident; and (c) Describing the progress of the resident and his or her response to the medication and services received. 5. Ensure all entries to a record of a resident are legible and complete, and authenticated and dated promptly by the person who is responsible for ordering, providing or evaluating the services provided. In authenticating the record, the person shall include his or her name and discipline. Authentication may include the signature or written initials of the person or a computer entry by the person. 6. Ensure all records of a resident document the following information, as appropriate: (a) The diagnosis of the resident at the time of admission; (b) The results of all consultative evaluations of the resident and the appropriate findings by clinical and other staff involved in caring for the resident; (c) Documentation of any complications suffered by the resident; (d) All orders of practitioners, reports of treatment, records of medication and other information necessary to monitor the condition of the resident; (e) A discharge summary that includes a description of the outcome of the stay at the psychiatric residential treatment facility, the disposition of the case and the provisions for follow-up care that have been provided to the resident; and (f) The final diagnosis of the resident. 7. Ensure that the record of a resident is completed not later than 30 days after the date on which he or she is discharged from the psychiatric residential treatment facility. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.448 Assessment and appropriate care of residents. ( NRS 449.0302 , 449.0303 ) 1. To provide a resident with the appropriate care at the time that the care is needed, the needs of the resident must be assessed by qualified personnel of the psychiatric residential treatment facility throughout the resident’s stay with the facility. The assessment must be comprehensive and accurate as related to the condition of the resident. 2. Each resident must receive, and the psychiatric residential treatment facility shall provide, individualized care and treatment based on the assessment of the resident that is appropriate to the needs of the resident and the severity of the condition from which the resident is suffering. 3. Each resident must be reassessed according to the policy of the psychiatric residential treatment facility: (a) When there is a significant change in the resident’s condition; (b) When there is a significant change in the resident’s diagnosis; or (c) To determine the resident’s response to the care that he or she is receiving. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) NAC 449.4495 Discharge planning. ( NRS 449.0302 , 449.0303 ) A psychiatric residential treatment facility shall: 1. Have a process for discharge planning that applies to all residents; 2. Develop and carry out policies and procedures regarding the process for discharge planning; 3. Ensure activities relating to discharge planning are conducted in a manner that does not contribute to delays in the discharge of the resident; 4. Ensure the evaluation of the needs of a resident relating to discharge planning and the discharge plan for the resident are documented in his or her record; and 5. Ensure the discharge plan is discussed with the resident or the person acting on behalf of the resident. (Added to NAC by Bd. of Health by R046-14, eff. 10-24-2014) FACILITIES FOR REFRACTIVE SURGERY NAC 449.450 “Facility” defined. ( NRS 449.0302 ) As used in NAC 449.450 to 449.4526 , inclusive, unless the context otherwise requires, “facility” means a facility for refractive surgery as defined in NRS 449.00387 . (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002; A by R042-06, 7-14-2006) NAC 449.4504 Administrator: Appointment; duties; qualifications. ( NRS 449.0302 ) 1. A licensee of a facility shall appoint an administrator to be legally responsible for: (a) The daily operation of the facility; and (b) Compliance with the applicable provisions of NAC 449.002 to 449.99939 , inclusive, and chapter 449 of NRS. 2. The administrator of a facility must: (a) Be at least 21 years of age; (b) Have at least 1 year of administrative experience in a health care setting; (c) Have experience in the administration and supervision of personnel; and (d) Possess such knowledge of the practice of medicine as to enable him or her to be conversant in surgical protocols. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002) NAC 449.4505 Administrator of facility that performs intraocular lens implants: Duties. ( NRS 449.0302 ) The administrator of a facility that performs intraocular lens implants shall: 1. Ensure that equipment and supplies are sufficient so that intraocular lens implants are performed in a manner that will not endanger the health and safety of the patient; 2. Ensure that all persons in the surgical area use aseptic techniques; 3. Provide suitable equipment for the rapid and routine sterilization of operating room materials; 4. Develop appropriate protocols that include a list of equipment, materials and supplies necessary to carry out the procedure properly; 5. Develop protocols for the provision of services in case of emergency and ensure that all personnel are appropriately trained in those protocols; and 6. Ensure that each circulating nurse in the operating room is a registered nurse. (Added to NAC by Bd. of Health by R042-06, eff. 7-14-2006) NAC 449.4506 Staffing requirements; personnel files. ( NRS 449.0302 ) The administrator of a facility shall ensure that: 1. The facility is adequately staffed with qualified personnel who: (a) Meet the needs of and ensure the safety of each person who visits the facility; and (b) Satisfy any applicable statutory requirements for the provision of care. 2. The facility employs at least one full-time registered nurse licensed pursuant to chapter 632 of NRS to supervise and manage the care provided to patients in the facility. 3. At least one registered nurse who is employed by the facility is present in the facility at all times that any patient is present in the facility. 4. Each member of the staff who provides patient care is adequately trained in emergency procedures and is currently certified to perform first aid and cardiopulmonary resuscitation. At least one member of the staff who is trained in emergency procedures and who has obtained the advanced certificate in first aid and adult cardiopulmonary resuscitation issued by the American Red Cross or an equivalent certification must be present in the facility whenever any patient is present in the facility. 5. A separate personnel file is established and maintained for each member of the staff of the facility that includes: (a) Proof of any training relating to emergency response required by the facility pursuant to the policies and procedures established by the facility pursuant to NAC 449.451 ; (b) Such health records as are required by chapter 441A of NAC which include evidence that the member of the staff employed by the facility or under contract with the facility has had a skin test for tuberculosis in accordance with NAC 441A.375 ; and (c) Evidence that the member of the staff employed by the facility or under contract with the facility has obtained any license, certificate or registration, and possesses the experience and qualifications, required for the position held by that person. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002; A by R042-06, 7-14-2006) NAC 449.4508 Maintenance of patient records. ( NRS 449.0302 ) 1. The administrator of a facility shall ensure that the facility establishes and maintains a record of each patient admitted to the facility which includes an assessment of the health needs of the patient and a description of any health care services provided to the patient at the facility. 2. Each record must be: (a) Protected against loss, destruction or unauthorized use; (b) Kept confidential, except as otherwise provided by law; and (c) Maintained for a period of 5 years after the date the patient is discharged from the facility. 3. If the facility closes, the administrator shall notify the Bureau of the disposition of its records. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002) NAC 449.451 Written policies and procedures. ( NRS 449.0302 ) 1. The administrator of a facility shall ensure that the facility has written policies and procedures available to members of the staff, patients and the public which govern the operation of the facility and services provided by the facility. 2. The policies and procedures must set forth, without limitation: (a) The scope of services offered by the facility, the cost of those services and the procedures for the payment of fees and obtaining a refund of any deposited fees; (b) The business hours of the facility and the care that is available at the facility during emergencies and after the normal business hours of the facility; (c) The criteria for admission to and discharge from the facility; (d) The qualifications required for each member of the staff of the facility and the scope of the duties of each member of the staff of the facility; (e) The appropriate action to be taken when an emergency arises in the facility and the equipment and medication that is required to be available at the facility for such an emergency; (f) The manner in which the equipment and physical environment of the facility will be maintained in accordance with the requirements set forth in NAC 449.4516 and 449.4522 ; (g) The conduct and responsibility of a patient relating to his or her treatment; (h) The right of a patient to refuse to participate in experimental research; (i) The procedure for filing a complaint or grievance at the facility; (j) The rights of a patient and the procedure for informing each patient of his or her rights; (k) The manner in which the records of a patient will be maintained and protected; and (l) The manner in which medication will be administered and dispensed to a patient admitted to the facility in accordance with the laws of this State and federal law. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002) NAC 449.4512 Program of quality improvement. ( NRS 449.0302 ) The administrator of a facility shall ensure that the facility has a program of quality improvement in place which: 1. Monitors and evaluates the quality of patient care; 2. Evaluates methods to improve patient care; 3. Identifies and corrects deficiencies; and 4. Reviews and resolves grievances of patients and maintains documentation of the resolutions of those grievances. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002) NAC 449.4514 Rights of patients; informed consent. ( NRS 449.0302 ) The administrator of a facility shall ensure that: 1. Each patient admitted to the facility is treated with respect, consideration and dignity. 2. Each patient admitted to the facility is provided appropriate privacy. 3. Each patient admitted to the facility is informed of his or her rights as a patient in accordance with the provisions of NRS 449A.118 . The patient must be informed, at the time of his or her admission, of the services available, the estimated cost of those services and the policy of the facility relating to obtaining a refund of any fees that were deposited with the facility. If a patient is unable to understand his or her rights, they must be explained to the patient’s legal guardian, next of kin or the agency financially responsible for his or her care. 4. Each patient admitted to the facility is given the opportunity to participate in decisions relating to his or her health care, unless the patient is unable to do so because of his or her medical condition. 5. An informed consent properly executed by a patient admitted to the facility or by his or her legal guardian is obtained before any surgery is performed. The informed consent must authorize, by name, the person performing the surgery to perform that surgery and must name or describe the surgical procedure to be performed. Any expectations, risks or complications relating to the surgery or alternatives to the surgery that are discussed with the patient must be set forth in the informed consent. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002) NAC 449.4516 Equipment and supplies. ( NRS 449.0302 ) 1. The administrator of a facility shall ensure that: (a) The facility is adequately equipped; (b) Any equipment used in the facility is periodically inspected and, if appropriate, tested, calibrated, serviced or repaired according to the manufacturer’s instructions to ensure that the equipment is functioning properly; (c) All equipment and supplies used in the facility are used in accordance with the manufacturer’s instructions; (d) Such records are maintained as required to ensure that appropriate inspections and maintenance of all equipment used in the facility are periodically accomplished by an appropriately qualified person; (e) Each laser used in the facility meets the requirements of any applicable federal standards set forth in 21 C.F.R. Part 1040; and (f) Appropriate evidence of compliance with 21 C.F.R. Part 1040 is maintained for each laser at the facility. 2. The administrator of the facility shall ensure that policies and procedures are established and implemented for each laser used in the facility which include, without limitation: (a) A safety program concerning the use of the laser; and (b) Education and training of each person who operates the laser, including, without limitation, requirements that each member of the staff be adequately trained in the use and safety of each laser used in patient care and that the administrator ensure that proof of any required training is maintained at the facility. 3. The administrator of the facility shall ensure that a safe environment for the use of lasers is provided, including, without limitation, ensuring that: (a) Only authorized persons are allowed in treatment areas; (b) Door and window coverings are used where appropriate; (c) Protective eyewear is used, when appropriate, by persons who operate a laser; (d) Laser components which have direct contact with a patient are appropriately disinfected or sterilized; (e) Records concerning the maintenance of each laser in the facility are maintained; and (f) Each laser in the facility is visually inspected and tested before each use. 4. The administrator of the facility shall ensure that appropriate fire protection concerning the use of each laser is provided, including, without limitation, the immediate availability of: (a) Fire extinguishers which are inspected at least once a year and determined to be appropriate for electrical fires by a person who is certified by the State Fire Marshal to conduct such inspections; (b) Water for the protection of the patient; and (c) Noncombustible materials, supplies and solutions, as appropriate. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002) NAC 449.4518 Liability for use of leased equipment. ( NRS 449.0302 ) If a licensee leases a laser or other equipment to another ophthalmologist for the surgical treatment of patients by photorefractive keratectomy and laser in situ keratomeleusis, the licensee remains responsible for the services performed by the other ophthalmologist in the facility. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002) NAC 449.4522 Sanitation and hygiene; space and storage. ( NRS 449.0302 ) 1. The administrator of a facility shall ensure that all parts of the facility, including its premises and equipment, are maintained in a neat and clean condition which is free of insects, rodents, litter and rubbish. Policies and procedures must be established and implemented for cleaning, sanitizing or sterilizing equipment and supplies. 2. The administrator of the facility shall ensure that the facility has a clean, comfortable waiting room with adequate space for any family member or caregiver of the patient being treated. A separate bathroom must be maintained for the exclusive use of patients and their family members or caregivers. Provisions for the safe storage of valuables must be made available for the use of the patient. 3. The operating room must be distinctly separate and segregated from any other area, including, without limitation, the waiting room, examination room, administrative area, physician’s office and staff lounge. 4. The facility must have sufficient space for the care and storage of instruments and supplies. 5. The facility must have adequate systems for ventilation and the control of temperature. 6. All medications must be stored, administered and maintained in accordance with the requirements of the laws of this State and federal law. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002) NAC 449.4524 Medical care of patients. ( NRS 449.0302 ) 1. The administrator of a facility shall ensure that: (a) Only local anesthesia and oral medication which is administered to a patient to relieve anxiety in the patient, if the medication is not given in a dosage which is sufficient to induce in a patient a controlled state of depressed consciousness or unconsciousness similar to the state produced pursuant to the administration of general anesthesia, deep sedation or conscious sedation, are used at the facility. (b) An appropriate and current history, including a list of current medications, dosages, physical examination and pertinent preoperative diagnostic studies, is incorporated into the patient’s medical record before surgery. (c) Surgical procedures are performed only by an ophthalmologist licensed pursuant to chapter 630 of NRS or a doctor of osteopathy licensed pursuant to chapter 633 of NRS. (d) A preoperative evaluation is conducted immediately before the surgical procedure by the ophthalmologist, licensed pursuant to chapter 630 of NRS, or the doctor of osteopathy, licensed pursuant to chapter 633 of NRS, who will be performing the surgery. (e) Emergency equipment and medications as required by the policies and procedures established by the facility pursuant to NAC 449.451 are available, and properly stored and maintained at the facility. (f) Outdated medications are destroyed in accordance with the requirements of the laws of this State and federal law. (g) Protocols are established and implemented for instructing patients in self-care after surgery, including, without limitation, written instructions to be given at the time of discharge. (h) A follow-up examination of a patient is conducted by an ophthalmologist licensed pursuant to chapter 630 of NRS, a doctor of osteopathy licensed pursuant to chapter 633 of NRS or a collaborating optometrist as provided in NRS 636.374 within 24 hours after the procedure. Documentation of the results of this examination must be included as part of the permanent medical record of the patient. 2. As used in this section: (a) “Conscious sedation” means a minimally depressed level of consciousness, produced by a pharmacologic or nonpharmacologic method or a combination thereof, in which the patient retains the ability independently and continuously to maintain an airway and to respond appropriately to physical stimulation and verbal commands. (b) “Deep sedation” means a controlled state of depressed consciousness, produced by a pharmacologic or nonpharmacologic method or a combination thereof, and accompanied by a partial loss of protective reflexes and the inability to respond purposefully to verbal commands. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002) NAC 449.4526 Application for indemnification for certain damages; claims against surety bond or substitute thereof. ( NRS 449.0302 ) 1. A person who has sustained damages as a result of the bankruptcy of or any breach of contract by a facility may file an application for indemnification with the Administrator of the Division. The Administrator of the Division shall return an incomplete application to the applicant. 2. An application filed pursuant to subsection 1 must include a copy of the court order or settlement agreement which indicates a determination that the patient sustained damages as a result of a breach of contract or bankruptcy of a facility, proof of the identity of the patient or patient’s legal representative that is acceptable to the Division and a statement of the patient or patient’s legal representative which includes the following information: (a) A brief description of the damages sustained by the patient as a result of the bankruptcy of or any breach of contract by the facility; (b) The date that the damages were sustained and the amount of damages claimed; and (c) The name and address of the facility in which the patient sustained damage. 3. The Division may bring an action for interpleader against all claimants upon the surety bond or substitute thereof filed or deposited pursuant to NRS 449.068 or 449.069 , as applicable. If the Division brings such an action, the Division shall publish notice of the action at least once each week for 2 weeks in a newspaper of general circulation in the county in which the facility has its principal place of business. The Division may deduct its costs of the action, including the costs of publication of the notices, from the amount of the surety bond or substitute thereof. 4. All claims against the surety bond or substitute thereof have equal priority. If the surety bond or substitute thereof is insufficient to pay all the claims in full, the claims must be paid pro rata. 5. If no claims have been filed against the surety bond or substitute thereof deposited with the Division within 12 months after the license of the facility expires or is revoked, the Division shall release the surety bond or substitute thereof to the facility and shall not consider any claim filed by a patient against the surety bond or substitute thereof after that time. 6. If one or more claims have been filed against the surety bond or substitute thereof within 12 months after the license of the facility expires or is revoked, the proceeds must not be released to the facility or distributed to any patient earlier than 18 months after the license of the facility expires or is revoked. (Added to NAC by Bd. of Health by R052-02, eff. 7-24-2002; A by R078-12, 12-20-2012) FACILITIES FOR TREATMENT OF IRREVERSIBLE RENAL DISEASE General Provisions NAC 449.501 Definitions. ( NRS 449.0302 ) As used in NAC 449.501 to 449.5795 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.502 to 449.519 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.502 “Advanced practice registered nurse” defined. ( NRS 449.0302 ) “Advanced practice registered nurse” has the meaning ascribed to it in NAC 632.020 . (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.504 “Charge nurse” defined. ( NRS 449.0302 ) “Charge nurse” has the meaning ascribed to it in NAC 632.033 . (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5045 “Competency” defined. ( NRS 449.0302 ) “Competency” means the demonstrated ability to carry out a specified task or activity with reasonable skill and safety in accordance with the prevailing standard of practice of the community in which the task or activity is carried out. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.505 “Dialysis” defined. ( NRS 449.0302 ) “Dialysis” means the method by which a dissolved substance is removed from the body of a patient by diffusion, osmosis and convection from one fluid compartment to another fluid compartment across a semipermeable membrane. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5053 “Dialysis technician” defined. ( NRS 449.0302 ) “Dialysis technician” means a person, other than a registered nurse or physician, who provides dialysis care under the direct supervision of a registered nurse or physician. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5055 “Direct supervision” defined. ( NRS 449.0302 ) “Direct supervision” means the supervision of a task or activity that is provided by a qualified person who is present on the premises of a facility during the period in which the task or activity is performed at the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5065 “End-stage renal disease” defined. ( NRS 449.0302 ) “End-stage renal disease” means a stage of renal impairment that is irreversible and permanent and requires a kidney transplantation or regular course of dialysis to preserve the life of the person who has the disease. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.507 “Facility” defined. ( NRS 449.0302 ) “Facility” means a facility for the treatment of irreversible renal disease as defined in NRS 449.0046 . (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.508 “Hemodialysis” defined. ( NRS 449.0302 ) “Hemodialysis” means dialysis of the blood. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.510 “Immediate supervision” defined. ( NRS 449.0302 ) “Immediate supervision” means the supervision of a task or activity that is provided by a person who: 1. Is present on the premises of a facility during the period in which the task or activity is performed at the facility; and 2. Directly observes the task or activity. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.511 “Intermediate level disinfection” defined. ( NRS 449.0302 ) “Intermediate level disinfection” means to treat a surface using a chemical germicide or other disinfectant that, when used in accordance with the instructions of the manufacturer of the chemical germicide or other disinfectant or the guidelines established by the facility concerning the chemical germicide or other disinfectant, inactivates microorganisms other than bacterial endospores, including, without limitation: 1. Viruses; 2. Fungi; and 3. Bacteria that are actively growing, including tubercle bacteria. Ê The term includes any bleach or any disinfectant that consists of 70 percent or more of ethanol or isopropanol. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.513 “Licensed practical nurse” defined. ( NRS 449.0302 ) “Licensed practical nurse” means a nurse who may collect data and perform a skill, intervention or other duty in accordance with the provisions of NAC 632.242 . (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.516 “Product water” defined. ( NRS 449.0302 ) “Product water” means the effluent that is obtained from the final component of the water treatment system of a facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.517 “Supervision” defined. ( NRS 449.0302 ) “Supervision” means the guidance and direction provided by a qualified person for the accomplishment of a task or activity, including the initial direction and periodic inspection by that person of the actual accomplishment of the task or activity. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.519 “Training” defined. ( NRS 449.0302 ) “Training” means to learn a task or activity through experience or instruction that is received during employment at a facility by a person who is capable of learning that task or activity through education or experience. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) Construction; Health and Safety NAC 449.520 New construction or remodeling: Notification; increase in number of stations for which facility is licensed. ( NRS 449.0302 , 449.050 ) 1. A facility shall notify the Bureau in writing at least 30 days before beginning any construction, renovation or modification of the physical plant of the facility. 2. A facility must obtain the approval of the Bureau before increasing the number of stations for which the facility is licensed. If a facility intends to increase the number of those stations, the facility must, at least 30 days before the proposed date to increase the number of stations, submit to the Bureau an application for a new license. The application must be submitted on a form approved by the Bureau and include: (a) Evidence satisfactory to the Bureau that: (1) The facility has reviewed the availability of the members of the staff of the facility and, if necessary, has increased the number of positions on the staff to accommodate the proposed increase in the number of stations; and (2) The water treatment system of the facility is sufficient to ensure the availability of water that is safe for the proposed increase in the number of stations; and (b) A fee of $250. 3. If a facility submits an application pursuant to the provisions of this section, the Bureau may, before considering the application, conduct an inspection of the facility to determine compliance with those provisions. 4. If the Bureau approves an application pursuant to the provisions of this section, the facility shall, not later than 21 days after commencing the use of the stations for which the application was approved, submit to the Bureau a written report concerning the chemical analysis and bacteriologic cultures of the product water of the stations. The written report must be prepared and submitted in accordance with the provisions of the most recently published edition of the American National Standard, Water Treatment Equipment for Hemodialysis Applications , which is hereby adopted by reference. A copy of the publication may be obtained from the Association for the Advancement of Medical Instrumentation, 1110 North Glebe Road, Suite 220, Arlington, Virginia 22201, for the price of $45 for members and $90 for nonmembers. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004) NAC 449.5205 New construction or remodeling: Submission of plans and specifications; minor changes; inspection. ( NRS 449.0302 ) 1. To determine compliance with the provisions of NAC 449.501 to 449.5795 , inclusive, each facility may submit to the Bureau for its approval any plans and specifications concerning the construction of a new facility or any alteration, addition, conversion, modernization or renovation of an existing building of the facility. The plans and specifications must be submitted in accordance with the provisions of this section. 2. A facility may request the Bureau to review any minor alterations or remodeling changes to the facility that, as determined by the Bureau, do not: (a) Alter any load-bearing partitions, change any functional operation or affect the fire safety of the facility; or (b) Add any additional stations to the facility. Ê A request submitted pursuant to the provisions of this subsection must be set forth in writing and include a brief description of the minor alterations or changes proposed by the facility. 3. If a facility submits any preliminary plan or specification for a project pursuant to the provisions of this section, the plan or specification must include information that is sufficient to determine the extent of the proposed project and to ensure compliance with the provisions of NAC 449.501 to 449.5795 , inclusive, concerning the design and space of the project. 4. If a facility submits any final drawings or specifications pursuant to the provisions of this section, the drawings or specifications must include a complete set of the drawings or specifications. Any working drawings submitted pursuant to the provisions of this subsection must: (a) Be of sufficient quality to ensure that a clear and distinct print may be obtained of the drawings; (b) Include accurate dimensions of the project for which the drawings are made; and (c) Include any required explanatory notes, schedules or legends. 5. The Bureau shall, upon completion of any construction, renovation or remodeling of a facility, conduct an inspection of the facility to ensure compliance with the provisions of NAC 449.501 to 449.5795 , inclusive, concerning the design and space of the facility. The inspection must be conducted at a time and date established by the Bureau. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.522 Construction, space and design; physical environment; restrictions for treatment of patients with hepatitis B. ( NRS 449.0302 ) 1. The Bureau shall consider a facility to be in compliance with the provisions of NAC 449.501 to 449.5795 , inclusive, relating to the construction, space or design of the facility if: (a) The facility was licensed on or before July 1, 2001; and (b) The existing construction of the facility does not have any deficiencies that are likely to cause serious injury, harm or impairment to the health and welfare of the members of the general public. If such a deficiency occurs, the facility must correct the deficiency before the facility may continue to operate. 2. Each facility shall provide a physical environment that protects the health and safety of the patients and members of the staff of the facility and the members of the general public. The premises and any structures located on the premises of the facility that are used by a patient of the facility, including, without limitation, any stairwell, corridor or passageway, must satisfy the provisions of any applicable local building or fire safety code relating to the requirements for the design and space of the premises and structures. 3. If a facility provides treatment for a patient who has tested positive for hepatitis B, the facility shall treat the patient with a designated machine, blood pressure cuff, sink and any other equipment that is appropriate for providing treatment to the patient. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5225 Safety and comfort of patients during construction; imposition of more stringent design and space requirements. ( NRS 449.0302 ) 1. If any construction occurs in or near an area of the facility that is occupied by a patient of the facility, the facility shall ensure the safety and comfort of the patient during the construction. 2. A facility may impose more stringent design and space requirements than the requirements set forth in NAC 449.501 to 449.5795 , inclusive. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.523 Safety requirements. ( NRS 449.0302 ) 1. Each facility shall install a system for lighting the facility that is capable of providing sufficient illumination to allow safe evacuation from each building of the facility during an emergency at the facility. Each battery pack system used by the facility must be maintained and tested at least once each month. If a facility maintains a backup generator, the generator must be installed, tested and maintained in accordance with the instructions of the manufacturer of the generator. The facility shall document the testing of the generator at least once every 6 months. 2. A facility must not be located in or adjacent to a building that is considered a high hazard building and meets the requirements of group H of Volume I of the Uniform Building Code , 1997 edition, which is hereby adopted by reference. A copy of those provisions may be obtained from the International Conference of Building Officials, 5360 Workman Mill Road, Whittier, California 90601, for the price of $67.50. 3. Each facility must be equipped with smoke detectors that are maintained in proper operating condition at all times. The smoke detectors must be tested in accordance with the specifications of the manufacturer of the smoke detectors. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5235 Maintenance and repair of equipment. ( NRS 449.0302 ) 1. Any equipment that is used by a facility, including any equipment used for backup, must be maintained free from any defect that may be hazardous to the patients or members of the staff of the facility or any visitors to the facility. Any maintenance or repair of the equipment must be performed by a member of the staff of the facility who is qualified to conduct the maintenance or repair or by contract personnel. 2. Each facility shall ensure that each person employed on the staff of the facility is able to identify any equipment that malfunctions and report the malfunction to the appropriate person for repair. 3. If any medical equipment of a facility malfunctions, the equipment: (a) Must be removed immediately from service at the facility; and (b) Must not be returned to service at the facility unless the malfunction is identified and corrected. 4. Each facility shall maintain written evidence of any activity concerning repair or maintenance that occurs at the facility. 5. If any repair or alteration is made to any equipment or system of a facility, the facility must test the equipment or system to ensure proper operation of the equipment or system before the equipment or system is returned to service at the facility. 6. Each facility shall comply with the provisions of 21 U.S.C. § 360i(b) concerning the reporting of a device, as defined in 21 U.S.C. § 321(h), that has or may have caused or contributed to the injury or death of a patient of the facility. 7. Each facility shall develop and comply with a written policy concerning preventative maintenance to ensure that all equipment which is used by the facility to treat a patient or which is provided by the facility for use by the patient in the patient’s residence receives electrical safety inspections, if appropriate, and maintenance at least annually or more often if recommended by the manufacturer of the equipment. Any maintenance conducted pursuant to the provisions of this subsection may be provided by a qualified member of the staff of the facility or by contract personnel. 8. Each facility shall ensure that at least one complete dialysis machine is available for use at the facility as a backup machine for every 14 dialysis machines used by the facility. 9. If a facility provides treatment for a pediatric patient, the facility shall use equipment and supplies, including, without limitation, blood pressure cuffs, dialyzers and blood tubing, that are appropriate for treating that patient. 10. Any appliance or other electrical equipment of a facility must be grounded in accordance with the provisions of section 7-5.1 of NFPA 99: Standard for Health Care Facilities , 1999 edition, which is hereby adopted by reference. A copy of those provisions may be obtained from the National Fire Protection Association, 11 Tracy Drive, Avon, Massachusetts 02322, for the price of $40.25. 11. A facility shall not use any electrical extension cord or cable in any portion of the permanent electrical wiring of the facility. 12. Each facility shall maintain emergency equipment and supplies that are immediately accessible in any area of the facility which is used to treat the patients of the facility. Such equipment and supplies include: (a) Oxygen; (b) Ventilatory assistance equipment, including airways, manual breathing bag and mask; (c) Suction equipment; (d) Any supplies specified by the medical director of the facility; and (e) If pediatric patients are treated, the appropriate type and size of emergency equipment and supplies required by subsection 9. 13. Each facility shall establish and comply with a written policy for periodically testing and maintaining all emergency equipment used by the facility. The members of the staff of the facility shall properly maintain the equipment and maintain a written record of the testing and maintenance of that equipment. 14. If a facility uses a central delivery system for bicarbonate dialysate, the system must be: (a) Drained at the end of each day of treatment; and (b) Cultured at least once each week to identify any potential bacterial contamination. If the results of a culture conducted pursuant to the provisions of this paragraph indicate the presence of more than 2,000 colony forming units per milliliter, the facility shall disinfect and reculture the system. 15. As used in this section, “pediatric patient” means a person who is not more than 14 years of age and is under the care of a facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.525 Water treatment system: General requirements. ( NRS 449.0302 ) 1. The design for the water treatment system of a facility must be: (a) Based on considerations of the source of water for the facility; and (b) Prepared by a person who, as determined by the Bureau, has obtained education, training or experience in the design of dialysis systems. 2. If a facility does not obtain water from a public water system, any water used by the facility for medical treatment must be subjected to a bacteriological analysis conducted by the appropriate health authority or by a commercial laboratory that is certified by the Division. An analysis must be conducted pursuant to the provisions of this subsection at least once every 3 months. 3. The area in which the water treatment system of a facility is located must be of sufficient size to allow for the maintenance, testing and repair of the equipment. If any dialysate is mixed in the area, the area must be of sufficient size to house and allow for the mixing of the dialysate and for the maintenance, testing and repair of any equipment used to mix the dialysate. 4. Each component of the water treatment system of a facility must be arranged and maintained in such a manner as to ensure that the amount of bacterial and chemical contaminants in the product water does not exceed the standards for hemodialysis water quality relating to hemodialysis systems and maximum level of chemical contaminants set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications , adopted by reference pursuant to the provisions of NAC 449.520 . 5. Each facility shall prepare and comply with a written policy concerning the operation of the water treatment system of the facility. The written policy must include guidelines for the operation of each component of the water treatment system. The facility shall: (a) Ensure that each person who operates those components is aware of the guidelines and operates those components in accordance with those guidelines; and (b) Establish and maintain in the area in which those components are located written procedures describing the actions to be taken if the guidelines are not complied with. 6. Except as otherwise provided in this subsection, the water treatment system of a facility must be equipped with reverse osmosis membranes or deionization tanks and not less than two carbon tanks arranged in series. If the source of water for the water treatment system is obtained from a private supply that does not use chlorine or chloramine, the water treatment system must be equipped with reverse osmosis membranes or deionization tanks and not less than one carbon tank. 7. If the water treatment system of a facility is equipped with reverse osmosis membranes, the membranes must satisfy the requirements relating to reverse osmosis set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications , adopted by reference pursuant to the provisions of NAC 449.520 . 8. If the water treatment system of a facility is equipped with a deionization system, the system must satisfy the requirements relating to regenerated or reconstituted devices and deionization set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications , adopted by reference pursuant to the provisions of NAC 449.520 . 9. Each carbon tank that is used in the water treatment system of the facility must: (a) Contain acid-washed 30-mesh or smaller carbon placed in series with a minimum empty bed contact time of 3 minutes for each tank or bank of tanks; and (b) Include a testing port that is located between the tanks or bank of tanks. The facility shall, at least once each day before providing treatment to any patient of the facility, test water from the port to determine the amount of chlorine and chloramine in the water. The initial test each treatment day for chlorine and chloramine must be conducted not less than 15 minutes after the water treatment system is started for that day. 10. If the results of a test conducted pursuant to the provisions of subsection 9 indicate the presence of more than 0.5 parts per million of chlorine or 0.1 parts per million of chloramine in the water that is obtained from the port between the initial tank and the final tank of the water treatment system, the facility shall replace the initial tank and conduct a test of the water from the final exit of the water treatment system. If the results of that test indicate the presence of chlorine or chloramine in an amount that is greater than the requirements specified in this subsection, the facility shall immediately terminate any dialysis treatment provided to a patient of the facility and notify the medical director of the facility of the results of the test. 11. If a facility uses a water softener in the water treatment system of the facility, the water softener must have the capacity to treat a sufficient amount of water to supply the facility for the entire treatment day. 12. If a facility uses a cartridge filter in the water treatment system of the facility, the cartridge filter must be made of material that does not leach surfactants, formaldehyde or other material that was used to manufacture the material. 13. If a facility uses a cartridge filter housing during disinfectant procedures, the housing must include a mechanism to clear the lower portion of the housing of the disinfecting agents. Each cartridge filter housing must be opaque. 14. The water treatment system of the facility must be: (a) Continuously monitored during the treatment of a patient of the facility; and (b) Protected by audible and visual alarms that are capable of being seen and heard in the dialysis treatment area if the quality of the water used in the water treatment system falls below the standards established by the facility for the water treatment system or the manufacturer of the water treatment system. 15. If the deionization tanks of the water treatment system of a facility do not follow a reverse osmosis system, standards for the rate of rejection of the membranes must ensure that the lowest rate accepted will provide product water in compliance with the maximum level of chemical contaminants set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications , adopted by reference pursuant to the provisions of NAC 449.520 . 16. Each facility shall maintain a written record of the operation of the water treatment system for each treatment day. The written record must include the guidelines established by the facility for operating each component of the system and any action taken during that day if the operation of a component was not within the guidelines established by the facility for that component. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004) NAC 449.5255 Water treatment system: Chemical testing of product water; records. ( NRS 449.0302 ) 1. Except as otherwise provided in this section, each facility shall, at least once every 6 months, conduct a chemical test of a sample of the product water of the water treatment system of the facility. The results of any test conducted pursuant to the provisions of this section must indicate that the quality of the product water satisfies the requirements relating to maximum level of chemical contaminants set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications , adopted by reference pursuant to the provisions of NAC 449.520 . 2. A facility shall conduct a chemical test pursuant to the provisions of this section if substantial changes are made to the water treatment system or if the percent of rejection of a reverse osmosis system decreases 5 percent or more from the percent of rejection measured at the time the water sample for the preceding chemical test was taken. If a facility uses a water treatment system that is portable, the facility shall, at least once each year, conduct a chemical test of the product water in accordance with the provisions of this section. 3. The records maintained by a facility concerning the operation of the facility must include: (a) The results of each test conducted pursuant to the provisions of this section and NAC 449.525 and 449.526 ; and (b) Evidence satisfactory to the Bureau that the medical director of the facility reviewed the results of those tests and required corrective action to be taken if indicated by those results. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004) NAC 449.526 Water treatment system: Microbiological testing of product water. ( NRS 449.0302 ) 1. Each facility shall, at least once each month or immediately after any repair or change is made to the water product treatment system of the facility, conduct a microbiological test of the product water. The results of any test conducted pursuant to the provisions of this section must indicate that the quality of the product water satisfies the requirements relating to hemodialysis systems set forth in the American National Standard, Water Treatment Equipment for Hemodialysis Applications , adopted by reference pursuant to the provisions of NAC 449.520 . 2. Sample sites selected by the facility to conduct the test must include the beginning of the distribution piping, the product water in the reuse room of the facility and the end of the distribution piping. If the results of the test do not satisfy the requirements specified in subsection 1, the facility shall immediately disinfect and reculture the water treatment system. If, after the water treatment system is disinfected and recultured, the results of the test do not satisfy those requirements, the facility shall determine the source of the contamination by immediately reculturing: (a) The sample sites; (b) Each patient station of the facility; (c) Each tank of the water treatment system that is used to store water; (d) All water that is used to mix dialysate; and (e) The product water obtained from the final component of the water treatment system. 3. A calibrated loop must not be used to conduct a test pursuant to the provisions of this section. As used in this subsection, “calibrated loop” means a mechanism that is used to: (a) Draw a sample of water from the water treatment system of a facility; and (b) Conduct a test of that water for the presence of chemicals, bacteria or other impurities. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004) NAC 449.5265 Reuse of hemodialyzer; transport of used dialyzer. ( NRS 449.0302 ) 1. If a facility reuses any hemodialyzer in providing treatment to a patient of the facility, the facility shall: (a) Ensure that the reuse of the hemodialyzer is conducted in accordance with the provisions of the American National Standard, Water Treatment Equipment for Hemodialysis Applications , adopted by reference pursuant to the provisions of NAC 449.520 . (b) Ensure that each transducer protector used during the treatment is: (1) Replaced, if it becomes wet during the treatment; and (2) Used only for one treatment. (c) Ensure that, in any area of the facility in which the reuse occurs, the supply of water in that area incorporates a mechanism to prevent any chemical agents from flowing into the water distribution system of the facility. (d) Ensure that any ventilation system installed in an area specified in paragraph (c): (1) Is connected to an exhaust system that: (I) Leads to the outside of the building in which the room is located; and (II) Is separate from the exhaust system of the building; (2) Has an exhaust fan that is located at the discharge end of the ventilation system; (3) Has a system of exhaust ducts that is constructed of material that is noncombustible and resistant to corrosion; and (4) Has an exhaust outlet that is located above the level of the roof of the building to which the exhaust outlet is attached, and if more than one exhaust outlet is installed, the facility shall ensure that each of those outlets is arranged in such a manner as to minimize any recirculation of exhaust air into the building. (e) Adopt and comply with a policy that sets forth the criteria for reuse, including the number of reuses allowed by the facility. (f) Ensure that access to an area of the facility specified in paragraph (c) is restricted to persons who are authorized by the facility to enter that area. (g) Before providing treatment to the patient: (1) Consider and address the health and safety of the patient if he or she is sensitive to disinfectant solution residuals; (2) Provide to the patient information regarding the policy of reuse for the facility and the opportunity to submit and receive a response to questions concerning the reuse; and (3) Obtain written consent for the reuse from the patient or legal representative of the patient. 2. A facility shall not transport any dialyzer that has been used in the treatment of a patient of the facility or allow a person to transport that dialyzer for reprocessing to a location that is off the premises of the facility unless the facility: (a) Requires the use of automated equipment at that location to reprocess the dialyzer; (b) Remains responsible for the entire process of reuse; (c) Adopts and complies with a policy which ensures that the transfer and transportation of any used or reprocessed dialyzer to and from the location does not increase the contamination of the dialyzer, the environment or any member of the staff of the facility; and (d) Allows an employee of the Bureau to enter the off-site reprocessing site as part of any inspection of the facility conducted by the Bureau. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004) NAC 449.528 Adoption of more stringent requirements for treatment of water and reuse of hemodialyzers. ( NRS 449.0302 ) A facility may adopt more stringent requirements for the treatment of water and the reuse of hemodialyzers than the requirements set forth in NAC 449.525 to 449.5265 , inclusive. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5285 Sanitation: Precautions regarding blood and bodily fluids. ( NRS 449.0302 ) 1. Any activity relating to the care of a patient of a facility must be provided in accordance with the provisions of 29 C.F.R. § 1910.1030(d)(1)-(3), relating to bloodborne pathogens. 2. Each member of the staff of the facility shall wash his or her hands immediately before and after each contact with a patient that may expose the member of the staff to any blood or fluids of the body of the patient. The location and arrangement of any area of the facility that is used for washing hands must permit ease of access and proper use. 3. A sink that is used for washing hands must be readily accessible in each area of the facility that is used to care for patients of the facility. Each fixture and lavatory located in that area must be trimmed with valves which may be operated without the use of hands. There must be sufficient clearance for the operation of blade-type handles, if those handles are used. 4. Provisions for drying hands must be included in any area of the facility that is used for washing hands. 5. If a patient of a facility or a member of the patient’s family intends to assist a member of the staff of the facility in conducting a procedure that may cause the patient or member of the patient’s family to come into contact with any blood or bodily fluids, the member of the staff of the facility shall, before the procedure is conducted: (a) Explain to the patient or member of the patient’s family the potential risks associated with blood and any products of blood; and (b) Provide to the patient or member of the patient’s family the appropriate equipment to protect the patient or member of the patient’s family from those risks. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.529 Sanitation: Control of infections; nonsmoking policy. ( NRS 449.0302 ) 1. Each facility shall designate a person to monitor and coordinate the activities occurring at the facility concerning the control of infections at the facility. 2. Each facility shall develop and maintain a system to identify, monitor and record the occurrence of infections at the facility. The system must be reviewed as a part of the program to ensure the quality of the facility conducted pursuant to the provisions of NAC 449.540 . The record maintained by a facility pursuant to the provisions of this subsection must include any trends, corrective actions and improvement actions taken by the facility. 3. Each facility shall establish and comply with a policy concerning nonsmoking at the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5295 Sanitation: Provision of sanitary environment; walls, floors and ceilings; blood spills. ( NRS 449.0302 ) 1. Each facility shall provide a sanitary environment that minimizes or prevents transmission of infectious diseases at the facility. 2. The base of each wall that is located in any area of a facility which is subject to frequent cleaning with water or any other liquid must be: (a) Tightly sealed to the floor and the wall to ensure that the base of the wall is impervious to the water or other liquid; and (b) Constructed without any voids that may harbor insects. 3. The material that is used for the surface of the floors of a facility must be easily cleanable and have resistance to wear that is appropriate for the location of the material in the facility. In each area of the facility that is subject to cleaning with water or any other liquid, the material must not be physically affected by germicidal or cleaning solutions. 4. The finish on the interior of each wall of a facility must be washable and, in the immediate area of any plumbing fixtures, must be smooth and resistant to moisture. 5. Each joint of a structural element of a facility and each floor or wall that is penetrated by a pipe, duct or conduit must be tightly sealed to reduce the possibility of entry by rodents or insects into the joint, floor or wall. 6. Each ceiling or ceiling structure that is exposed in an area of a facility which is regularly occupied by patients, staff or visitors of the facility must be finished to ensure that the ceiling or structure is cleanable with equipment which is used in daily housekeeping activities. If any tile that is located in the ceiling of any room of a facility becomes stained with blood, the facility shall clean or replace the tile immediately or as soon as practicable after the tile becomes stained. 7. A facility shall not use a ceiling fan in any area of the facility that is used to treat a patient of the facility. 8. Each spillage of blood that occurs at a facility must be cleaned immediately or as soon as practicable after the spillage occurs using a disposable cloth and an appropriate chemical disinfectant. If a blood spill occurs: (a) The surface of the area must be subjected to intermediate level disinfection in accordance with the instructions of the manufacturer of the disinfectant that is used to clean the spill, if a commercial liquid chemical disinfectant is used; or (b) If chlorine bleach or any other solution of sodium hypochlorite is used to clean the spill, the solution must consist of not less than 1 percent of sodium hypochlorite. Each surface that is cleaned with the chlorine bleach or other solution must be compatible with that solution. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.531 Sanitation: Disinfection of dialysis machines; culturing dialysate; cleaning of machines and equipment; handling of waste. ( NRS 449.0302 ) 1. Each facility shall periodically disinfect each active and backup dialysis machine in accordance with the policy of the facility concerning the disinfection of those machines. Any disinfection conducted pursuant to the provisions of this subsection must achieve at least intermediate level disinfection. 2. Each facility shall, at least once each month: (a) Randomly collect a sample of dialysate from a dialysis machine that is used by the facility; and (b) Conduct a culture of the sample. Ê The results of a culture conducted pursuant to the provisions of this subsection must not exceed 2,000 colony forming units per milliliter. A hemodialysis machine that is used by a patient of a facility at his or her residence must be cultured at least once each month until results not exceeding 2,000 colony forming units per milliliter are obtained for 3 consecutive months. If those results are obtained, quarterly samples must be cultured. 3. Immediately after each patient shift but before the next patient shift, the staff of the facility shall clean the exterior of each machine that is used for dialysis, treatment chairs, tourniquets and hemostats. Any blood pressure cuff that becomes contaminated with blood must be removed from service, disinfected and allowed to dry before it is returned to service at the facility. 4. Each facility shall comply with the requirements concerning the handling of waste from health care related facilities that are established by this State or by any local government which has authority to regulate that activity at the facility. 5. All sewage or liquid waste must be disposed of in a municipal sewerage system or a septic tank system for which a permit has been obtained by the facility pursuant to state law or local regulations. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5315 Hepatitis B: Vaccinations for certain staff members; postvaccination screening; adoption of related provisions. ( NRS 449.0302 ) 1. If any member of the staff of a facility is susceptible to hepatitis B and has not been vaccinated for that disease, the facility shall offer vaccination for the disease to that member of the staff in accordance with the provisions of 29 C.F.R. § 1910.1030(f)(1) and (2), relating to bloodborne pathogens. If a member of the staff of a facility is vaccinated pursuant to the provisions of this subsection, a written record of the vaccination must be included in the health record of the member of the staff maintained by the facility. 2. Each facility shall establish and comply with a policy to conduct postvaccination screening of each member of the staff of the facility. The serologic screening must be conducted within 60 days after the final dose of vaccine is administered to the member of the staff of the facility. Any additional screening and follow-up must be based upon the results of the testing for the hepatitis B surface antigen. 3. The provisions of Appendices I and II of the National Surveillance of Dialysis-Associated Diseases in the United States , 1993 edition, are hereby adopted by reference. A copy of those provisions may be obtained free of charge from the Public Health Service, Centers for Disease Control and Prevention, National Center for Infectious Diseases, Hospital Infections Program, Mail Stop C01, Atlanta, Georgia 30333. If a facility determines pursuant to subsection 2 that a member of the staff of the facility is a responder as defined in Appendix II of those provisions, the facility shall not require the member of the staff to submit to further screening pursuant to subsection 2. If the facility determines that a member of the staff of the facility is a nonresponder as defined in that appendix, the facility shall ensure that the member of the staff is tested at least once every 6 months pursuant to that subsection. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.532 Hepatitis B: Vaccinations for certain patients. ( NRS 449.0302 ) 1. If advised by and with the consent of a patient’s attending nephrologist, each facility shall offer hepatitis B vaccine to each patient who is susceptible to hepatitis B. 2. Each facility shall, upon request by a patient of the facility, make available to the patient a publication or other information concerning the risks and benefits of receiving the vaccine for hepatitis B. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5325 Hepatitis B surface antigen: Screening of patients; additional serologic screening. ( NRS 449.0302 ) 1. Each candidate for dialysis at a facility must, if practicable, be screened for the hepatitis B surface antigen before being admitted to the facility. The screening may be performed at any time within 30 days before the person is admitted to the facility. 2. Additional serologic screening must be based on the antigen or antibody status of the patient, as follows: (a) If the patient tests negative for the hepatitis B surface antigen, the facility shall screen the patient at least once each month. (b) If the patient tests positive for the hepatitis B surface antigen or anti-hepatitis B surface antigen, the facility may screen the patient less than once each month if the policy of the facility concerning the screening of that patient complies with the provisions of Appendices I and II of the National Surveillance of Dialysis-Associated Diseases in the United States , adopted by reference pursuant to the provisions of NAC 449.5315 . (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.534 Hepatitis B surface antigen: Treatment of patients who test positive. ( NRS 449.0302 ) 1. If a patient of a facility tests positive for the hepatitis B surface antigen, the facility shall provide treatment for the patient: (a) On a machine that is dedicated for patients who test positive for the hepatitis B surface antigen; and (b) In an area of the facility that includes: (1) A sink for washing hands; (2) A work area; (3) An amount of equipment and supplies that is sufficient to care for the patient; and (4) Sufficient space to prevent contamination of any other patient of the facility. 2. A patient specified in subsection 1 must be dialyzed on equipment that is dedicated for patients who test positive for the hepatitis B surface antigen. 3. If a patient specified in subsection 1 is discharged from the facility, all equipment that is provided for that patient pursuant to the provisions of subsection 2 must be given intermediate level disinfection before the equipment is used for a patient who tests negative for the hepatitis B surface antigen. 4. If a patient is admitted to a facility for treatment before a test for the hepatitis B surface antigen is conducted, the facility shall provide treatment to that patient as if he or she had tested positive for that antigen. The facility shall not treat the patient on a machine that is used for a patient of the facility who has tested positive for the antigen. 5. If a facility uses a central delivery system, the facility shall treat a patient specified in subsection 4 on a designated machine. The facility may not reuse the dialyzer for that machine until the results of testing for that patient are known by the facility. The dialysis machine used by the patient must be given intermediate level disinfection before the machine may be used by any other patient of the facility. 6. The facility shall obtain the results of testing for a patient specified in subsection 4 not later than 7 days after the patient is admitted to the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5345 Tuberculosis: Screening of staff and patients. ( NRS 449.0302 ) 1. A facility shall screen each member of the staff of the facility to determine whether the member has tuberculosis. The facility shall screen each member of the staff: (a) Upon commencement of employment at the facility or upon receiving privileges as a member of the medical staff of the facility; or (b) Before the member of the staff has any physical contact with a patient of the facility. Ê The screening must be conducted in accordance with the provisions of NAC 441A.375 . 2. A facility shall screen each patient of the facility for tuberculosis if indicated by the presence of risk factors for tuberculosis or if the patient experiences any sign or symptom of tuberculosis. The screening must be performed after any possible exposure by a patient of the facility to active laryngeal or pulmonary tuberculosis. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) Provision of Services NAC 449.540 Program of quality assurance; recordation of accidents and incidents; reporting of certain events. ( NRS 449.0302 ) 1. Each facility shall: (a) Conduct a systematic and comprehensive review of the facility and the care provided to each patient of the facility; and (b) Adopt and comply with a program to ensure the quality of the facility. The program must be based on information concerning the facility provided to the facility by the End-Stage Renal Disease Network. 2. The facility shall demonstrate through quality assurance activities that the members of the staff of the facility have: (a) Evaluated the care and services provided by the facility to the patients of the facility; (b) Established goals concerning the treatment of those patients; (c) Identified any available opportunities to improve the care and services provided to those patients; (d) Developed and carried out a plan to improve the care and services specified in paragraph (c); and (e) Evaluated the effectiveness of the plan specified in paragraph (d) until a resolution of any problems is obtained. 3. Each core staff member of the facility shall actively participate in the quality assurance activities conducted pursuant to the provisions of this section. As used in this subsection, “core staff member” means the medical director, supervising nurse, dietitian, social worker and administrator of a facility. 4. Not less than once each quarter, each facility shall conduct a meeting concerning the quality of the facility. The facility shall: (a) Prepare written minutes of each meeting held; and (b) Maintain the written minutes in the business office of the facility. 5. If an accident or incident occurs at a facility, including, without limitation, any error in providing medication to a patient of the facility or any adverse reaction of a patient to a drug administered to the patient at the facility, the facility shall immediately prepare a written record of the accident or incident. A written record prepared pursuant to this subsection must be maintained by the facility and be made available for review by the Bureau. 6. A facility shall report each of the following events to the Bureau within 7 days after the event occurs: (a) Each accident or incident concerning a patient of the facility that: (1) Occurs during dialysis treatment of the patient; and (2) Results in the death of the patient or requires the admission of the patient to a hospital overnight; (b) The occurrence of any fire at the facility; or (c) If a member of the staff of the facility or a patient of the facility converts to positive for the hepatitis B surface antigen. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5405 Rights of patients. ( NRS 449.0302 ) 1. In addition to the requirements set forth in NRS 449A.100 to 449A.118 , inclusive, each facility shall adopt and comply with a policy which ensures that each patient of the facility is: (a) Treated with respect, dignity and complete recognition of the individuality and personal requirements of the patient; (b) Provided with sufficient privacy during treatment to ensure that any unwarranted exposure of the patient does not occur and to ensure confidentiality of the clinical record of that patient; (c) Provided with a safe and comfortable environment for receiving any treatment provided by the facility; (d) Provided with information concerning the patient’s treatment in a manner which ensures that the patient or the legal representative of the patient understands that information; (e) Informed by a physician of the medical status of the patient; (f) Informed about all modalities and settings for the treatment of end-stage renal disease; (g) Informed about and participates in, if requested by the patient, each aspect of care, including, without limitation, the right to refuse treatment and the medical consequences of refusing that treatment; (h) Aware of any services that are available to the patient at the facility and the charges for those services; and (i) Informed about any reuse of dialysis supplies by the facility, including hemodialyzers. If any brochures or other printed materials are used to describe the facility or any services provided by the facility, the facility shall ensure that the brochures or other printed materials include a statement specifying the policy of the facility concerning the reuse of those supplies. 2. Each facility shall ensure that each patient of the facility: (a) Receives a reasonable response by the facility to any request or requirement of the patient for treatment or service in accordance with any applicable law or regulation and within the capacity of the facility to provide the requested treatment or service; (b) Is transferred only for: (1) A medical reason; (2) The welfare of the patient or any other patient or member of the staff of the facility; or (3) The nonpayment of fees owed by the patient to the facility; (c) Is provided with information concerning advance directives and the provisions of NRS 450B.400 to 450B.590 , inclusive, concerning do-not-resuscitate identification and do-not-resuscitate orders; and (d) Is fully informed of: (1) The rights specified in this subsection; and (2) All rules established by the facility concerning the conduct and responsibilities of the patient during the period he or she is a patient of the facility. 3. Upon admission of a patient to a facility, the facility shall provide to the patient or his or her legal representative a written copy of the patient’s rights and responsibilities. A copy of those rights and responsibilities must be posted: (a) In the waiting room or other area of the facility to which the members of the general public have access; and (b) In close proximity to the license of the facility. 4. A facility shall not transfer or discharge a patient of the facility for the nonpayment of fees by the patient unless the facility notifies the patient in writing of the intent of the facility to transfer or discharge the patient. The written notice must include a statement indicating the amount of the fees owed by the patient to the facility. 5. Upon admitting a patient to a facility, the facility shall provide to the patient a written statement that informs the patient of the manner in which he or she may file a complaint against the facility. The statement must include, without limitation: (a) A statement indicating that the patient may direct such a complaint to the Bureau or file the complaint with the Division; and (b) The telephone number of the local office of the Division. 6. Except as otherwise provided in subsection 7, if a facility has admitted more than eight patients who read the same language other than English, all written information provided by the facility to any of those patients pursuant to the provisions of this section must be written in that other language. 7. In lieu of providing written information in a language other than English pursuant to the provisions of subsection 6, a facility may use the services of an interpreter to provide that information to a patient specified in that subsection if, as determined by the Bureau, the facility maintains written documentation which indicates that the information conveyed by the interpreter to the patient was sufficient to ensure the ability of the patient to participate in the decisions made concerning his or her treatment at the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.541 Interdisciplinary teams; plans for care of patients. ( NRS 449.0302 ) 1. Each facility shall establish and comply with a policy which specifies that the services provided to each patient of the facility are coordinated using an interdisciplinary team. The interdisciplinary team must consist of: (a) The primary dialysis physician of the patient; (b) A registered nurse; (c) A social worker; and (d) A licensed dietitian. 2. Each interdisciplinary team specified in subsection 1 shall develop a written, individualized and comprehensive plan to provide care to the patient for whom the plan is prepared. The plan must: (a) Specify the services that are required to address the medical, psychological, social and functional needs of the patient; and (b) Include a statement setting forth the objectives for providing treatment to the patient. 3. Each plan for the care of a patient prepared pursuant to the provisions of subsection 2 must include: (a) If required to ensure the provision of safe care for the patient, evidence of coordination with any other provider of service for the patient, including a hospital, long-term care facility, an agency that provides residential or community support services, or a provider of transportation; and (b) Evidence indicating that: (1) The provisions of the plan were disclosed to the patient or his or her legal representative; and (2) The patient or his or her legal representative was provided an opportunity to participate in and discuss the preparation of the plan. 4. Each plan for the care of a patient must be: (a) Prepared within 30 days after the patient is admitted to the facility; and (b) Revised at least once every 6 months or immediately after the occurrence of any change in the medical, nutritional or psychosocial condition of the patient. 5. Each member of the interdisciplinary team shall periodically evaluate the progress of the patient toward achieving the objectives specified in the plan. Any action taken by a member of the interdisciplinary team, if the objectives are not achieved, must be documented and included in the clinical record of the patient. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012) NAC 449.5415 Preparations for emergencies and disasters. ( NRS 449.0302 ) 1. Each facility shall adopt a written procedure to be followed by each patient and member of the staff of the facility if any emergency occurs at the facility, including, without limitation, any fire, equipment failure, power outage, medical emergency or natural disaster that may threaten the health or safety of any patient or member of the staff of the facility or any member of the general public. 2. Each facility shall prepare a plan for obtaining emergency medical services that are available for use by the facility. 3. Each facility shall employ personnel who are qualified to operate emergency equipment at the facility and to provide emergency care at the facility. The personnel must be available to operate the emergency equipment and provide emergency care during each period in which treatment is provided to a patient of the facility. A charge nurse who is qualified to provide basic cardiopulmonary life support must be present at the facility and available in the treatment area during any period in which a patient of the facility is present in that area. Each member of the clinical staff of the facility must maintain current certification and competency in basic cardiopulmonary life support. 4. Each facility shall enter into an agreement with at least one hospital that provides acute dialysis service, inpatient care and other hospital services to the patients of the facility. The agreement must include: (a) Documentation from the hospital indicating that the patients of the facility will be accepted and treated during any emergency that occurs at the facility; and (b) Reasonable assurances that: (1) The transfer or referral of a patient will occur between the hospital and the facility if the transfer or referral is determined to be medically appropriate by the attending physician of the patient; (2) The exchange of medical and other information necessary or useful in the care and treatment of the patient transferred will occur within 1 working day after the transfer or referral of the patient; and (3) All personal property belonging to and transferred with the patient will be accounted for and protected from theft, loss or damage. 5. Each facility shall establish and comply with a written plan to protect each patient of the facility if a fire occurs at the facility. The written plan must include: (a) Provisions concerning the evacuation of each person from each building of the facility during a fire; and (b) A diagram that specifies the routes to be taken to evacuate each of those buildings. A copy of each diagram prepared pursuant to the provisions of this paragraph must be posted in a conspicuous place in the building for which the diagram is prepared. 6. Each facility shall, not less than once each quarter, conduct a fire drill at the facility. The facility shall rotate the occurrence of the fire drills to ensure that each patient shift participates in a fire drill at least once each year. Each fire drill must include the use of alarms and equipment and a discussion with the patients, visitors, employees and members of the staff of the facility concerning evacuation from each building of the facility. After conducting a fire drill, the facility shall prepare and maintain a written report concerning the fire drill. The written report must include evidence that the members of the staff and the patients of the facility participated in the fire drill. 7. Each facility shall ensure that each member of the staff of the facility is familiar with the location of all equipment that is used to suppress fires at the facility. The equipment must be located in such a manner that a person is not required to travel more than 75 feet from any location in the facility to reach the equipment. 8. Each facility shall prepare and comply with a written plan concerning preparation for any disaster that may occur at the facility. The plan must: (a) Be based on an assessment of the probability and type of disaster in each region and the local resources available to the facility; (b) Include procedures that are designed to: (1) Minimize the harm to the patients and members of the staff of the facility; and (2) Ensure the safe operation of the facility during a disaster; and (c) Include provisions concerning: (1) The assignment of responsibilities for each member of the staff of the facility during a disaster, including the assignment of direction and control of the facility; (2) The maintenance of equipment used for communication during a disaster; (3) The use of warning systems; and (4) Evacuation from and closure of the facility because of a disaster. 9. Each facility shall adopt written procedures to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004) NAC 449.543 Pharmaceutical services. ( NRS 449.0302 ) 1. Each facility shall provide pharmaceutical services in accordance with accepted professional principles and any applicable federal and state statutes and regulations. 2. Medication may be administered to a patient of a facility only if the medication is ordered by: (a) The patient’s physician; (b) A physician assistant; or (c) An advanced practice registered nurse. 3. Any verbal or telephone order for medication must be received by a licensed nurse and countersigned by the physician of the patient for which the order was received. 4. Any medication that is maintained by a facility at the site of the facility must be: (a) Placed in a container that is of sufficient size to store the medication; and (b) Stored in a manner which ensures that the medication is not accessible to a person who is not authorized by the facility to obtain the medication. Any refrigerator that is used to store the medication must be maintained at a temperature that is appropriate for that medication. 5. Each facility shall maintain a supply of medications that, as determined by the medical director of the facility, is sufficient to satisfy the requirements of each patient of the facility during an emergency at the facility. 6. Any medication that is prepared for administration to a patient of a facility must be prepared in an area of the facility that includes a work counter and a sink. The area must be located in a portion of the facility that prohibits any contamination of the medication. 7. If any medication is prepared for a patient of a facility and the medication is not administered to the patient immediately after it is prepared, the medication must be labeled with the: (a) Name of the patient; (b) Name of the medication; (c) Dosage prepared; (d) Initials of the person who prepared the medication; and (e) Date on which the medication was prepared. 8. Except as otherwise provided in this subsection, any medication that is prepared for a patient of a facility must be administered by the person who prepared the medication. A dialysis technician who is qualified in accordance with the provisions of NAC 449.5705 to 449.5775 , inclusive, may administer intravenous normal saline, intravenous heparin and subcutaneous lidocaine as part of a routine treatment of hemodialysis. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5435 Nursing services; physicians and other staff. ( NRS 449.0302 ) 1. Each facility shall provide nursing services to each patient of the facility to prevent or reduce complications and to maximize the functional status of the patient. 2. Each facility shall employ a full-time registered nurse to supervise and manage the care provided to patients of the facility. 3. The registered nurse employed pursuant to the provisions of subsection 2 shall: (a) Conduct an assessment of a patient during the admission of the patient to the facility; (b) Conduct an assessment of a patient if requested by the patient or if required because of a change in the medical status of the patient; (c) Participate in a team review of the progress of the patient pursuant to the provisions of NAC 449.541 ; (d) Recommend changes in treatment, if appropriate, based on the immediate requirements of the patient; (e) Facilitate communication between the patient, the patient’s family and each member of the interdisciplinary team established for the patient to ensure the delivery of care required for the patient; (f) Provide oversight and direction to dialysis technicians and licensed practical nurses; and (g) Participate in activities conducted by the facility to ensure the quality of the facility. 4. Each facility shall ensure that a registered nurse or a physician is present at the site of the facility and available to the treatment area to provide care at all times during which treatment is provided to a patient of the facility in that area. 5. Nursing services at the facility must be provided or supervised by a registered nurse. The registered nurse may be the charge nurse of the facility. Each facility shall ensure that a sufficient number of registered nurses, licensed practical nurses and other qualified persons are available to satisfy the requirements for nursing care of each patient of the facility. 6. Each facility shall ensure that a sufficient number of the members of the staff of the facility are available at the site of the facility to provide care directly to each patient of the facility and to satisfy the requirements of each of those patients. 7. A licensed nurse or dialysis technician shall evaluate each patient before and after treatment is provided to the patient in accordance with the policy of the facility and the amount of training received by the licensed nurse or dialysis technician. 8. A registered nurse shall conduct an initial nursing assessment of each patient of the facility at the time the patient receives his or her first treatment at the facility. The assessment must be completed by the registered nurse within 2 weeks after the beginning of that treatment. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.544 Nutrition services. ( NRS 439.200 , 449.0302 , 449.1915 ) 1. Each facility shall provide nutrition services to each patient of the facility and the provider of care for that patient to maximize the nutritional status of the patient. 2. The licensed dietitian for a patient of a facility shall: (a) Conduct an assessment of the nutrition of the patient; (b) Participate in a team review of the progress of the patient in accordance with the provisions of NAC 449.541 ; (c) After consulting with the physician of the patient, recommend or order a therapeutic diet for the patient based on: (1) The cultural preferences of the patient; (2) Changes in the treatment of the patient; and (3) The nutritional requirements of the patient; (d) Except as otherwise provided in subsection 7: (1) Counsel the patient and the provider of care for that patient, if required, concerning any diet prescribed for the patient at the facility; and (2) Monitor the patient’s adherence and response to that diet; (e) Refer the patient for assistance with any resources that are available to the patient, including, without limitation, financial assistance, community resources or assistance at the residence of the patient; (f) Participate in activities conducted at the facility to ensure the quality of the facility; and (g) Monitor the nutritional status of the patient to determine the need for intervention and follow-up by the facility. In making that determination, the licensed dietitian shall consider: (1) Changes in the weight of the patient; (2) The chemistry of the blood of the patient; (3) The adequacy of the dialysis treatment provided to the patient; and (4) Changes in the medication prescribed for the patient. 3. Each facility shall collect data to assess the nutritional status of a patient of the facility not later than 2 weeks after the patient is admitted to the facility or immediately after the patient receives seven treatments at the facility, whichever occurs later. A comprehensive assessment of the nutritional status of the patient must be completed within 30 days after the patient is admitted to the facility or immediately after the patient receives 13 treatments at the facility, whichever occurs later. Such an assessment must include a determination by the dietitian of the degree to which the patient understands the diet prescribed for him or her by the facility. 4. Each facility shall, annually or more often if required by the circumstances concerning the treatment of the patient, revise the comprehensive assessment of the nutritional status of each patient specified in subsection 3. 5. Each facility shall employ or contract with a licensed dietitian to provide nutrition services for each patient of the facility. If a facility provides treatment for 100 or more patients, the facility shall ensure that one full-time equivalent licensed dietitian is available at the facility. 6. Nutrition services must be available at each facility during scheduled periods for treatment. The facility may require a patient to obtain an appointment with a licensed dietitian before receiving those services. 7. The provisions of paragraph (d) of subsection 2 do not apply to a correctional institution. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012; R048-22, 12-29-2022) NAC 449.5445 Social services. ( NRS 449.0302 ) 1. Each facility shall provide social services to each patient of the facility and to the provider of care for the patient, if required. The facility shall ensure that the social services support and maximize the adjustment, social functioning and rehabilitation of each patient of the facility. 2. The social worker shall: (a) Conduct a psychosocial evaluation of each patient of the facility; (b) Participate in a team review of the progress of the patient in accordance with the provisions of NAC 449.541 ; (c) Recommend changes in the treatment of the patient based on the psychosocial requirements of the patient; (d) Except as otherwise provided in subsection 7, provide casework and group work services to the patient and, if needed, to members of his or her family concerning the problems associated with treating end-stage renal disease; (e) Except as otherwise provided in subsection 7, identify public agencies that may provide social services for the patient or other resources that are available to the patient and assist the patient and each member of his or her family in the use of those resources; and (f) Participate in activities conducted at the facility to ensure the quality of the facility. 3. Each facility shall ensure that the initial contact between the social worker and each patient of the facility occurs and is documented in writing not more than 2 weeks after the patient is admitted to the facility or immediately after the patient receives seven treatments at the facility, whichever occurs later. A comprehensive psychosocial assessment of the patient must be completed within 30 days after the patient is admitted to the facility or immediately after the patient receives 13 treatments at the facility, whichever occurs later. 4. Each facility shall, annually or more often if required by the circumstances concerning the treatment of the patient, revise the comprehensive psychosocial assessment of each patient specified in subsection 3. 5. Each facility shall employ or contract with a social worker to meet the psychosocial requirements of each patient of the facility. If a facility provides treatment for 100 or more patients, the facility shall ensure that one full-time equivalent social worker is available at the facility. 6. Social services must be available at each facility during scheduled periods for treatment. The facility may require a patient to obtain an appointment with a social worker before receiving those services. 7. The provisions of paragraphs (d) and (e) of subsection 2 do not apply to a correctional institution. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.546 Patient care: Advanced practice registered nurses and physician assistants; medical emergencies. ( NRS 449.0302 ) 1. If an advanced practice registered nurse or a physician assistant provides treatment for a patient of a facility, the facility shall ensure that there is evidence of communication with the treating physician of the patient if the advanced practice registered nurse or physician assistant changes any order for treatment in accordance with the provisions of chapter 630 or 632 of NRS. 2. An advanced practice registered nurse or a physician assistant specified in subsection 1 may not replace the treating physician of the patient concerning: (a) Participation in planning for the care of the patient; or (b) Activities conducted at the facility to ensure the quality of the facility. 3. If a medical emergency occurs concerning a patient of a facility, the treating physician for that patient: (a) Must be immediately notified; and (b) Shall direct the provision of care for the patient during the emergency. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5465 Patient care: Licensed practical nurses and dialysis technicians. ( NRS 449.0302 ) 1. The provisions of NAC 449.501 to 449.5795 , inclusive, do not prohibit a licensed practical nurse from practicing in accordance with the regulations adopted by the State Board of Nursing. If a licensed practical nurse acts in the capacity of a licensed practical nurse during the treatment of a patient of a facility, the licensed practical nurse must be certified to give intravenous injections by a board that is approved by the State Board of Nursing. 2. A member of the staff of a facility who acts in the capacity of a dialysis technician at the facility must be qualified in accordance with the provisions of NAC 449.5705 to 449.5775 , inclusive. If the facility determines that the member of the staff is not qualified pursuant to those provisions, the facility shall not allow the member of the staff to act in the capacity of a dialysis technician until the member of the staff becomes qualified pursuant to those provisions. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.547 Self-dialysis: Provision of training and certain services. ( NRS 449.0302 ) 1. If a facility provides training to a patient of the facility concerning the performance of dialysis by the patient, a licensed nurse who has at least 12 months of experience in the applicable dialysis modality, including hemodialysis or peritoneal dialysis, must be responsible for training the patient and each member of the family of the patient who intends to assist the patient in conducting the dialysis. The licensed nurse shall supervise all other members of the staff of the facility who assist in providing that training. 2. If a patient of a facility performs dialysis for himself or herself at the patient’s residence, the facility shall provide the following services to the patient: (a) A yearly physical examination; (b) Monthly communication from a member of the staff of the facility by: (1) Telephone; (2) Visits to the facility by the patient; or (3) Visits to the patient’s residence by a member of the staff; (c) A visit to the facility at least once every 3 months; (d) Communication with the appropriate member of the interdisciplinary team that is established for the patient pursuant to the provisions of NAC 449.541 ; (e) Routine laboratory work in accordance with the policy of the facility; and (f) A method by which the patient may contact a member of the staff of the facility, including the primary physician of the patient, at any time if an emergency concerning the condition of the patient occurs. 3. If a patient of a facility performs hemodialysis for himself or herself at the patient’s residence, the facility shall provide the following services to the patient: (a) Surveillance of the patient’s home adaptation, including provisions for visits to his or her residence; (b) Consultation with a registered nurse, social worker and licensed dietitian; (c) A system for maintaining a record of treatment that ensures continuity of care for the patient; (d) Installation and maintenance of the equipment required to perform the hemodialysis; (e) Testing and appropriate treating of the water used for the hemodialysis; and (f) Ordering of supplies on a continual basis. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012) NAC 449.5475 Continuous ambulatory peritoneal dialysis. ( NRS 449.0302 ) If a facility provides continuous ambulatory peritoneal dialysis for a patient of the facility, the facility shall provide the following services to the patient: 1. Consultation with a registered nurse, social worker and licensed dietitian; 2. A system for maintaining a record of treatment that ensures continuity of care for the patient; and 3. Ordering of supplies on a continual basis. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012) NAC 449.549 Continuous cycling peritoneal dialysis. ( NRS 449.0302 ) If a facility provides continuous cycling peritoneal dialysis to a patient of the facility, the facility shall provide the following services to the patient: 1. Surveillance of the patient’s home adaptation, including provisions for visits to his or her residence; 2. Consultation with a registered nurse, social worker and licensed dietitian; 3. A system for maintaining a record of treatment that ensures continuity of care for the patient; 4. Installation and maintenance of the equipment required to perform the dialysis; and 5. Ordering of supplies on a continual basis. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012) NAC 449.5495 Patient services by contract; laboratory. ( NRS 449.0302 ) 1. If a facility provides services to a patient of the facility by contract, the facility remains responsible for supervising the treatment of the patient and providing adequate care for the patient in accordance with the provisions of NAC 449.501 to 449.5795 , inclusive. 2. If a facility maintains a laboratory for use by the facility, the laboratory must be licensed in accordance with the provisions of chapter 652 of NRS. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) Administration and Personnel NAC 449.550 Governing body. ( NRS 449.0302 ) 1. Each facility shall establish a governing body that is legally responsible for developing and carrying out the policies of the facility regarding the management and operation of the facility. 2. The policies established and carried out pursuant to the provisions of subsection 1 must include, without limitation: (a) The governance of the governing body; (b) The care and safety of the patients of the facility; (c) The general operation of the facility; and (d) The protection of the personal and property rights of each patient of the facility. 3. The governing body shall: (a) Receive and act upon any recommendation submitted to the governing body by a member of the staff of the facility; (b) Appoint a medical director for the facility pursuant to the provisions of NAC 449.5505 ; and (c) Ensure that the facility complies with all state and local statutes, ordinances and regulations that apply to the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5505 Medical director. ( NRS 449.0302 ) 1. The medical director of a facility: (a) Must be certified in nephrology or pediatric nephrology or be eligible for that certification by a board that is approved by the American Medical Association; or (b) During the 5 years immediately preceding July 1, 2001, must have served for at least 12 months as the director of a dialysis program. 2. The medical director shall: (a) Develop objectives for the treatment of patients of the facility based on a review of data assessed through activities conducted at the facility to ensure the quality of the facility; (b) Ensure that each licensed nurse and dialysis technician employed at the facility has received adequate training; (c) Monitor the care and treatment provided to each patient of the facility; and (d) Develop and carry out each policy that the facility is required to establish pursuant to the provisions of NAC 449.501 to 449.5795 , inclusive. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.552 Physicians. ( NRS 449.0302 ) 1. Each patient of a facility must be under the care of a physician who is a member of the medical staff of the facility. 2. If a patient of the facility receives pediatric dialysis at the facility, the treatment provided to the patient must be supervised by a pediatric nephrologist or a pediatrician. If a pediatric nephrologist is not available to serve as the primary physician for the patient, an adult nephrologist may serve as the primary physician for the patient if a direct patient evaluation is prepared by a pediatric nephrologist or a pediatrician at the initiation of care for the patient and annually until the patient reaches 6 years of age. 3. Each patient who receives treatment at the facility must be evaluated at least once each month by a physician who is a member of the medical staff of the facility. If a patient of the facility performs dialysis for himself or herself at the patient’s residence, the patient must be examined by such a physician at least once every 3 months. The record of any examination conducted pursuant to the provisions of this subsection must include evidence of: (a) A monthly assessment concerning any new or recurrent problems; and (b) A review of the adequacy of the treatment provided to the patient. 4. Each facility shall ensure that at least one physician who is a member of the medical staff of the facility is available, in person or by telecommunication, 24 hours each day to patients and members of the staff of the facility. 5. Any order concerning the treatment of a patient of a facility must be prepared in writing and signed by the physician preparing the order. If a physician prepares a routine order for treatment, the order must: (a) Be revised at least annually; and (b) Include a statement indicating the: (1) Duration of treatment; (2) Dialyzer to be used for that treatment; (3) Rate of the flow of blood for the patient during that treatment; (4) Target weight of the patient; and (5) Medications required for the patient, including heparin. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5525 Orientation program for new employees; continuing education. ( NRS 449.0302 ) 1. Each facility shall develop and carry out a program to orient and familiarize each new employee of the facility with: (a) The policies and operation of the facility; and (b) The responsibilities of the position for which the employee is employed by the facility. 2. Each new member of the staff of a facility who will provide care directly to patients of the facility must be allowed a sufficient period to become familiar with the facility. The orientation program provided by the facility for each of those new members must: (a) Be at least 2 weeks in duration, if the new member has experience concerning the performance of dialysis; and (b) Include 2 weeks of training concerning the direct care of patients of the facility, if the new member has no experience concerning the performance of dialysis. 3. If a facility employs a licensed nurse who has no experience concerning the performance of dialysis, the orientation program provided by the facility to that nurse must be at least 6 weeks in duration and must include training in the following subjects: (a) Fluid, electrolyte and acid-base balance; (b) Kidney disease and the treatment of that disease; (c) Dietary management of kidney disease; (d) Principles of dialysis; (e) Dialysis technology; (f) Techniques for performing venipuncture; (g) Care of the dialysis patient; (h) Psychological, social, financial and physical complications of long-term dialysis; (i) Prevention of hepatitis and other diseases; and (j) Risks and benefits of reusing hemodialyzers, if the facility reuses any hemodialyzer in providing treatment to a patient of the facility. 4. Each facility shall ensure that each member of the staff of the facility who provides care to a patient of the facility completes a course of continuing education concerning end-stage renal disease. The course must be at least 5 hours in duration and must be completed annually by each such member of the staff of the facility. The course may be provided by a member of the staff of the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.553 Medical staff: Generally. ( NRS 449.0302 ) 1. Each physician who is a member of the medical staff of a facility must be licensed to practice medicine in this State. 2. The membership of the medical staff of a facility may include a nephrologist or any other physician who has training or demonstrated experience in providing care for a patient who is diagnosed with end-stage renal disease. 3. If a facility employs an advanced practice registered nurse or a physician assistant: (a) The advanced practice registered nurse must be qualified in accordance with the provisions of chapter 632 of NRS; and (b) The physician assistant must be qualified in accordance with the regulations adopted by the Board of Medical Examiners. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5535 Nurses. ( NRS 449.0302 ) 1. Each nurse employed by a facility must be licensed to practice nursing in this State. 2. Except as otherwise provided in subsection 3, each nurse of a facility who is assigned charge responsibilities must: (a) Be a registered nurse; and (b) Have at least 6 months of experience as a nurse in performing hemodialysis or in providing nursing care for a patient with permanent kidney failure. The experience required pursuant to the provisions of this paragraph must be obtained within the 2 years immediately preceding the date on which the nurse is assigned charge responsibilities by the facility. 3. The provisions of paragraph (b) of subsection 2 do not apply to a registered nurse who holds a current certificate in nephrology nursing or hemodialysis issued by a board that is nationally recognized. 4. Each charge nurse of a facility shall: (a) Make daily assignments based on the requirements of each patient of the facility for treatment; (b) Provide immediate supervision of the care provided to each of those patients; (c) Conduct an assessment of a patient of the facility if required by the circumstances concerning the treatment of the patient; and (d) Communicate with the patient’s physician and the social worker and licensed dietitian of the facility concerning the treatment of the patient. 5. If a facility provides training concerning self-care for patients of the facility, a registered nurse who has at least 12 months of experience in performing dialysis and experience in the applicable dialysis modality must: (a) Be responsible for training the patient and each member of the family of the patient who intends to assist the patient in providing care for the patient; and (b) Supervise other members of the staff of the facility who assist in providing that training. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012) NAC 449.555 Dietitians. ( NRS 449.0302 ) Each dietitian employed by a facility must be a licensed dietitian. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012) NAC 449.5555 Social workers. ( NRS 449.0302 ) Each social worker employed by a facility must: 1. Be licensed as a social worker in this State and hold a master’s degree in social work from a graduate school of social work that is accredited by the Council on Social Work Education; or 2. Have worked for at least 2 years as a social worker, 1 year of which was in a facility or transplantation program before September 1, 1976, and have established a consultative relationship with a social worker who has a master’s degree in social work from a graduate school of social work that is accredited by the Council on Social Work Education. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.556 Staff responsible for operating water treatment system. ( NRS 449.0302 ) 1. Each member of the staff of a facility who is responsible for operating the water treatment system of the facility must demonstrate to the satisfaction of the Bureau that he or she understands the risks to patients of exposure to water that has not been treated by the water treatment system. The facility shall, for each of those members, prepare and maintain at the facility a written record of the training provided to those members concerning the safe operation of the water treatment system of the facility. 2. A facility shall not allow a person to repair or replace any component of the water treatment system of the facility unless the person is qualified to repair or replace the component pursuant to the provisions of NAC 449.5565 . If the facility allows a person who is qualified pursuant to those provisions to repair or replace any component of the water treatment system of the facility, the facility shall prepare and maintain at the facility a written record of the training, education and experience of the person. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5565 Staff that repairs or maintains equipment used to provide care to patients. ( NRS 449.0302 ) A facility shall not allow a member of the staff of the facility to repair or maintain any equipment of the facility that is used to provide care to a patient of the facility unless the member has completed a course of instruction and demonstrated competency in repairing or maintaining that equipment. The course must include instruction in the following subjects: 1. The prevention of the transmission of hepatitis through any equipment that is used for dialysis; 2. The requirements for safety of systems that are used to deliver dialysate; 3. The control of bacteria; 4. Standards for water quality; and 5. The repair and maintenance of equipment used for dialysis or other equipment used by the facility to provide care to a patient of the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) Clinical Records NAC 449.558 Preparation and maintenance. ( NRS 449.0302 ) 1. Each facility shall establish a system for preparing and maintaining a clinical record for each patient of the facility. The system must be developed to ensure that the care provided to each patient of the facility is: (a) Completely and accurately documented; (b) Readily available for retrieval by the facility; and (c) Systematically organized to facilitate the compilation and retrieval of information. 2. If the facility maintains any clinical record on microfilm, optical disc or by any other electronic means, the facility shall ensure that the clinical record is available for review by the Bureau within 48 hours after the facility receives a request for the clinical record from the Bureau. 3. All information concerning the medical history or care provided to or treatment received by a patient at the facility must be: (a) Maintained in the clinical record of the patient; and (b) Protected by the facility against theft, loss or damage. 4. Each facility shall establish an area in which to store the clinical records of the facility. The area must be separate from any area of the facility that is used to provide treatment for patients of the facility and must have adequate space for reviewing, dictating, sorting or recording the information included in the clinical records. If a facility uses an optical disc, microfilm or any other electronic means to create or maintain a clinical record, the area used to store the clinical record must have adequate space for transcribing the information created or maintained on the optical disc, microfilm or by any other electronic means. If the facility determines that the clinical record of a patient of the facility is active, the facility shall store the active clinical record at the site of the facility. 5. Each facility shall ensure that: (a) The clinical record of a patient of the facility remains confidential and is retained in accordance with the provisions of NRS 629.051 ; and (b) Each entry or other information that is placed in the clinical record regarding the delivery of care to the patient is not altered without evidence and explanation of that alteration. A signature stamp must not be used to authenticate an entry in the clinical record of a patient of the facility. 6. If a facility determines that a clinical record is inactive, the facility shall store that clinical record. The facility may store the record on microfilm, optical disc or by any other electronic means and may store the clinical record at a location other than at the site of the facility if the facility ensures that: (a) The clinical record remains secure from unauthorized access at that location; and (b) The record is readily retrievable for review by the Division. 7. Each clinical record must include: (a) Information concerning the identity of the patient for whom the clinical record is prepared; (b) Each written notice provided to the patient at the facility and each written consent obtained from the patient at the facility; (c) Each order prepared by a physician at the facility concerning the patient; (d) Each progress note prepared by the facility concerning the patient; (e) A list that specifies all problems incurred concerning the treatment and care of the patient; (f) The physical and medical history of the patient; (g) Each assessment concerning the patient prepared by a registered nurse, social worker or licensed dietitian employed by the facility; (h) The record of each medication administered by the facility to the patient: (1) During treatment at the facility; or (2) For use at his or her residence; (i) The record of each transfusion received by the patient at the facility; (j) Each laboratory report prepared or received by the facility concerning the patient; (k) Each diagnostic study concerning the patient that is ordered by the attending nephrologist; (l) Each appropriate record of hospitalization; (m) Each record of consultation with the patient that is requested by the attending nephrologist; (n) If practicable, the record of creation and revision of access for each dialysis treatment provided to the patient; (o) Each plan prepared by the facility concerning the care of the patient, including the plan developed for the patient pursuant to the provisions of NAC 449.541 and all amendments to that plan; (p) Evidence indicating that the facility has complied with the provisions of NAC 449.501 to 449.5795 , inclusive, concerning the furnishing of educational materials to the patient; (q) Each record of the daily treatment received by the patient at the facility; and (r) A discharge summary, if the patient is discharged from the facility. 8. As used in this section, “progress note” means a note or other written statement that: (a) Is signed and dated by a member of the staff of a facility; and (b) Summarizes the facts concerning the care provided to a patient of the facility and the response of the patient to that care for the period specified in the note or other written statement. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012) NAC 449.5585 Additional requirements. ( NRS 449.0302 ) 1. In addition to the provisions of NAC 449.558 , the clinical record of each patient of a facility must include: (a) An accurate assessment of the progress of the patient, including all changes in the medical status of the patient; (b) The results of each diagnostic test concerning the patient that is requested by the attending nephrologist; (c) Consultation reports; and (d) All unusual occurrences concerning the care and treatment of the patient. 2. Each member of the interdisciplinary team established pursuant to the provisions of NAC 449.541 shall prepare a written record concerning the progress of the patient. The written record must be prepared at least once every 6 months or more often if required by a change in the medical, nutritional or psychosocial condition of the patient. 3. The condition of each patient of a facility and the response of the patient to treatment must be noted on the daily treatment record of the patient. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.559 Medical history and physical examination. ( NRS 449.0302 ) Each facility shall prepare a medical history of each patient of the facility and conduct a physical examination of the patient. The medical history and physical examination must be completed within 30 days before the patient is admitted to the facility or within 2 weeks after he or she is admitted to the facility. Before the patient receives his or her first treatment at the facility, the physician for the patient must notify the charge nurse for the facility of the diagnoses, medications, hepatitis status, allergies and prescription for dialysis of the patient. All information provided by the physician to the charge nurse pursuant to the provisions of this section must be included in the clinical record of the patient. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5595 Transient patients. ( NRS 449.0302 ) 1. The clinical record of each transient patient of a facility must include: (a) Each order for the treatment of the patient at the treating facility; (b) Each laboratory report ordered by the treating facility concerning the patient that is prepared within 30 days after receiving treatment at the treating facility, including hepatitis B antigen status; (c) The most recent patient care plan and treatment records received from the home facility of the patient; and (d) All records received from the home facility concerning the care and treatment of the patient. 2. As used in this section, “transient patient” means a patient of a facility who: (a) Is not a resident of the community in which the facility is located; and (b) Does not receive treatment at the facility for more than 6 weeks. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.561 Discharge or transfer of patients; removal of records. ( NRS 449.0302 ) 1. If a patient of a facility is discharged from the facility, the facility shall, within 30 days after the patient is discharged, prepare a discharge summary concerning the patient. The discharge summary must specify the disposition of the patient and include: (a) A diagnosis of the patient or, if the patient has died, the cause of death; (b) The date of the discharge or, if the patient has died, the date and location of his or her death; (c) If the patient receives a kidney transplant or is relocated, information concerning the kidney transplant or relocation; and (d) If the patient is discharged for a reason other than kidney transplantation or death, the reason for the discharge. 2. All clinical records prepared or maintained by a facility are the property of the facility and must not be removed from the area in which the clinical records are stored except pursuant to a subpoena or order of a court or to preserve the clinical records if a disaster or other emergency occurs at the facility. 3. If a patient of a facility is transferred to another facility, the facility from which the patient is transferred shall provide to the other facility a copy of the clinical record of the patient. The copy of the clinical record must include: (a) The most recent orders for dialysis treatment; (b) The last three records of treatment; (c) The most recent hepatitis status of the patient; (d) The most recent plan of care concerning the patient; and (e) If the patient is transferred to an outpatient facility, the most recent medical history and physical examination of the patient and the assessment of each member of the interdisciplinary team established for the patient pursuant to the provisions of NAC 449.541 . (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5615 Cessation of operation of facility. ( NRS 449.0302 ) If a facility ceases to operate, the facility shall: 1. Ensure the preservation of the clinical records of the facility; and 2. Not more than 30 days after the facility ceases to operate, notify the Bureau in writing of the location of the clinical records of the facility. The written notice must include the name and address of the custodian of the clinical records. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) Dialysis Technicians NAC 449.570 General qualifications; identification to be worn during training; provision of care; requirements to act as preceptor. ( NRS 449.0302 ) 1. A person may not act as a dialysis technician at a facility unless he or she is qualified in accordance with the provisions of NAC 449.5705 to 449.5775 , inclusive. 2. If a dialysis technician receives training in any area of a facility in which treatment is provided to a patient of the facility, the dialysis technician shall, during the period in which he or she is located in that area, wear a tag or similar device that identifies the dialysis technician. The tag or similar device must be worn in a visible manner. 3. Until a dialysis technician becomes qualified in accordance with the provisions of NAC 449.5705 to 449.5775 , inclusive, the dialysis technician may provide care to a patient of a facility only if the care is provided: (a) As part of the training received by the dialysis technician at the facility; and (b) Under the immediate supervision of a registered nurse or preceptor who is assigned for that purpose by the facility. 4. A person shall not act as a preceptor for a facility unless he or she: (a) Is a licensed nurse or dialysis technician who has at least 6 months of experience in performing hemodialysis obtained within the 24 months immediately preceding the date the person becomes a preceptor for the facility; (b) Obtains a recommendation from the supervising nurse of the facility to be a preceptor; and (c) Files with the facility a current written list concerning his or her knowledge and skills that is prepared in accordance with the provisions of NAC 449.5745 . (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5705 Qualification of technician determined to be qualified before July 1, 2001. ( NRS 449.0302 ) 1. If a person completes an orientation program of a facility pursuant to the provisions of NAC 449.5525 and has been determined by the facility to be qualified to provide dialysis treatment before July 1, 2001, the person may qualify as a dialysis technician if he or she: (a) Except as otherwise provided in subsection 2, passes the written examination specified in NAC 449.571 and demonstrates competency by obtaining a written list concerning his or her knowledge and skills prepared in accordance with the provisions of NAC 449.5745 ; or (b) Demonstrates to the satisfaction of an instructor or supervising nurse for the facility that the person is competent to assume the responsibilities of a dialysis technician and obtains from the instructor or supervising nurse a written list concerning his or her knowledge and skills prepared in accordance with the provisions of NAC 449.5745 . 2. In lieu of passing the written examination pursuant to the provisions of paragraph (a) of subsection 1, a dialysis technician who is certified as a dialysis technician by a nationally recognized testing organization may provide a copy of that certification to the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.571 Program of training: Curriculum; duties of instructor; written examinations. ( NRS 449.0302 ) 1. Each program for training a dialysis technician provided by a facility must consist of a written curriculum that specifies the objectives for each portion of the course. 2. The written curriculum must include at least the following subjects: (a) Introduction to dialytic therapies, including: (1) The history of dialysis; (2) Definitions and terminology; (3) Communication skills; (4) Ethics and confidentiality; (5) The multidisciplinary process; (6) The roles of the members of an interdisciplinary team established pursuant to the provisions of NAC 449.541 ; and (7) Information concerning renal organizations and resources; (b) The principles of hemodialysis, including: (1) The principles of dialysis; (2) Access to the circulatory system; and (3) Anticoagulation, local anesthetics and normal saline; (c) Understanding a person who suffers from kidney failure, including: (1) Basic renal anatomy, physiology and pathophysiology; (2) The effect of renal failure on the systems of the body; (3) The symptoms and findings related to the uremic state; (4) The modes of renal replacement therapy, including kidney transplantation; (5) Basic renal nutrition; (6) Basic psychosocial aspects of end-stage renal disease; (7) The medications commonly administered to a patient who is diagnosed with end-stage renal disease, including the manner of administering and the effects of those medications; (8) Confidentiality of the personal and clinical records of a patient of a facility; (9) Professional conduct; (10) The rights and responsibilities of a patient of a facility; and (11) Rehabilitation of a patient of a facility; (d) Procedures relating to dialysis, including: (1) Using aseptic techniques; (2) The technical aspects of dialysis, operation and monitoring of equipment, and the commencement and termination of dialysis; (3) Delivering dialysis treatment adequately and circumstances that may result from inadequate treatment; (4) Observing and reporting the reaction of a patient to treatment; (5) Monitoring glucose and hemoglobin or hematocrit monitoring; (6) Emergency procedures and responses, including cardiopulmonary resuscitation, the management of an air embolism, and the proper response to line separation and hemolysis; (7) External and internal disasters, fire, natural disasters and preparation for an emergency; and (8) Safety, control of quality and improvement of quality; (e) Information concerning devices used for hemodialysis, including: (1) The theory and practice of conventional, high efficiency and high flux dialysis; (2) Dialysate composition, options, indications, complications and safety; (3) Monitoring and safety; and (4) Disinfecting equipment; (f) The treatment of water, including: (1) Standards for water treatment used for dialysis as described in the American National Standard, Water Treatment Equipment for Hemodialysis Applications , adopted by reference pursuant to the provisions of NAC 449.520 ; (2) Systems and devices; (3) Monitoring; and (4) The risk of harm to a patient who uses untreated water; (g) If the facility reuses water, information concerning the reprocessing of water, including: (1) Principles of reuse; (2) Safety, control of quality, standard precautions and water treatment; and (3) Standards for reuse as described in the American National Standard, Water Treatment Equipment for Hemodialysis Applications , adopted by reference pursuant to the provisions of NAC 449.520 ; (h) Providing instruction for a patient of a facility, including: (1) The role of the technician in supporting the goals of the patient concerning education; and (2) The principles of adult education; (i) Safety and the control of infection, including: (1) The risk of harm to a patient from nosocomial infections and from accidents and errors in providing treatment; (2) Standard precautions, aseptic and sterile techniques, and proper handling of a specimen; (3) Basic bacteriology and epidemiology; (4) The risk of harm to an employee of a facility resulting from exposure to blood and chemicals; and (5) Electrical, fire, disaster and environmental safety and hazardous substances; and (j) The assurance and improvement of quality, including: (1) The role of the dialysis technician in activities concerning the assurance of quality; (2) The principles of the assurance and improvement of quality; and (3) The importance of the assurance of quality to ensure that safe dialysis treatments are provided to each patient of the facility. 3. In addition to the requirements set forth in subsection 2, if a dialysis technician intends to assist in providing training or treatment to a patient of the facility who receives peritoneal dialysis, the program of training for the dialysis technician must include the following subjects: (a) The principles of peritoneal dialysis; (b) Sterile techniques; (c) The systems for the delivery of peritoneal dialysis; (d) The symptoms of peritonitis; and (e) The complications of peritoneal dialysis. 4. In addition to the requirements set forth in subsection 2, if a dialysis technician intends to cannulate a dialysis access during the treatment of a patient of the facility or administer normal saline, heparin or lidocaine to that patient, the program of training for the dialysis technician must include the following subjects: (a) Access to circulation, including: (1) Fistula: creation, development, placement of needles and prevention of complications; (2) Grafts: materials used, creation, placement of needles and prevention of complications; and (3) Symptoms to report; (b) Safe administration of medications, including: (1) Identifying the patient; (2) Ensuring the proper administration of medication; (3) Measuring the correct dose; (4) Ascertaining the correct route to administer the dose; and (5) Ensuring the correct time to administer the dose; (c) Administration of normal saline, including: (1) The reasons for administration; (2) Potential complications; (3) The limits of administration; and (4) Information to report and record; (d) Administration of heparin, including: (1) The reasons for administration; (2) The methods of administration; (3) The preparation of an ordered dose; (4) Potential complications; and (5) Information to report and record; and (e) Administration of lidocaine, including: (1) The reasons for administration; (2) The method of administration; (3) The preparation of an ordered dose; (4) Potential complications and risks; and (5) Information to report and record. 5. The instructor of a course of training provided to a dialysis technician shall: (a) Maintain a roster of attendance for each dialysis technician enrolled in the course; and (b) At least once each week during the course, evaluate each dialysis technician enrolled in the course to determine the progress of the dialysis technician in completing the course. 6. Except as otherwise provided in subsection 7, each dialysis technician specified in subsection 5 must complete a written examination. The examination must include each of the subjects specified in subsections 2 and 3. If the dialysis technician intends to cannulate a dialysis access during the treatment of a patient of the facility or administer normal saline, heparin or lidocaine to that patient, the examination must include the subjects specified in subsection 4. To pass the written examination, the dialysis technician must achieve a score of not less than 80 percent on each of the subjects required to be included in the written examination pursuant to the provisions of this subsection. 7. The provisions of subsection 6 do not apply to a dialysis technician who is certified as a dialysis technician by an organization that is approved by the Bureau. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R075-04, 8-5-2004) NAC 449.5715 Program of training: Qualifications of instructors. ( NRS 449.0302 ) Each instructor who provides instruction pursuant to a program of training specified in NAC 449.571 must be: 1. A physician who is qualified as a medical director in accordance with the provisions of NAC 449.5505 ; 2. A registered nurse who: (a) Has at least 12 months of experience in performing hemodialysis obtained within the 2 years immediately preceding the date he or she begins instruction pursuant to the program; and (b) Has provided to the facility a current written list concerning his or her knowledge and skills that is prepared pursuant to the provisions of NAC 449.5745 ; 3. A registered nurse who provides instruction for a course of training for a dialysis technician at an accredited college or university; or 4. A licensed dietitian or social worker who provides instruction within his or her area of expertise. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012) NAC 449.573 Program of training: Certain persons authorized to provide instruction and serve as preceptor. ( NRS 449.0302 ) If a licensed nurse or dialysis technician has at least 1 year of experience in performing hemodialysis and has filed with the facility a current written list concerning his or her knowledge and skills prepared in accordance with the provisions of NAC 449.5745 , the licensed nurse or dialysis technician may: 1. Assist in providing instruction to a dialysis technician at the facility; and 2. Serve as a preceptor at the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5735 Program of training: Required hours. ( NRS 449.0302 ) 1. Except as otherwise provided in subsection 2, each program of training specified in NAC 449.571 must consist of at least 80 hours of education in the classroom and 200 hours of directly supervised clinical training for each dialysis technician who is enrolled in the program. 2. A program of training for a dialysis technician who has experience in providing care directly to a patient of a facility may consist of not less than 80 hours of combined education in the classroom and clinical training if the dialysis technician demonstrates to the satisfaction of the facility that he or she is competent to provide that care. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.574 Committee to review program of training. ( NRS 449.0302 ) Each facility shall appoint a committee to review the training provided pursuant to a program of training specified in NAC 449.571 . The membership of the committee must consist of at least the medical director, supervising nurse and chief technician of the facility. The committee shall: 1. Review the records of each dialysis technician enrolled in the program, including: (a) The results of each examination taken by the dialysis technician pursuant to the provisions of NAC 449.571 ; and (b) Each written list concerning the knowledge and skills of the dialysis technician prepared pursuant to the provisions of NAC 449.5745 ; 2. Receive and consider all comments concerning the dialysis technician submitted to the committee by an instructor or preceptor; and 3. Verify that the dialysis technician has successfully completed the program of training. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5745 Written list concerning knowledge and skills. ( NRS 449.0302 ) The supervising nurse or a registered nurse of a facility who qualifies as an instructor for the facility shall complete a written list to determine the knowledge and skills of each dialysis technician in performing the following activities: 1. Assembling supplies required to provide treatment to a patient of the facility; 2. Preparing dialysate according to procedure and dialysis prescription; 3. Assembling and preparing the dialysis extracorporeal circuit; 4. Securing the correct dialyzer for the patient; 5. Installing and rinsing the dialyzer and all required tubing for the dialyzer; 6. Testing monitors and alarms, conductivity and, if applicable, testing for the presence or absence of residual sterilants; 7. Setting monitors and alarms in accordance with the protocols of the facility and the instructions of the manufacturer of the monitor or alarm; 8. Obtaining predialysis vital signs, weight and temperature of a patient of the facility in accordance with the protocols of the facility and, after obtaining that information, notifying the supervising nurse or registered nurse of all unusual findings; 9. Inspecting the dialysis access of the patient for patency and, after cannulation is performed and heparin is administered, initiating dialysis in accordance with the patient’s prescription, observing universal precautions and reporting all unusual findings to the supervising nurse or registered nurse; 10. Adjusting the rate of the flow of blood in accordance with the protocols of the facility and the prescription of the patient; 11. Calculating and setting the dialysis machine to allow the removal of fluid at a rate established in accordance with the protocols of the facility and the prescription of the patient; 12. Monitoring the patient and equipment during treatment, responding appropriately to the requirements of the patient and to machine alarms, and reporting all unusual occurrences to the supervising nurse or registered nurse; 13. Changing the rate of the removal of fluid, placing the patient in the Trendelenburg position and administering replacement normal saline as directed by: (a) The supervising nurse or registered nurse; (b) An order of a physician; or (c) The protocols of the facility; 14. Documenting all findings and actions in accordance with the protocols of the facility; 15. Describing the appropriate response to: (a) Emergencies relating to dialysis, including, without limitation, cardiac or respiratory arrest, needle displacement or infiltration, clotting, blood leaks or air emboli; and (b) Nonmedical emergencies, including, without limitation, power outages or equipment failures; 16. Discontinuing dialysis and establishing hemostasis, including: (a) Inspecting, cleaning and dressing the dialysis access of the patient in accordance with the protocols of the facility; and (b) Reporting all unusual findings or occurrences to the supervising nurse or registered nurse; 17. Obtaining and recording the temperature, weight and postdialysis vital signs of the patient and reporting all unusual findings to the supervising nurse or registered nurse; 18. Discarding supplies and sanitizing the equipment and treatment chair in accordance with the protocols of the facility; 19. Communicating all emotional, medical, psychological or nutritional concerns of the patient to the supervising nurse or registered nurse; 20. Obtaining current certification in cardiopulmonary resuscitation; and 21. Maintaining professional conduct, good communication skills and confidentiality concerning the care of the patients of the facility. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.576 Peritoneal dialysis: Additional activities required. ( NRS 449.0302 ) In addition to the written list required pursuant to the provisions of NAC 449.5745 , if a dialysis technician who is enrolled in a course of training pursuant to the provisions of NAC 449.571 intends to provide training or treatment for a patient of the facility who receives peritoneal dialysis, each of the following activities must be completed satisfactorily by the dialysis technician: 1. Assisting patients in ordering supplies; 2. Performing an exchange of dialysate by draining and refilling the peritoneal space with dialysate, including procedures for conducting a continuous ambulatory peritoneal dialysis exchange and the commencement or discontinuation of continuous cycling peritoneal dialysis; 3. Observing peritoneal effluent; 4. Recognizing and understanding the appropriate observations to report; 5. Collecting a specimen of dialysate; 6. Performing a change of transfer tubing; and 7. Setting up and operating the equipment required to conduct continuous cycling peritoneal dialysis. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5765 Cannulation or administration of normal saline or heparin: Additional activities required. ( NRS 449.0302 ) In addition to the written list required pursuant to the provisions of NAC 449.5745 , if a dialysis technician who is enrolled in a course of training pursuant to the provisions of NAC 449.571 intends to cannulate a dialysis access of a patient of the facility or administer normal saline and heparin to that patient, each of the following activities must be completed satisfactorily by the dialysis technician: 1. Cannulation, including: (a) Inspecting the dialysis access of the patient for patency; (b) Preparing the skin; (c) Using aseptic techniques; (d) Placing needles correctly; (e) Establishing blood access; (f) Replacing needles; (g) Recognizing the circumstances under which a call for assistance may be required; and (h) Securing needles; 2. The administration of heparin, including: (a) Checking the prescription of the patient; (b) Preparing the dose; (c) Labeling the prepared syringe; (d) Administering the dose; and (e) Observing the patient for complications experienced by the patient; 3. The administration of normal saline, including: (a) Understanding unit protocol; (b) Checking the prescription of the patient; (c) Recognizing signs of hypertension experienced by the patient; (d) Notifying the registered nurse; (e) Administering normal saline; and (f) Rechecking vital signs; and 4. The administration of lidocaine, including: (a) Checking the prescription of the patient; (b) Identifying the correct vial of medication for the patient; (c) Preparing the dose; (d) Administering the dose; and (e) Observing the patient for complications experienced by the patient. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.577 Cannulation or administration of normal saline, heparin or lidocaine: Verification and documentation of competency required. ( NRS 449.0302 ) If a dialysis technician intends to cannulate a dialysis access during the treatment of a patient of the facility or administer normal saline, heparin or lidocaine, the medical director of the facility must, before the dialysis technician performs those tasks at the facility, verify and document whether the dialysis technician is competent to perform those activities. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5775 Documentation of successful completion of program of training; employment by another facility. ( NRS 449.0302 ) 1. A facility shall issue to each dialysis technician who successfully completes a program of training and receives an evaluation of his or her competency provided to him or her by the facility pursuant to the provisions of NAC 449.5705 to 449.5775 , inclusive, a document indicating that the dialysis technician has successfully completed the program of training. 2. Each document issued pursuant to the provisions of subsection 1 must include a statement indicating that the program for which the document is issued satisfies the requirements of NAC 449.5705 to 449.5775 , inclusive. 3. A document issued pursuant to the provisions of subsection 1 may be accepted by any other facility that employs the dialysis technician. The document may be accepted only for 6 months after the date on which the document is issued. If the dialysis technician is employed by any other facility after that date, the dialysis technician shall obtain from the facility that employs the dialysis technician a written list concerning his or her knowledge and skills prepared in accordance with the provisions of NAC 449.5745 . (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.579 Patient care: Technicians must demonstrate certain knowledge and competency. ( NRS 449.0302 ) A dialysis technician who provides care directly to a patient of a facility must demonstrate knowledge of and competency to carry out the responsibilities specified in NAC 449.5705 to 449.5775 , inclusive. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) NAC 449.5795 Prohibited acts. ( NRS 449.0302 ) A dialysis technician of a facility shall not: 1. Initiate the provision of education for any patient of the facility; 2. Alter any treatment that is ordered for a patient of the facility, including shortening the period for providing treatment to the patient; 3. Administer any medication to a patient of the facility other than the administration of normal saline, heparin or lidocaine during the regular course of treatment for the patient; 4. Administer any blood or products of blood to a patient of the facility; 5. Perform a venipuncture other than a venipuncture at the point of access for dialysis; 6. Perform an arterial puncture; or 7. Accept the order of a physician. (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001) PROVISION OF CERTAIN SPECIAL SERVICES REVISER’S NOTE. Ch. 517, Stats. 2021, which replaced provisions of NRS for the licensing of obstetric centers with provisions for the licensing of freestanding birthing centers, contains the following provision not included in NRS: “Sec. 36.5. The regulations adopted by the State Board of Health pursuant to NRS 439.200 and 449.0302 which are codified as NAC 449.6113 to 449.61178 , inclusive, are hereby declared void. In preparing the supplements to the Nevada Administrative Code on or after January 1, 2022, the Legislative Counsel shall remove those regulations.” Open-Heart Surgery NAC 449.612 Definitions. ( NRS 449.0302 ) As used in NAC 449.612 to 449.61256 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.612011 to 449.612017 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health, eff. 8-31-89; A 8-1-91; R107-98, 3-18-99) NAC 449.612011 “Approval” defined. ( NRS 449.0302 ) “Approval” means the approval granted by the Division to a hospital authorizing the hospital to perform open-heart surgery. (Added to NAC by Bd. of Health by R107-98, eff. 3-18-99) NAC 449.612012 “Approved hospital” defined. ( NRS 449.0302 ) “Approved hospital” means a hospital that has obtained approval from the Division to perform open-heart surgery. (Added to NAC by Bd. of Health by R107-98, eff. 3-18-99) NAC 449.612014 “Cardiac surgery” defined. ( NRS 449.0302 ) “Cardiac surgery” means an operation performed on the heart or on the blood vessels connected to the heart in which access to the area of interest is provided by means of an incision in the wall of the thorax or for which the use of a heart-lung bypass machine is required. (Added to NAC by Bd. of Health by R107-98, eff. 3-18-99) NAC 449.612017 “Open-heart surgery” defined. ( NRS 449.0302 ) “Open-heart surgery” means any cardiac surgery requiring the use of a heart-lung bypass machine. (Added to NAC by Bd. of Health by R107-98, eff. 3-18-99) NAC 449.61202 Prerequisites to initial provision of service. ( NRS 449.0302 ) A hospital that desires to provide a new service for the performance of open-heart surgery must make application to the Division requesting approval of the service. A hospital shall not provide such a service until the Division has given its approval in writing. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61204 Form and contents of application for approval to provide service. ( NRS 449.0302 ) 1. The application for approval must include a statement describing: (a) The qualifications of the personnel of the hospital to perform open-heart surgery; (b) The facilities and equipment to be used in performing open-heart surgery; and (c) The manner in which the facilities and personnel of the hospital meet or exceed the requirements of NAC 449.612 to 449.61256 , inclusive. 2. The application must contain a statement by the chief of cardiac service for the hospital that the hospital has the facilities, equipment, personnel, staffing, policies and procedures required to perform surgeries at or above the rate required by NAC 449.61214 . 3. The application must contain a statement by the chief operating officer of the hospital that the hospital is committed to maintaining the support personnel and equipment required to perform surgeries at or above the rate required by NAC 449.61214 . 4. The application must indicate whether the hospital will, if its application is approved, perform open-heart surgery on infants or children. 5. The Division shall prescribe a uniform form of application. (Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99) NAC 449.61206 Notification of applicant upon review of application; site inspection required. ( NRS 449.0302 ) 1. Within 10 days after it receives an application for approval from a hospital, the Division shall notify the hospital, in writing, whether the application is complete. If the application is incomplete, the Division shall inform the applicant which parts of the application are deficient. If the application is complete, the Division shall notify the applicant of the composition of the site inspection team, the date of the team’s visit to the site and the scheduled date for the team to present its findings to the Division. The Division shall notify the applicant of any changes in this timetable as they occur. 2. The application must not be approved by the Division until the findings of the site inspection team verify that the hospital complies with the requirements of NAC 449.612 to 449.61256 , inclusive. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61208 Composition and duties of site inspection team. ( NRS 449.0302 ) The site inspection team: 1. Must be composed of: (a) A cardiothoracic surgeon; (b) A cardiologist; (c) A cardiac intensive care nurse; (d) An administrator of a hospital at which open-heart surgery is currently performed; (e) A surveyor of health facilities from the Division; and (f) If the hospital indicated in its application that it would perform open-heart surgery on infants or children, a pediatric cardiologist. 2. Shall review the service of the hospital for open-heart surgery and make findings concerning: (a) The adequacy of the equipment of the hospital for use in such surgery. (b) Whether the personnel of the hospital meet the requirements of NAC 449.612 to 449.61256 , inclusive. (c) The adequacy of the size of the staff available to perform open-heart surgery at the hospital. (d) The adequacy and appropriateness of the policies and procedures adopted by the hospital relating to the service. (e) Whether the hospital has sufficient facilities, staff and equipment to perform open-heart surgeries at the rate required by NAC 449.61214 . (Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99) NAC 449.6121 Hospital to pay costs of inspection. ( NRS 449.0302 ) The costs incurred in connection with any inspection required by the provisions of NAC 449.612 to 449.61256 , inclusive, must be paid by the hospital affected. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61212 Approval or denial of application; period of validity of approval; cessation of performance of surgeries. ( NRS 449.0302 ) 1. Within 15 working days after it receives the findings of the site inspection team, the Division shall approve or notify the hospital of its intention to disapprove the application. 2. An approval issued pursuant to this section is valid until it is revoked or suspended pursuant to NAC 449.61256 . 3. A hospital that ceases to perform open-heart surgeries shall notify the Division in writing within 30 days after the last surgery is performed. If a hospital has notified the Division in writing that it is ceasing to perform open-heart surgeries and subsequently decides that it desires to begin performing open-heart surgery again, it must reapply for approval pursuant to the provisions of NAC 449.612 to 449.61256 , inclusive. (Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99) NAC 449.61214 Amount of surgery required following approval. ( NRS 449.0302 ) After approval of a service for open-heart surgery is granted, such surgeries must be performed in an approved hospital at the following rates: 1. Not less than 80 operations during the first 12 months after approval. 2. Not less than 150 operations during the second 12-month period after approval. 3. Not less than 200 operations during the third and each succeeding 12-month period after approval. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61216 Provision of patient with preoperative instruction. ( NRS 449.0302 ) On specific orders from the patient’s physician, a cardiac surgical nurse shall provide each nonemergent cardiac surgical patient with preoperative instruction concerning the proposed surgical procedure and the general course of his or her treatment. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61218 Surgical team: Composition; privileges and qualifications of members; participation of qualified nurses. ( NRS 449.0302 ) 1. A surgical team assigned to each open-heart surgery at an approved hospital must be composed of a cardiovascular surgeon who will be the primary surgeon and at least one other person chosen by the primary surgeon who must be a: (a) Cardiovascular surgeon; (b) Vascular surgeon; (c) General surgeon; (d) Person who is authorized by the medical staff of the approved hospital to assist in such surgeries; or (e) A senior surgical resident who is enrolled in a medical training program accredited by the Accreditation Council for Graduate Medical Education. 2. The primary surgeon must be certified or eligible for certification by the American Board of Thoracic Surgery. 3. A person who is authorized to assist in the surgery pursuant to paragraph (d) of subsection 1 must be accorded the privileges of a member of the allied health professions by the medical staff of the approved hospital. The medical staff shall: (a) Establish criteria for authorizing persons to assist in open-heart surgery that are consistent with current professional standards; and (b) Reevaluate those criteria at least once every 2 years. 4. A team of open-heart surgical nurses whose training has been verified by the head nurse shall participate in each operation. 5. As used in this section, “medical staff” means the medical staff organized by an approved hospital pursuant to NAC 449.358 . (Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99) NAC 449.6122 Qualifications of anesthesiologist. ( NRS 449.0302 ) Anesthesia during open-heart surgery at an approved hospital must be administered by an anesthesiologist who: 1. Is certified by or who is eligible for certification by the American Board of Anesthesiologists; and 2. Has special training or experience in the administration of anesthesia in open-heart surgery. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61222 Qualifications of nurse in charge of service. ( NRS 449.0302 ) The registered nurse in charge of the service for open-heart surgery at an approved hospital must: 1. Have not less than 2 years of operating room nursing experience and not less than 1 year of current experience in open-heart surgery; and 2. Be permanently assigned to that service. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61224 Perfusion team: Use required; qualifications; approval of members by surgeon of record. ( NRS 449.0302 ) 1. An approved hospital shall use a perfusion team, which must include a senior perfusionist who is responsible for the supervision of all perfusion services provided by the team. 2. The senior perfusionist must be certified by the American Board of Cardiovascular Perfusionists. The other perfusionists of the heart-lung bypass machine must be certified or eligible for certification by the Board. 3. The senior perfusionist and the other perfusionists must: (a) Be trained in: (1) Aseptic techniques required in an operating room; (2) Perfusion physiology; and (3) The use of monitoring equipment; and (b) Have a general understanding of commonly performed cardiac surgical procedures. 4. The cardiac surgeon of record shall approve each perfusionist involved with the surgeon’s patients as being competent to operate the heart-lung bypass machine properly before allowing that person to operate the machine during open-heart surgery. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61226 Operating rooms: General requirements. ( NRS 449.0302 ) 1. An approved hospital shall maintain two fully equipped operating rooms, one dedicated to and another available for services for open-heart surgery. Each operating room must have a minimum clearance of 400 square feet, exclusive of fixed cabinets and built-in shelves. Entry to the operating rooms must be limited to persons participating in the service. 2. The ventilation and temperature control systems of each operating room must be able to provide a minimum of 15 air changes per hour in the operating room and maintain the air temperature between 70 ° F and 75 ° F, with a relative humidity between 50 and 60 percent. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61228 Operating rooms: Equipment and staff. ( NRS 449.0302 ) 1. Each operating room designated or available for open-heart surgery must be equipped with: (a) A heart-lung bypass machine. (b) Proper suction and plumbing outlets for heat exchangers for the heart-lung bypass machine. (c) An adequate supply of electrical power, including, without limitation, standby emergency electrical power. (d) Surgical instruments. (e) A device to conserve blood. (f) An electronic warmer for blood. (g) Monitors to review the electrocardiogram and the pressure in two channels of blood flow. (h) Operating lights which are sufficiently bright to illuminate the inside of body cavities and sufficiently maneuverable to illuminate two operating fields on a patient simultaneously. (i) A defibrillating apparatus. 2. The operating room must have available: (a) A complete set of pump oxygenator equipment. (b) Facilities and appropriate support personnel for the use of an intra-aortic balloon. 3. Each operating room designated for open-heart surgery must be provided with the number of surgical nurses, technicians and ancillary personnel needed to staff the equipment and stations required in performing general surgical operations. (Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99) NAC 449.6123 Intensive care facility: General requirements. ( NRS 449.0302 ) 1. An approved hospital shall maintain an intensive care facility within the hospital. The facility must: (a) Have accommodations which can isolate patients; (b) Have a sufficient system for controlling temperature to maintain comfortable conditions for the patients and members of the hospital’s staff; and (c) Be equipped to provide continuous electrocardiographic monitoring of each patient in the facility. 2. Each bed in the intensive care facility must be equipped with: (a) Outlets for suction and oxygen; and (b) Adequate lighting for illuminating minor surgical procedures. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61232 Intensive care facility: Staff. ( NRS 449.0302 ) 1. The administration of intensive care units in an approved hospital for patients recovering from or awaiting open-heart surgery must be under the direction of a qualified physician approved by the cardiac surgeon. 2. A nursing supervisor must be permanently assigned to the intensive care units designated for cardiac surgery patients. The supervisor must have not less than 2 years of experience in intensive care nursing and not less than 1 year of current experience in intensive care nursing of patients recovering from open-heart surgery. 3. The nursing supervisor and the surgical team shall: (a) Provide organized training and continuing in-service education to each nurse; and (b) Determine that each nurse is qualified to perform services related to postcardiac surgery, Ê before assigning the nurse without direct supervision to full-time or periodic duty in the intensive care units. 4. One nurse on each shift must be designated as the nurse in charge for the intensive care units. There must be one nurse for not more than two cardiac surgery patients in the intensive care units for the first 24 hours after surgery. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61234 Intensive care facility: Equipment and supplies. ( NRS 449.0302 ) 1. The following equipment must be immediately available to the intensive care facility: (a) A laryngoscope. (b) Endotracheal tubes. (c) Respirators. (d) Hypothermia equipment. (e) Tracheostomy sets. (f) Thoracotomy sets. (g) A board for massaging a closed chest. (h) An external pacemaker. (i) An external defibrillator. (j) Respiratory support equipment. (k) Intravenous drip counters. (l) An intravenous diffusion pump. (m) Equipment which can remotely monitor, record and play back electrocardiographs and count extra systole pulses. (n) An open-heart set with sternal spreader, staple remover, internal defibrillatory paddles, wire cutters and sufficient sutures and clamps. (o) An intra-aortic balloon pump. (p) An ambu bag. 2. There must be a supply of appropriate medicines stored within the intensive care facility. 3. Tele-transmitters and electronic rate counters must be used for patients with heart pacemakers while they are in the intensive care facility. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61236 Orientation and continuing education of personnel. ( NRS 449.0302 ) An approved hospital shall provide, under the direction of the cardiac surgeon, an orientation program and a program of continuing education for surgical nurses, technicians and any personnel who participate in the service for open-heart surgery. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61238 Maintenance of blood bank. ( NRS 449.0302 ) An approved hospital shall maintain a blood bank which operates 24 hours a day under the direction of qualified specialists. These persons must be able to supply blood and blood derivatives to surgical teams assigned to open-heart surgery. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.6124 Maintenance of cardiac catheterization laboratory. ( NRS 449.0302 ) 1. An approved hospital shall maintain a cardiac catheterization laboratory which operates 24 hours a day under the direction of a qualified specialist. 2. The laboratory must be located in the hospital and must have sufficient equipment to perform: (a) Hemodynamic studies; (b) Preoperative elective studies; (c) Postoperative elective studies; and (d) Emergency procedures. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61242 Maintenance of medical laboratory. ( NRS 449.0302 ) An approved hospital shall maintain a medical laboratory which operates 24 hours a day. The laboratory must have sufficient equipment to: 1. Perform standard laboratory tests; 2. Make pH determinations; and 3. Analyze samples for blood-gas and electrolytes. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61244 Maintenance of facilities to perform contrast studies and equipment to review films of operations. ( NRS 449.0302 ) An approved hospital shall maintain: 1. Facilities in which contrast studies of the cardiovascular system may be performed. 2. Film projectors and a proper filing system so that surgeons may review films of cardiac catheterization operations at any time. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61246 Maintenance of registry to record results for each patient. ( NRS 449.0302 ) A registry must be maintained at an approved hospital and used for recording the results of open-heart surgery for each patient. This registry must include or indicate, for each such patient: 1. The patient’s patient identification number. 2. The patient’s race. 3. The patient’s age. 4. The patient’s sex. 5. Any history of hypertension, smoking, diabetes mellitus, cerebrovascular disease, coronary bypass, myocardial infarction, chronic obstructive pulmonary disease or renal disease. 6. The period during which the surgery is performed. 7. The period during which the heart-lung bypass machine is used. 8. The period during which a crossclamp is in place. 9. The patient’s ASA acquity classification. 10. The patient’s New York Heart Association functional classification. 11. A record of any angioplasty performed or thrombolytic therapy. 12. A record of any use of an intra-aortic balloon pump. 13. Whether the patient is an elective, emergency or transfer case. 14. The number of days he or she is intubated. 15. The number of days he or she is in the cardiac surgery unit. 16. The length of the patient’s hospital stay. 17. The location to which he or she is discharged. 18. A record of his or her 30-day follow-up examination. 19. A record of his or her ventricular function (ejection fraction). 20. The description of the surgical procedure and, if applicable, the number of vessels involved and the type of graft (mammary or saphenous). 21. A record of any complications, including: (a) Additional surgery for bleeding; (b) Peri-operative myocardial infarction; (c) Infections of the sternum, leg or intra-aortic balloon pump site; or (d) Stroke. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61248 Maintenance of program to follow recovery of patient. ( NRS 449.0302 ) An approved hospital shall maintain a comprehensive program for following the recovery and progress of the patient toward his or her optimum condition of health. The condition of the patient must be assessed after discharge from the hospital by the surgeon or his or her designee. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.6125 Annual review and inspection of hospital. ( NRS 449.0302 ) Unless the hospital has notified the Division that it has ceased to perform open-heart surgeries, a surveyor of health facilities from the Division shall review each approved hospital annually to verify that the hospital is complying with the provisions of NAC 449.612 to 449.61256 , inclusive. (Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99) NAC 449.61252 Annual inspection of hospital: Assessment of rate of mortality. ( NRS 449.0302 ) 1. As a part of the annual inspection of each approved hospital, the Division shall perform a detailed review of the patient files relating to all mortalities at the hospital. 2. In assessing whether a hospital’s adjusted rate of mortality is acceptable for the purposes of NAC 449.612 to 449.61256 , inclusive, the inspection team shall fully consider, among other things, the age and sex of the patient, the acuity of the patient’s illness and the information contained in the registry maintained pursuant to NAC 449.61246 . 3. As used in this section, “mortality” means the death of any patient who dies within 30 days after undergoing open-heart surgery. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61254 Further review or on-site inspection for failure to comply with provisions or for excessive rate of mortality; notice; plan for compliance. ( NRS 449.0302 ) 1. If the review conducted pursuant to NAC 449.6125 discloses that the hospital is not in full compliance with the provisions of NAC 449.612 to 449.61256 , inclusive, or if a facility’s adjusted rate of mortality, after considering the factors enumerated in NAC 449.61252 , is considered excessive, the Division may, at the expense of the hospital, require: (a) A second review; or (b) An on-site inspection, Ê conducted by one or more of the persons specified in NAC 449.61208 . When the Division has completed its final review or inspection pursuant to this subsection, it shall notify the hospital in writing of the violations and the recommendations for improvements in the hospital’s service made by the person or persons who conducted the review or inspection pursuant to this subsection. 2. Within 30 days after it receives the notice, the hospital shall reply to the Division in writing, indicating the measures to be taken to achieve compliance with the provisions of NAC 449.612 to 449.61256 , inclusive, and to carry into effect the recommendations made by the person or persons who conducted the review or inspection pursuant to subsection 1. 3. If the Division determines that the hospital’s plan is satisfactory, all of the corrective actions proposed by the hospital must be completed within 90 days after the Division has received the plan. After that time, the Division may require another review of the hospital pursuant to NAC 449.6125 or a review or inspection conducted pursuant to subsection 1 of this section. (Added to NAC by Bd. of Health, eff. 8-31-89; A by R107-98, 3-18-99) NAC 449.61256 Denial, suspension or revocation of approval: Grounds; hearing. ( NRS 449.0302 ) 1. The Division may deny, suspend or revoke its approval because of the failure of the hospital affected to comply with any provision of NAC 449.612 to 449.61256 , inclusive. 2. The Division shall advise the hospital affected in writing whenever it intends: (a) To deny an application for approval or for renewal of approval; (b) To revoke approval; or (c) To order a hospital to cease and desist providing services for open-heart surgery. 3. The hospital affected may request a hearing on the proposed action of the Division. The hearing must be conducted in accordance with the procedures set forth in NAC 439.300 to 439.395 , inclusive. (Added to NAC by Bd. of Health, eff. 8-31-89; A by R044-97, 10-30-97) Transplantation of Organs NAC 449.6126 Definitions. ( NRS 449.0302 ) As used in NAC 449.6126 to 449.6127 , inclusive, unless the context otherwise requires: 1. “Approval” means the approval granted by the Division to a hospital authorizing it to provide a service for the transplantation of organs. 2. “Transplantation of organs” means the implantation of one or more organs from the body of a human being into the body of another as a substitute for one or more abnormally functioning organs of the recipient. (Added to NAC by Bd. of Health, eff. 8-31-89; A 8-1-91) NAC 449.61262 Application for approval to provide services. ( NRS 449.0302 ) An application for approval submitted pursuant to NRS 449.087 must include: 1. A statement of the kinds of organs that are to be transplanted; 2. Proof that the hospital is a member of the United Network for Organ Sharing; 3. A letter of commitment from the hospital to accept all patients eligible for the service; 4. A statement signed by the chief operating officer of the hospital that the hospital is committed to providing a service for the transplantation of organs and that an adequate budget will be maintained to ensure that the service is provided continuously for not less than 3 years; 5. A statement signed by the administrator of the hospital that: (a) The hospital will, in testing for histocompatibility in connection with the service, use a laboratory accredited by the American Society for Histocompatibility and Immunogenetics; and (b) The hospital maintains letters of agreement or contracts with one or more members of the Association of Organ Procurement Organizations or hospital-based organizations for the procurement of organs that comply with the standards of ethics and criteria for membership adopted by the Association of Organ Procurement Organizations, except that the hospital is not required to be a nonprofit institution; and 6. If approval for the service is required by NRS 439A.100 , a copy of the letter of approval from the Director of the Department of Health and Human Services. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61264 Evaluation of application for approval. ( NRS 449.0302 ) 1. The Division will evaluate the application to determine whether it conforms with the requirements of NAC 449.6126 to 449.6127 , inclusive. If the Division finds that the application is incomplete, it will inform the applicant which parts of the application are deficient. 2. If the application is found to be complete and in compliance with the provisions of NAC 449.6126 to 449.6127 , inclusive, approval will be given to the hospital, effective for 5 years. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61266 Duties of hospital providing services. ( NRS 449.0302 ) A hospital that provides services for the transplantation of organs shall: 1. Supply the Division with the same information from the patient registry that is provided to the United Network for Organ Sharing, at the time that information is provided. 2. Comply with the representations required by NAC 449.61262 . (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.61268 Revocation of approval. ( NRS 449.0302 ) 1. The Division may revoke its approval if: (a) The hospital fails to comply with any provision of NAC 449.6126 to 449.6127 , inclusive; (b) The United Network for Organ Sharing suspends or terminates the membership of the hospital; or (c) The hospital resigns its membership in the United Network for Organ Sharing. 2. If the Division revokes its approval, the hospital affected may not reapply for approval for 2 years after the date of the revocation. (Added to NAC by Bd. of Health, eff. 8-31-89) NAC 449.6127 Notice of intent to deny application or revoke approval; hearing. ( NRS 449.0302 ) 1. If the Division intends to deny an application for approval or to revoke its approval, it shall so advise the hospital affected in writing. 2. The hospital may request a hearing on the proposed action of the Division. The hearing must be conducted in accordance with the procedures set forth in NAC 439.300 to 439.395 , inclusive. (Added to NAC by Bd. of Health, eff. 8-31-89; A by R044-97, 10-30-97) INDEPENDENT CENTERS FOR EMERGENCY MEDICAL CARE Licensing NAC 449.61302 Limitations on issuance of license. ( NRS 449.0302 ) The Division shall not issue a license to operate an independent center for emergency medical care unless the center: 1. Is located more than 30 minutes by ground transportation from a facility which is licensed to provide a higher level of emergency medical care; and 2. Routinely provides limited emergency medical care or holds itself out to the general public as a facility which provides limited emergency medical care. (Added to NAC by Bd. of Health, eff. 11-1-95; A by R044-97, 10-30-97) NAC 449.61306 Denial of application for license or renewal of license. ( NRS 449.0302 ) An application for a license to operate an independent center for emergency medical care or for the renewal of the license may be denied if the center, employees of the center or equipment within the center do not meet the requirements of NAC 449.61302 to 449.61384 , inclusive, or, in the opinion of the Division, threaten or potentially threaten the health or safety of the general public. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61308 Compliance with regulations; ground for suspension or revocation of license. ( NRS 449.0302 ) For the duration of his or her license to operate an independent center for emergency medical care, a licensee shall continuously maintain the center in compliance with the provisions of NAC 449.61302 to 449.61384 , inclusive. Any violation of those provisions is a ground for the suspension or revocation of the license. (Added to NAC by Bd. of Health, eff. 11-1-95) Administration and Personnel NAC 449.6132 Requirement of governing body; adoption of written rules. ( NRS 449.0302 ) 1. Except as otherwise provided in NAC 449.61322 , each independent center for emergency medical care must have a governing body. The chair of the governing body must be a person who is a principal in the organization of the center with legal authority for the operation of the center. 2. The governing body shall adopt written rules which: (a) Prescribe criteria for the selection of the members and officers of the governing body, their terms of office and duties; (b) Specify the frequency of the meetings of the governing body; (c) Require the annual review and approval of the rules by the governing body; and (d) Require the recordation of the minutes of the meetings of the governing body and provide for the availability of the minutes to all members of the body. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61322 Exception to requirements of governing body. ( NRS 449.0302 ) 1. If the licensee of an independent center for emergency medical care is a physician operator, the center operated by the licensee is not required to have a governing body or an administrator. In the absence of a governing body or an administrator, the licensee is responsible for complying with the provisions of NAC 449.61302 to 449.61384 , inclusive. 2. As used in this section, “physician operator” means any physician or group of physicians: (a) Licensed pursuant to the provisions of chapter 630 or 633 of NRS; and (b) Operating an independent center for emergency medical care. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61324 Standards of care; policy for authentication. ( NRS 449.0302 ) 1. The governing body of an independent center for emergency medical care or, if there is no governing body, the medical director, shall ensure that: (a) Each patient of the center receives care which is supervised by a physician licensed pursuant to the provisions of chapter 630 or 633 of NRS; (b) Each patient of the center has a comfortable and clean environment which protects him or her from injury or accident; (c) At least one physician and one registered nurse are on the premises of the center during all hours of its operation; (d) An annual operating budget and plan for capital expenditures are established; (e) The center is adequately staffed and equipped; and (f) The center maintains documents concerning the qualifications of all consultants under contract with the center and all employees of the center. 2. The governing body or, if there is no governing body, the medical director, shall establish a policy for authentication that: (a) Authorizes the use of rubber stamps and prohibits the use of any stamp by any person other than the person whose signature the stamp represents; (b) Approves a method for identifying the person making an entry in any record or chart; and (c) Requires that the professional title of the person making such an entry and the date of that entry is included with the entry. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61326 Program to review quality of care; contents of program. ( NRS 449.0302 ) Each independent center for emergency medical care shall establish a program to review the quality of care provided at the center. The program must designate which person or group of persons will review the quality of care. The program must include, without limitation, a review of: 1. The documentation in the medical records of a patient which describes the medical care provided to the patient and the results of that care; 2. The time of arrival and the time the patient was seen by a provider of medical care at the center; 3. The medical condition of the patient when he or she was discharged from the center; 4. The appropriateness of the instructions given to the patient upon his or her discharge and the documentation that the patient understood the instructions; and 5. If a patient is transferred to another medical center or facility, the appropriateness of the transfer, the method of transfer, the date and time the transfer was requested and the date and time the patient was discharged from the center. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61328 Integration into local emergency medical system. ( NRS 449.0302 ) Each independent center for emergency medical care shall take all action necessary to ensure that it is integrated into the local emergency medical system for providing treatment for trauma. The integration with the local system must include: 1. The capability to communicate with ambulances, air ambulances, agency vehicles and hospitals in accordance with the local health authority as defined in NRS 450B.077 ; 2. Written agreements with hospitals which are licensed to provide acute medical and trauma care for the transfer of patients; and 3. A system to maintain information on each patient treated at the center which includes the external cause of injury to a patient as classified in the index of international classification of diseases. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.6133 Appointment and responsibilities of administrator. ( NRS 439.200 , 449.0302 ) 1. Except as otherwise provided in NAC 449.61322 , the governing body of an independent center for emergency medical care shall appoint a person to administer the center. The administrator is responsible for: (a) The daily operation of the center; (b) Serving, along with any committee appointed for the purpose of serving, as a liaison between the governing body, the medical staff and all the departments of the center; (c) Reporting the pertinent activities of the center to the governing body at regular intervals; (d) Appointing a person responsible for the center in the absence of the administrator; (e) Planning for the services provided by the center and the operation of the center; and (f) Ensuring that: (1) Each employee who provides care to victims of sexual assault or attempted sexual assault is: (I) Provided training that meets the requirements of subsection 2 not later than 60 days after the date on which the employee commenced his or her employment and at least biennially thereafter; and (II) Evaluated for competency in providing information concerning emergency contraception and prophylactic antibiotics, including, without limitation, possible side effects of using those medications, not later than 30 days after receiving the training required by sub-subparagraph (I) and provided with additional training if the employee is not competent to provide such information; and (2) Evidence of compliance with the requirements of subparagraph (1) is maintained in the personnel file for each employee who is subject to those requirements. 2. The training required by sub-subparagraph (I) of subparagraph (1) of paragraph (f) of subsection 1 must include, without limitation, providing the employee with access to the most current version of the document developed pursuant to paragraph (a) of subsection 1 of NRS 449.1885 and reviewing the document with the employee. (Added to NAC by Bd. of Health, eff. 11-1-95; A by R048-22, 12-29-2022) NAC 449.61332 Employment and duties of medical director. ( NRS 449.0302 ) Each independent center for emergency medical care shall employ a physician to serve as medical director of the center. Except as otherwise provided in NAC 449.61322 , the director is answerable to the governing body for the quality of medical care provided to patients and the ethical and professional practices of the members of the medical staff. The director shall: 1. Create and carry out policies for the care of patients; and 2. Coordinate medical care at the center. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61334 Standards and procedures for selection, treatment and retention of medical staff and members of allied health professions. ( NRS 449.0302 ) 1. Each independent center for emergency medical care shall adopt standards and procedures for: (a) The selection of members of the medical staff of the center; (b) The privileges which will be accorded to members of the medical staff and members of allied health professions who provide services at the center; (c) Appealing the withdrawal or denial of any privilege; and (d) The reappraisal and appointment of each member of the medical staff. 2. A roster which specifies the privileges accorded each member of the medical staff must be kept in the files of the center. 3. Each member of the medical staff shall abide by the rules of the center and NAC 449.61302 to 449.61384 , inclusive. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61336 Rules for organization of medical staff. ( NRS 449.0302 ) The medical staff of an independent center for emergency medical care must be organized under a set of rules approved by the governing body or, if there is no governing body, by the medical director. The rules must include: 1. An outline which describes the organization of the medical staff; 2. A statement concerning the qualifications which a member of the medical staff must possess to practice at the center; 3. A policy concerning the requirements for meetings of the medical staff, including the minimum number of meetings each member of the staff must attend each year; 4. A provision requiring, except in a medical emergency, the informed consent of a patient or his or her legal representative for a surgical procedure; 5. A requirement that if a patient is treated for dental or podiatric care at the center, a physician who is responsible for the medical care of the patient must be in attendance throughout the patient’s care at the center; and 6. A requirement that if any member of an allied health profession provides services at the center, his or her entries on the medical record of a patient must be verified by his or her signature. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61338 Employment and duties of chief nurse; size of on-duty nursing staff; limitation on scope of practice by person who is not registered nurse; oversight of nursing staff. ( NRS 449.0302 ) 1. Each independent center for emergency medical care shall employ a chief nurse who is a registered nurse and is responsible for the supervision and evaluation of the nursing staff and its activities. The chief nurse shall: (a) Establish job descriptions for the nursing staff of the center; (b) Provide for the orientation and training of the nursing staff; (c) Evaluate the performance of the nursing staff; and (d) Assign nurses. 2. A sufficient number of members of the nursing staff must be on duty at all times during the operation of the center to ensure: (a) That proper care is provided to each patient; and (b) The immediate availability of a registered nurse for the care of any patient. 3. A person who is not a registered nurse may be assigned to care for a patient to the extent consistent with his or her education, experience and authorized scope of practice. 4. The governing body or, if there is no governing body, the medical director, shall ensure the adequacy of treatment, medications and care provided by the nursing staff. (Added to NAC by Bd. of Health, eff. 11-1-95) Facilities NAC 449.6135 Design, construction, equipment and maintenance: General requirements; prerequisites to approval for licensure. ( NRS 449.0302 ) 1. An independent center for emergency medical care must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the independent center for emergency medical care and members of the general public. 2. An independent center for emergency medical care shall comply with all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Environmental, health, fire and local building codes, Ê related to the construction and maintenance of the independent center for emergency medical care. If there is a difference between state and local requirements, the more stringent requirements apply. 3. Except as otherwise provided in subsection 4, before any new construction of an independent center for emergency medical care or any remodeling of an existing independent center for emergency medical care is begun, the independent center for emergency medical care must submit building plans for the new construction or remodeling to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 . The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the independent center for emergency medical care. The Bureau shall not approve an independent center for emergency medical care for licensure until all construction is completed and a survey is conducted at the site of the independent center for emergency medical care. 4. An independent center for emergency medical care is not required to submit plans for remodeling to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 if the remodeling is limited to refurbishing an area within the independent center for emergency medical care, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area, and replacing window or wall coverings in the area. (Added to NAC by Bd. of Health, eff. 11-1-95; A by R035-97, 10-30-97; R076-01, 10-18-2001; R070-04, 8-4-2004) NAC 449.61352 Contents of center: Emergency entrance; reception and waiting areas; treatment and examination rooms; space for storage and maintenance of medical records and supplies. ( NRS 449.0302 ) An independent center for emergency medical care must contain: 1. An emergency entrance located at the ground level which: (a) Is sheltered from the weather; (b) Can accommodate a stretcher without rotating the stretcher more than 30 degrees about the longitudinal axis or 30 degrees about the lateral axis; and (c) Is readily identifiable as an entrance and accessible to the general public; 2. A reception area located near the entrance; 3. A waiting area for the general public with toilets, a telephone, a drinking fountain and adequate seating; 4. Treatment rooms which meet the requirements of NAC 449.61354 ; 5. Rooms for the general examination of patients which must: (a) Be at least 80 square feet in area, including at least two and one-half feet of clearance at the foot and at each side of the examination table; (b) Have at least one sink for washing hands; (c) Be near a toilet which is located near the examination room and easily accessible for a person in a wheelchair; and (d) Be easily accessible for a standard size stretcher with sufficient space to transfer a person onto a stretcher without jeopardizing the physical condition of the person; 6. Special examination rooms which must not be smaller in size than the general examination rooms and which are near a toilet which is easily accessible for a person in a wheelchair; 7. Treatment rooms for minor surgery, including cast procedures, which must be: (a) At least 120 square feet in area, and at least 10 feet in length and width; and (b) Located near a toilet which is easily accessible for a person in a wheelchair; and 8. Sufficient space for: (a) Equipment and storage; (b) A clean workroom with a sink for the storage and assembly of supplies for medical procedures; and (c) Storage and maintenance of medical records. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61354 Contents of treatment rooms; accessibility to person in wheelchair. ( NRS 449.0302 ) 1. Each treatment room in an independent center for emergency medical care must contain: (a) Cabinets for the storage of supplies and equipment; (b) A sink for washing hands; (c) A sink for dirty equipment or an area designated for the cleaning and handling of dirty equipment which is separate from the sink for washing hands; (d) A work counter; (e) Sufficient space for a stretcher; and (f) Emergency medical equipment and supplies necessary to perform critical procedures and resuscitation in a cardiopulmonary or traumatic emergency, including, without limitation: (1) A device for monitoring the electrical activity of the heart with the capability of performing manual defibrillation and external cardiac pacing; (2) Equipment for the advanced management of a patient’s airway including a laryngoscope, and blades and endotracheal tubes in sizes for infants, children and adults; (3) A sterile tray with tracheostomy tubes in sizes for infants, children and adults necessary to create an emergency surgical airway; (4) Sterile needles, tubing and other equipment necessary to administer intravenous and intraosseous therapy for infants and children and specialized procedures to stabilize the vital signs of a patient; (5) Apparatus for the suction of an airway with wide-bore tubing and rigid pharyngeal suction tips and assorted sizes of sterile suction catheters; (6) Devices to stabilize a patient’s neck in sizes for infants, children and adults; and (7) A sterile tray and equipment necessary to insert a tube into a patient’s chest, appropriate for the age, size and sex of the patient, for drainage of the chest cavity. 2. Each treatment room must be located near a toilet which is easily accessible for a person in a wheelchair. (Added to NAC by Bd. of Health, eff. 11-1-95) Medical Services and Medical Records NAC 449.6137 Requirement for minimum level of care in certain situations. ( NRS 449.0302 ) Each independent center for emergency medical care shall maintain on its premises, during all hours of operation, the staff, equipment and drugs necessary to provide an initial evaluation and stabilization of a patient of any age whose condition threatens the loss of the patient’s life, any of his or her limbs or his or her functional ability, including, without limitation, the staff, equipment and drugs necessary to enable the center: 1. To perform advanced cardiopulmonary resuscitation; and 2. To provide appropriate diagnostic radiology and clinical laboratory services. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61372 Criteria for denial of care, transfer or discharge of patient; compliance with state and federal laws. ( NRS 449.0302 ) 1. An independent center for emergency medical care shall not deny a person emergency medical care at the center because of the inability of the person to pay unless a physician has evaluated the person and determined that he or she does not have a medical condition which requires emergency medical care. 2. An independent center for emergency medical care shall not transfer or discharge a patient from the center unless the transfer or discharge is appropriate based upon the medical needs of the patient. 3. An independent center for emergency medical care shall comply with all applicable state and federal laws concerning the admission, discharge and transfer of patients. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61374 Laboratory services and reports; procedures for storage and administration of tissue specimens, blood and blood products; agreements with outside blood banks; review of blood transfusions and reactions. ( NRS 449.0302 ) 1. Each independent center for emergency medical care shall maintain or have available adequate laboratory services during all hours of operation provided by a medical laboratory which is licensed pursuant to chapter 652 of NRS to meet the needs of its patients and medical staff. 2. If laboratory services are provided by a laboratory outside the center: (a) The original report of services must be provided by a laboratory which is licensed pursuant to the provisions of chapter 652 of NRS and contained in the medical record of the patient; and (b) The conditions, procedures and availability of work performed by the laboratory must be in writing and available within the center. 3. Each independent center for emergency medical care shall ensure that each laboratory report is promptly filed in the medical record of the patient and that the physician requesting the report is notified of its availability. 4. All laboratory reports of tissue specimens must be signed by a pathologist. The medical staff of an independent center for emergency medical care and a pathologist shall determine whether a tissue specimen requires a macroscopic examination, a microscopic examination, or both. 5. If an independent center for emergency medical care provides for the storage and administration of blood and blood products: (a) The center shall ensure that an authorized physician provides adequate control and supervision of the storage and administration; and (b) The refrigerator for the storage of blood and blood products must: (1) Have an adequate recording thermograph and temperature alarm system; (2) Be regularly inspected; and (3) Be otherwise safe and adequate to prevent the deterioration of the blood and blood products. 6. If an independent center for emergency medical care depends upon outside blood banks for the storage of blood and blood products, the center shall have an agreement with a blood bank which governs the procurement, transfer and availability of blood which is reviewed and approved by: (a) The medical staff of the center; and (b) The administrator and governing body of the center or, if none, the medical director of the center. 7. Each independent center for emergency medical care shall: (a) Provide for the prompt blood typing, cross-matching and investigation of transfusion reactions; and (b) Have a committee of the medical staff of the center review all transfusions of blood and blood derivatives and blood or blood derivative reactions which occur at the center and make recommendations concerning the policies governing these practices. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61376 Program for control of infection. ( NRS 449.0302 ) Each independent center for emergency medical care shall establish a program for the control of infection at the center, including, without limitation: 1. Policies and procedures for the control of infectious agents and diseases; 2. Methods of disposal of blood and bodily fluids; and 3. Methods of treatment of equipment and supplies contaminated with blood and bodily fluids. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61378 Radiological services: Availability; interpretation and reporting of films; storage and retention. ( NRS 449.0302 ) 1. Each independent center for emergency medical care shall provide basic radiological services performed by a person who is certified by the American Registry of Radiological Technologists or a person who has equivalent qualifications. Radiological services must be available during all hours of operation of the center to meet the needs of its patients and medical staff. 2. All X-ray films requested by a physician at an independent center for emergency medical care must be interpreted by a radiologist. The radiologist shall provide a final report for each X-ray film signed by the radiologist which must be filed with the medical record of the patient. A duplicate copy of the report must be kept within the radiology department of the center. Any positive or abnormal results from the X-ray report must be reported to the patient and the physician who requested the X-ray. 3. All X-ray reports and roentgenograms must be preserved or microfilmed for at least the length of time specified in the applicable statute of limitations governing medical malpractice. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.6138 Distribution and administration of drugs and controlled substances. ( NRS 449.0302 ) 1. Each independent center for emergency medical care shall provide for the distribution and administration of drugs in conformance with all federal, state and local laws. A list of the drugs available for use at the center must be maintained. 2. All dangerous drugs and controlled substances distributed at an independent center for emergency medical care must be: (a) Owned by and stored in a licensed pharmacy; or (b) Owned by a licensed physician. 3. If a pharmacy is located on the premises of an independent center for emergency medical care, the pharmacy must be licensed by the State Board of Pharmacy. 4. If a pharmacy is not located on the premises of an independent center for emergency medical care, the center must contain an area for the storage, administration, quality control and dispensing of drugs. The storage area must include locked storage for drugs and double-locked storage for controlled substances, and refrigerated storage for both drugs and controlled substances. Refrigerators for the storage of drugs and controlled substances must be maintained between 36 degrees Fahrenheit and 46 degrees Fahrenheit. Room temperature for the storage of drugs and controlled substances must not exceed 86 degrees Fahrenheit. Facilities for washing hands must be located near the area of distribution. 5. A drug or controlled substance may not be administered at an independent center for emergency medical care without the order of a physician. The order must be entered in the medical record of the patient and signed by the physician. The order must include the name of the drug or controlled substance, the dosage, the time or frequency of administration and if the drug or controlled substance is not to be taken orally, the method of administration. 6. The development and training of the medical staff of an independent center for emergency medical care must include training provided by a pharmacist licensed by the State Board of Pharmacy. The training must include policies and procedures concerning the procurement, storage, repackaging and dispensing of drugs. The distribution of drugs at the center must be physically monitored at least quarterly by a licensed pharmacist, who shall report his or her findings and recommendations to the administrator or medical director of the center. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61382 Medical records: Maintenance; access; authorized release; completion after discharge. ( NRS 449.0302 ) 1. Each independent center for emergency medical care shall maintain medical records in accordance with accepted professional practices for each patient admitted to the center. 2. Only authorized personnel may have access to the medical records. Information contained in a medical record of a patient must not be released without the written consent of the patient or his or her guardian except: (a) As required by law; (b) Under a contract assented to by the patient with a person or entity who has agreed to pay for the medical expenses of the patient; or (c) As otherwise provided by the agreement of admission assented to by the patient. 3. Original medical records must not be removed from an independent center for emergency medical care unless a court of competent jurisdiction authorizes their removal. A medical record may be microfilmed if the record can be legibly reproduced. 4. Each medical record must be protected from loss, destruction and unauthorized use. 5. If a licensee of an independent center for emergency medical care ceases the operation of the center, he or she shall notify the Division of the arrangements made for the safe preservation of and access to the medical records of each patient. 6. The records of each patient discharged from an independent center for emergency medical care must be completed within 30 days after the date of discharge. (Added to NAC by Bd. of Health, eff. 11-1-95) NAC 449.61384 Contents of medical records. ( NRS 449.0302 ) The medical record of each patient of an independent center for emergency medical care must be complete, authenticated, accurate and current. Each medical record must contain the following: 1. A complete identification of the patient, including information on his or her next of kin and the person or agency who is legally or financially responsible for the patient; 2. A statement concerning the admission and diagnosis of the patient; 3. The medical history of the patient; 4. Evidence of any informed consent given by the patient or his or her legal guardian for the care of the patient; 5. Any clinical observation of the patient, including notes of a physician, nurse or any other professional in attendance; 6. Reports of all prescribed tests and examinations of the patient; 7. Confirmation of the original diagnosis or, if the diagnosis changed, the diagnosis at the time of discharge; 8. A summary of the discharge of the patient prepared in accordance with established policy, including any provisions made for the continuing care or follow-up treatment of the patient after his or her discharge; and 9. If the patient has died, the documentation of death and necropsy report, if available. (Added to NAC by Bd. of Health, eff. 11-1-95) FREESTANDING BIRTHING CENTERS NAC 449.61387 Definitions. ( NRS 439.200 , 449.0302 ) As used in NAC 449.61387 to 449.61396 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.613875 , 449.61388 and 449.613885 have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613875 “Birth assistant” defined. ( NRS 439.200 , 449.0302 ) “Birth assistant” means a member of the staff of a freestanding birthing center who performs nonclinical tasks and routine clinical tasks and procedures under supervision. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.61388 “Certified nurse-midwife” defined. ( NRS 439.200 , 449.0302 ) “Certified nurse-midwife” has the meaning ascribed to it in NRS 449.198 . (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613885 “Clinical provider” defined. ( NRS 439.200 , 449.0302 ) “Clinical provider” means a provider on the staff of a freestanding birthing center who is ultimately responsible for the care of a pregnant person, a person who has given birth or a newborn. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.61389 Proof and maintenance of accreditation; maintenance of documents relating to issuance or renewal of accreditation; specification of capacity in application for license. ( NRS 439.200 , 449.0302 ) 1. Except as otherwise provided in subsection 2, a freestanding birthing center shall, not later than 6 months after initial licensure pursuant to NRS 449.080 , submit to the Division proof that the freestanding birthing center holds accreditation as a birth center from the Commission for the Accreditation of Birth Centers, or its successor organization. 2. If the Commission for the Accreditation of Birth Centers, or its successor organization, notifies a freestanding birthing center that the Commission is not able to accredit the freestanding birthing center within the period described in subsection 1, the freestanding birthing center shall: (a) Immediately notify the Division; and (b) Submit to the Division proof of such accreditation not later than 12 months after initial licensure pursuant to NRS 449.040 . 3. A freestanding birthing center shall maintain the accreditation described in subsection 1 for the duration of its operations. If a freestanding birthing center ceases to maintain such accreditation, the freestanding birthing center shall immediately notify the Division. 4. A freestanding birthing center shall maintain for the duration of its operations any material submitted or received as part of an application for the issuance or renewal of the accreditation described in subsection 1, including, without limitation: (a) The application for accreditation; (b) A report from any self-evaluation; (c) Any letter from the Commission for the Accreditation of Birth Centers, or its successor organization, announcing a decision on an application for the issuance or renewal of accreditation; and (d) Any report from the Commission for the Accreditation of Birth Centers, or its successor organization, concerning a site visit. 5. An application for the issuance or renewal of a license as a freestanding birthing center must specify the number of beds in the freestanding birthing center. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613895 Design, construction, equipment and maintenance. ( NRS 439.200 , 449.0302 ) 1. A freestanding birthing center must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the pregnant persons, persons who have given birth and newborns who receive care at the freestanding birthing center, the staff of the freestanding birthing center and members of the general public. 2. A freestanding birthing center must have: (a) Designated parking for pregnant persons and visitors; and (b) At least one parking space reserved for emergency vehicles. 3. Each birth room in a freestanding birthing center must have: (a) An area of at least 100 square feet; (b) At least one window; (c) Only one bed; (d) Sufficient lighting to allow for the safe provision of care; and (e) Except as otherwise provided in this paragraph, a sink and a toilet. A birth room is not required to have a toilet if there is a sink and a toilet in an adjacent room. 4. Each corridor and door in a freestanding birthing center must allow access by emergency medical personnel. Each corridor in a freestanding birthing center must be: (a) At least 36 inches wide if the freestanding birthing center has a maximum occupancy of 50 persons or fewer; or (b) At least 44 inches wide if the freestanding birthing center has a maximum occupancy of greater than 50 persons. 5. A freestanding birthing center must have an automated external defibrillator on the premises. 6. A freestanding birthing center shall procure and maintain batteries sufficient to provide power to operate all emergency lighting and clinical equipment in the freestanding birthing center for at least 2 hours or an electric generator with sufficient fuel to provide such power. The director of the freestanding birthing center shall: (a) Ensure that the batteries or electric generator, as applicable, are serviced regularly; and (b) Maintain records of such service for at least 3 years after the service. 7. A freestanding birthing center must have a specific area for the storage of drugs in accordance with NAC 449.613956 , including, without limitation, locked refrigerated storage and locked storage at room temperature. 8. A freestanding birthing center must have: (a) A dirty work area for cleaning used instruments, equipment and supplies that: (1) Is equipped with a sink and a storage area; and (2) Is separate from all clean storage areas. (b) A clean area for the storage of disinfected or sterile instruments, equipment and supplies. (c) A sufficient number of handwashing or hand sanitizing stations to comply with the policies and procedures adopted pursuant to NAC 449.61391 . 9. A freestanding birthing center that was licensed as an obstetric center before January 1, 2022, and is deemed to be licensed as a freestanding birthing center pursuant to section 36 of Assembly Bill No. 287, chapter 517, Statutes of Nevada 2021, at page 3444 , shall be deemed to be in compliance with the requirements of subparagraph 1 of paragraph (a) of subsection 8. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.6139 Submission of plans for new construction or remodeling; prerequisites to approval of facility for licensure; exception. ( NRS 439.200 , 449.0302 ) 1. Except as otherwise provided in subsection 2, before any new construction of a freestanding birthing center or any remodeling of an existing freestanding birthing center is begun, the freestanding birthing center must submit building plans for the new construction or remodeling to the entity designated by the Division to review such plans pursuant to the provisions of NAC 449.0115 . The review of those plans conducted by the entity is advisory only and does not constitute approval for the licensing of the freestanding birthing center. The Division shall not issue a license to the freestanding birthing center or renew the license of the freestanding birthing center, as applicable, until all construction is completed and a survey is conducted at the site of the freestanding birthing center. 2. A freestanding birthing center is not required to submit plans for remodeling to the entity designated by the Division to review such plans pursuant to the provisions of NAC 449.0115 if the remodeling is limited to refurbishing an area within the freestanding birthing center, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area and replacing window or wall coverings in the area. 3. Before issuing an initial license to a freestanding birthing center, the Division shall conduct an on-site inspection of the freestanding birthing center. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613905 Supply of oxygen; policies and procedures for administration and storage of oxygen. ( NRS 439.200 , 449.0302 ) 1. A freestanding birthing center must have a supply of oxygen, which may include, without limitation, portable oxygen, that is adequate to provide oxygen supplementation to all pregnant persons, persons who have given birth and newborns receiving care at the freestanding birthing center. 2. The director of a freestanding birthing center shall establish policies and procedures for the safe administration and storage of oxygen at the freestanding birthing center. Those policies and procedures must include, without limitation, policies and procedures for the safe storage of portable oxygen in accordance with standards for the safe storage of a medical gas prescribed by a nationally recognized fire protection association or another appropriate nationally recognized organization. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.61391 Policies and procedures for control of infection: Manufacturer’s guidelines; training and evaluation of employees; notification to employees upon revision; supply of personal protective equipment. ( NRS 439.200 , 449.0302 ) 1. A freestanding birthing center shall develop and implement written policies and procedures to be followed by the members of the staff of the freestanding birthing center for the control of infection that are in accordance with nationally recognized guidelines. Acceptable guidelines include, without limitation, the most recent version of the Guidelines for Environmental Infection Control in Health-Care Facilities published by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services. 2. The policies and procedures developed pursuant to subsection 1 must prescribe the procedures for: (a) Hand hygiene; (b) Cleaning and disinfecting surfaces and substances that pose a risk of infection to pregnant persons, persons who have given birth and newborns; (c) The proper use of syringes, needles, vials and lancets; and (d) The proper sterilization and disinfection of all reusable equipment. 3. The director of a freestanding birthing center shall make a copy of the policies and procedures developed by the freestanding birthing center pursuant to subsection 1 available to each member of the staff of the freestanding birthing center. 4. Each member of the staff of a freestanding birthing center shall follow the manufacturer’s guidelines for the use and maintenance of equipment, devices and supplies. The director of a freestanding birthing center shall make the manufacturer’s guidelines for equipment, devices or supplies available to each member of the staff of the freestanding birthing center who uses or maintains the equipment, devices or supplies. 5. A freestanding birthing center shall: (a) Train each member of the staff of the freestanding birthing center who has exposure to pregnant persons, persons who have given birth or newborns, or specimens of such persons, or who participates in the disinfection or sterilization of equipment at the freestanding birthing center on the policies and procedures for the control of infection developed pursuant to subsection 1; and (b) Require a supervisor of each member of the staff described in paragraph (a) to evaluate the member of the staff on his or her knowledge and skills concerning those policies and procedures within 10 working days after beginning his or her service on the staff and at least once each year thereafter. 6. If a freestanding birthing center revises the policies and procedures for the control of infection developed pursuant to subsection 1, the freestanding birthing center shall: (a) Give notice of the change to each member of the staff of the freestanding birthing center who has exposure to pregnant persons, persons who have given birth or newborns, or specimens of such persons, or who participates in the disinfection or sterilization of equipment at the freestanding birthing center; and (b) Train each member of the staff described in paragraph (a) concerning the revised policies and procedures within 10 working days after adopting the revised policies and procedures. 7. A freestanding birthing center shall maintain at least a 14-day supply of personal protective equipment to protect members of the staff of the freestanding birthing center from infectious diseases. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613915 Compliance with certain laws, regulations, codes and ordinances; participation in National Healthcare Safety Network; provision of records to Division. ( NRS 439.200 , 449.0302 ) 1. A freestanding birthing center shall comply with all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; (c) Environmental, health and local building codes; and (d) Fire and safety codes, including, without limitation, those codes relating to ingress and egress of occupants, placement of smoke alarms, fire extinguishers or sprinkler systems and fire escape routes, Ê related to the design, construction and maintenance of the freestanding birthing center. If there is a difference between state and local requirements, the more stringent requirements apply. 2. A freestanding birthing center shall comply with: (a) The provisions of NAC 444.662 and 444.664 governing the storage and disposal of solid waste. (b) All applicable federal and state laws and regulations governing the disposal of hazardous waste and nationally recognized guidelines selected by the director of the freestanding birthing center governing the disposal of hazardous waste. Appropriate guidelines include, without limitation, guidelines prescribed by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services. (c) The provisions of chapter 440 of NRS and chapter 440 of NAC concerning the registration of births and deaths. (d) The provisions of chapter 446 of NRS and chapter 446 of NAC concerning the preparation and storage of food. 3. A freestanding birthing center shall participate in the National Healthcare Safety Network, or any successor in interest to the Network, and comply with the provisions of NRS 439.800 to 439.890 , inclusive, and any regulations adopted pursuant thereto governing the reporting of sentinel events. 4. The director of a freestanding birthing center shall ensure that any laboratory services provided to pregnant persons, persons who have given birth or newborns who are patients at the freestanding birthing center are performed in compliance with all applicable federal and state laws and regulations, including, without limitation: (a) The Clinical Laboratory Improvement Amendments of 1988, Public Law No. 100-578, 42 U.S.C. § 263a; and (b) Chapter 652 of NRS and chapter 652 of NAC. 5. Upon the request of the Division, a freestanding birthing center shall provide to the Division any record maintained by the freestanding birthing center, including, without limitation, any record maintained pursuant to NAC 449.61389 . (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.61392 Adoption of publication by reference; revision of publication after adoption; compliance with adopted standards. ( NRS 439.200 , 449.0302 ) 1. Indicators of Compliance with Standards for Birth Centers is hereby adopted by reference in the form most recently published by the Commission for the Accreditation of Birth Centers, unless the Board gives notice that the most recent revision is not suitable for this State pursuant to subsection 2. A copy of the publication may be obtained at no cost at the Internet address https://birthcenteraccreditation.org/go-get-cabc-indicators/ or, if that Internet website ceases to exist, from the Board. 2. The Board will review each revision of the publication adopted by reference in subsection 1 to ensure its suitability for this State. If the Board determines that a revision is not suitable for this State, the Board will hold a public hearing to review its determination within 12 months after the date of the publication of the revision and give notice of that hearing. If, after the hearing, the Board does not revise its determination, the Board will give notice within 30 days after the hearing that the revision is not suitable for this State. If the Board does not give such notice, the revision becomes part of the publication adopted by reference pursuant to subsection 1. 3. A freestanding birthing center shall: (a) Provide care during labor and delivery, care for newborns and care during recovery; (b) Comply with the standards prescribed in the publication adopted by reference in subsection 1 to the extent those standards do not conflict with the provisions of this chapter and chapter 449 of NRS; and (c) Maintain a copy of the most recent version of the publication adopted by reference in subsection 1 on the premises of the freestanding birthing center and make the copy available to all members of the staff of the freestanding birthing center. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613925 Qualifications of clinical provider; director to maintain personnel file and ensure licensure, certification or registration of employees; staff requirements for delivery and care. ( NRS 439.200 , 449.0302 ) 1. A clinical provider at a freestanding birthing center must be: (a) A physician licensed pursuant to chapter 630 or 633 of NRS; (b) A certified nurse-midwife; or (c) A midwife who meets the requirements prescribed in the publication adopted by reference in NAC 449.61392 for serving on the professional midwifery staff of a freestanding birthing center. 2. The director of a freestanding birthing center shall ensure that the freestanding birthing center maintains a personnel file for each member of the staff of the freestanding birthing center. The personnel file must include, without limitation, a statement of whether the member of the staff to whom the personnel file pertains has received an immunization for COVID-19 and, if the person has not received such an immunization, the reason that the person has not received the immunization. 3. The director of a freestanding birthing center shall ensure that each member of the staff of the freestanding birthing center who performs a task for which a license, certificate or registration is required by title 54 of NRS holds the applicable license, certificate or registration. 4. Each delivery of a newborn at a freestanding birthing center must be attended by at least two members of the staff of the freestanding birthing center approved by the director of the freestanding birthing center to attend a delivery. At least one of those attendants must be a clinical provider who is authorized under federal and state law to possess and administer dangerous drugs. 5. Each pregnant person, person who has given birth or newborn at a freestanding birthing center must be assigned a clinical provider who is primarily responsible for the care of the pregnant person, person who has given birth or newborn, as applicable. 6. A member of the staff of a freestanding birthing center may only provide care that he or she is competent to provide. While care is being provided at a freestanding birthing center, at least one member of the staff of the freestanding birthing center who is competent to provide that care and, except as otherwise provided in subsection 7, is authorized under federal and state law to administer dangerous drugs must be present on the premises of the freestanding birthing center. 7. A member of the staff of a freestanding birthing center who is authorized under federal and state law to administer dangerous drugs is not required to be on the premises of a freestanding birthing center while care is being provided under the circumstances identified in the publication adopted by reference in NAC 449.61392 under which a nonlicensed birth assistant may be the only staff member present. 8. As used in this section, “dangerous drug” has the meaning ascribed to it in NRS 454.201 . (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.61393 Birth assistants: Qualifications. ( NRS 439.200 , 449.0302 ) A birth assistant in a freestanding birthing center must: 1. Hold a certification in basic life support issued by the American Heart Association, or its successor organization, or hold an equivalent certification, and have successfully completed training in the techniques of administering neonatal resuscitation provided through the Neonatal Resuscitation Program of the American Academy of Pediatrics, or any successor to that program; and 2. Have successfully completed: (a) A program of training for birth assistants offered by: (1) A nationally recognized organization for training birth assistants, including, without limitation, the American Association of Birth Centers, or its successor organization; or (2) An accredited college or university; (b) Phase 2: Clinicals as Assistant Under Supervision of the entry-level portfolio evaluation process of the North American Registry of Midwives, or its successor organization; (c) The Clinicals as Assistant Under Supervision component of a program provided by a school accredited by the Midwifery Education Accreditation Council, or its successor organization; (d) A program of supervised training for providers of health care that meets the requirements of NAC 449.61394 ; or (e) A program of training for birth assistants that: (1) Issues a certificate to persons who have successfully completed the program; (2) Is administered by a freestanding birthing center; and (3) Includes, without limitation, training in accordance with an evidence-based curriculum, an assessment of skills and requirements concerning attendance of births outside of a hospital setting. The evidence-based curriculum must include, without limitation, training concerning: (I) Medical terminology; (II) The anatomy and physiology of pregnant persons and newborns; (III) The ability to find, understand and use information and services to inform decisions concerning pregnant persons, persons who have given birth and newborns; (IV) Vital signs; (V) The process of labor and birth; (VI) Care for a person who has given birth and the newborn after birth; (VII) Medications relevant to the practice of a birth assistant; (VIII) Breastfeeding; (IX) Minor deviations from what is normal during labor, birth and the postpartum period; and (X) Major complications during labor. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613935 Birth assistants: Supervision; delegation of tasks; personnel files; prohibited tasks. ( NRS 439.200 , 449.0302 ) 1. A birth assistant at a freestanding birthing center must be supervised at all times by the director of the freestanding birthing center or a clinical provider at the freestanding birthing center. 2. The supervisor of a birth assistant may only delegate to the birth assistant tasks that the birth assistant has been trained and is competent to perform, as documented in the personnel file of the birth assistant pursuant to subsection 3. Such tasks may include, without limitation: (a) Checking vital signs and fetal heart tones; (b) Educating and providing support to pregnant persons and their supporters; (c) Nonclinical tasks, including, without limitation, cleaning, laundry, organization, and ordering and stocking supplies; (d) Assisting clinical providers with required documentation, including, without limitation, the documentation of data relating to vital signs; (e) Assisting pregnant persons or persons who have given birth with activities of daily living, including, without limitation, getting dressed, bathing and mobility; (f) Assisting a clinical provider or other member of the staff of the freestanding birthing center in an emergency; and (g) Ensuring that equipment and supplies are cleaned, disinfected or sterilized, as applicable, in the manner prescribed by the policies and procedures developed pursuant to NAC 449.61391 . 3. The personnel file of a birth assistant who is on the staff of a freestanding birthing center must include, without limitation, a list of the tasks that the birth assistant has been trained and is competent to perform. 4. A birth assistant at a freestanding birthing center shall not render a diagnosis, initiate a treatment, start an intravenous line, perform a pelvic or dilation examination, perform an intravaginal procedure, perform an examination of a newborn, prescribe or administer a drug or perform any other task that a birth assistant is prohibited from performing by the standards prescribed in the publication adopted by reference in NAC 449.61392 . (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.61394 Program of supervised training: Supervision; instruction; policies and procedures. ( NRS 439.200 , 449.0302 ) 1. A program of supervised training for providers of health care offered at a freestanding birthing center: (a) Must be supervised by: (1) A preceptor registered with the North American Registry of Midwives, or its successor organization; (2) A certified nurse-midwife who has been practicing as a midwife for the immediately preceding 3 years; or (3) A physician licensed pursuant to chapter 630 or 633 of NRS who has been practicing in the area of obstetrics for the immediately preceding 3 years. (b) Must include instruction provided in accordance with an evidence-based curriculum concerning: (1) The process of childbirth; (2) Care available in the community for a pregnant person, a person who has given birth and a child before and after birth; (3) Family planning; (4) Laws and regulations governing midwifery; (5) Nutrition during pregnancy and lactation; (6) Breastfeeding; and (7) Skills for clinical midwifery. 2. The director of a freestanding birthing center that offers a program of supervised training for providers of health care shall: (a) Develop policies and procedures to carry out the program; and (b) Review those policies and procedures annually and revise the policies and procedures as necessary. 3. The policies and procedures developed pursuant to subsection 2 must include, without limitation: (a) The number of births that must be attended by a participant in the program as: (1) An assistant under supervision; and (2) The primary clinician under supervision; (b) The number of prenatal examinations, examinations of a newborn and postpartum examinations that must be successfully performed by a participant in the program; (c) A requirement that a participant in the program must: (1) Obtain certification in basic life support issued by the American Heart Association, or its successor organization, or hold an equivalent certification; and (2) Successfully complete training in the techniques of administering neonatal resuscitation provided through the Neonatal Resuscitation Program of the American Academy of Pediatrics, or any successor to that program; and (d) Procedures for an assessment of skills and an evaluation of competency. 4. As used in this section, “program of supervised training for providers of health care” does not include a program of training for birth assistants described in paragraph (e) of subsection 2 of NAC 449.6193. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613945 Establishment of criteria and protocols concerning pregnancy; requirements for birth at birthing center; exception. ( NRS 439.200 , 449.0302 ) 1. The director of a freestanding birthing center shall establish: (a) Criteria for determining whether the risk of a pregnancy is too high for a person to give birth in the freestanding birthing center. Those criteria must align with the risk factors prescribed in the publication adopted by reference in NAC 449.61392 . (b) Protocols for determining whether a pregnant person is progressing normally through active labor. 2. A freestanding birthing center may allow a pregnant person to give birth at the freestanding birthing center if: (a) The pregnant person is eligible to give birth in the freestanding birthing center when evaluated using the criteria established pursuant to paragraph (a) of subsection 1; (b) Except as otherwise provided in subsection 3, the pregnant person is not less than 15 years of age or greater than 40 years of age; (c) The gestational age of the pregnancy is not less than 252 days and not greater than 294 days; (d) There is no medical, obstetric, fetal or neonatal condition that would preclude a safe labor, birth and postpartum period at the freestanding birthing center, including, without limitation: (1) No previous history of major surgery of the uterine wall or more than one previous cesarean birth; and (2) No clinically significant signs or symptoms of: (I) Chronic hypertension with or without medications; (II) Polyhydramnios or oligohydramnios; (III) Abruptio placenta; (IV) Chorioamnionitis; (V) Multiple gestation; (VI) Retardation of intrauterine growth; (VII) Meconium-stained amniotic fluid associated with signs of fetal intolerance of labor; (VIII) Fetal intolerance of labor; (IX) Active substance use disorder; (X) Placenta previa; (XI) Medication dependent diabetes; or (XII) Anemia that is not resolved with treatment; (e) During active labor, the pregnant person does not demonstrate clinically significant signs or symptoms of: (1) Intrapartum hemorrhage; (2) Active herpes simplex II of the genitals; or (3) Malpresentation of the fetus, including, without limitation, breech presentation; (f) The pregnant person is progressing normally through active labor, as determined by the clinical providers of the freestanding birthing center in accordance with the protocols established pursuant to paragraph (b) of subsection 1; (g) The membranes of the pregnant person did not rupture more than 48 hours before the admission of the pregnant person to the freestanding birthing center; (h) The pregnant person shows no evidence of a significant infection for which treatment is beyond the scope of practice of the clinical provider who will be responsible for the care of the pregnant person; and (i) The pregnancy is appropriate for a setting where anesthesia is limited to a local infiltration of the perineum, a pudendal block or the use of nitrous oxide for pain relief during labor. 3. The director of a freestanding birthing center may allow a pregnant person who does not meet the requirements of paragraph (b) of subsection 2 to give birth at the freestanding birthing center if, after reviewing the specific case of the pregnant person, the director determines that it is safe for the pregnant person to give birth at the freestanding birthing center. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.61395 Information to be provided to patient; access of patient to medical record; adoption of procedure for complaint. ( NRS 439.200 , 449.0302 ) 1. A freestanding birthing center shall inform each pregnant person or person who has given birth who seeks care from the freestanding birthing center orally and in writing in a language understood by the person of: (a) The rights prescribed in NRS 449A.100 , 449A.106 and 449A.112 . (b) The provisions of NRS 449.101 to 449.104 , inclusive, and the regulations adopted pursuant thereto. (c) The right to file a complaint with the Division concerning care provided by the freestanding birthing center, including, without limitation, the address and telephone number for filing such a complaint. (d) The risks and benefits of care provided by a freestanding birthing center and the alternatives to such care. The information provided pursuant to this paragraph must be evidence based and obtained from a source that is nationally recognized for research relating to freestanding birthing centers. Acceptable sources include, without limitation, the American Association of Birth Centers, or its successor organization, and the Journal of Midwifery and Women’s Health. 2. In addition to the information prescribed by subsection 1, a freestanding birthing center shall fully inform each pregnant person or person who has given birth who seeks care from the freestanding birthing center orally or in writing in a language understood by the person concerning: (a) The health status of the pregnant person or person who has given birth, as applicable, and the fetus or newborn, including, without limitation, any medical conditions of the pregnant person, person who has given birth, fetus or newborn; and (b) The existence of any known complications or risks of the pregnancy. 3. A freestanding birthing center shall allow a pregnant person or person who has given birth to: (a) Inspect the medical record of the pregnant person or person who has given birth, as applicable, or any portion thereof; and (b) Purchase photocopies of the medical record of the pregnant person or person who has given birth, as applicable, or any portion thereof at a cost of not more than 60 cents per page. 4. The director of a freestanding birthing center shall adopt a procedure by which a person may submit a complaint concerning care provided by the freestanding birthing center or care that was not provided by the freestanding birthing center without discrimination or reprisal. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613953 Exclusions from term “surgery.” ( NRS 439.200 , 449.0302 ) For the purposes of NRS 449.198 , surgery does not include: 1. Episiotomy; or 2. Repair of lacerations sustained during the delivery of a newborn. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.613956 Duties of director relating to drugs and laboratory testing supplies; use of prescribed drug by patient. ( NRS 439.200 , 449.0302 ) 1. The director of a freestanding birthing center shall: (a) Ensure that drugs are administered and stored in the freestanding birthing center in accordance with all applicable federal, state and local laws and regulations; (b) Ensure that drugs are administered and possessed in a freestanding birthing center only by persons authorized under federal and state law to administer or possess, as applicable, those drugs; (c) Ensure that drugs and laboratory testing supplies are stored: (1) In accordance with all applicable federal, state and local laws and regulations; and (2) At the temperature ranges recommended by the manufacturers; (d) Establish a policy to ensure the quality of drugs used and dispensed at the freestanding birthing center; and (e) Establish and maintain a list of drugs that may be administered at the freestanding birthing center and ensure that only drugs on that list are administered in the freestanding birthing center. 2. A patient at a freestanding birthing center may use a drug lawfully prescribed to the patient when the patient is admitted to the freestanding birthing center under the supervision of a clinical provider at the freestanding birthing center who is authorized under federal and state law to possess and administer the drug. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) NAC 449.61396 Death of patient; notification of Division; provision of counseling. ( NRS 439.200 , 449.0302 ) 1. Not later than 24 hours after the death of a pregnant person, a person who has given birth or a newborn at a freestanding birthing center, the director of the freestanding birthing center or a designee thereof shall notify the Division of the death. 2. The director of a freestanding birthing center shall establish a procedure to ensure the provision of appropriate counseling to a member of the staff of the freestanding birthing center, a pregnant person, a person who has given birth or a member of the family of a pregnant person or person who has given birth who is affected by a death at the freestanding birthing center. (Added to NAC by Bd. of Health by R062-21, eff. 9-28-2022) INTERMEDIATE CARE FACILITIES General Provisions NAC 449.614 Definitions. ( NRS 449.0302 ) As used in NAC 449.614 to 449.743 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.617 to 449.659 , inclusive, have the meanings ascribed to them in those sections. (Supplied in codification; A by Bd. of Health by R066-04, 8-4-2004) NAC 449.617 “Administrator” defined. ( NRS 449.0302 ) “Administrator” means a licensee or a person appointed by the licensee who has the responsibility for the management of a facility. [Bd. of Health, Intermediate Care Facilities Reg. § 1.2, eff. 12-5-75] NAC 449.623 “Facility” defined. ( NRS 449.0302 ) “Facility” means an intermediate care facility. [Bd. of Health, Intermediate Care Facilities Reg. § 1.5, eff. 12-5-75] NAC 449.629 “Intermediate care facility as a distinct part of a health and care facility furnishing more than one level of care” defined. ( NRS 449.0302 ) 1. “Intermediate care facility as a distinct part of a health and care facility furnishing more than one level of care” means an intermediate care facility which is an entire unit such as a clearly identifiable ward or contiguous wards, wing, floor or building consisting of all beds and related facilities in the unit and housing all intermediate care residents. It is clearly identified and is licensed by the Division as an intermediate care facility. 2. The distinct part may share such central services and facilities as management services, dietary, maintenance and laundry with other units. [Bd. of Health, Intermediate Care Facilities Reg. §§ 1.1.2 & 1.1.2.1, eff. 12-5-75] NAC 449.632 “Intermediate care facility for persons with an intellectual disability or persons with a developmental disability” defined. ( NRS 449.0302 ) “Intermediate care facility for persons with an intellectual disability or persons with a developmental disability” means a facility which offers specialized services to persons with intellectual disabilities and persons with developmental disabilities. [Bd. of Health, Intermediate Care Facilities Reg. § 1.1.1, eff. 12-5-75] NAC 449.635 “Licensee” defined. ( NRS 449.0302 ) “Licensee” means the person, corporation, partnership, voluntary association, or other public or private organization responsible for the overall operation of an intermediate care facility. [Bd. of Health, Intermediate Care Facilities Reg. § 1.6, eff. 12-5-75] NAC 449.638 “Long-term care facility” defined. ( NRS 449.0302 ) “Long-term care facility” means an intermediate care facility, a skilled nursing facility or a chronic disease hospital. [Bd. of Health, Intermediate Care Facilities Reg. § 1.7, eff. 12-5-75] NAC 449.644 “Mixed facility” defined. ( NRS 449.0302 ) “Mixed facility” means a skilled nursing facility which also admits residents of an intermediate care facility who receive care and services appropriate to their needs. Residents are discriminately assigned to beds in the facility and are not assigned to a distinct part of the facility. [Bd. of Health, Intermediate Care Facilities Reg. § 1.9 eff. 12-5-75] NAC 449.647 “New facility” defined. ( NRS 449.0302 ) “New facility” means an intermediate care facility which is a newly built structure or an intermediate care facility which is under new ownership. [Bd. of Health, Intermediate Care Facilities Reg. § 1.13, eff. 12-5-75] NAC 449.650 “Nursing home” defined. ( NRS 449.0302 ) “Nursing home” means an intermediate care facility or a skilled nursing facility. [Bd. of Health, Intermediate Care Facilities Reg. § 1.10, eff. 12-5-75] NAC 449.653 “Patient in an intermediate care facility I” defined. ( NRS 449.0302 ) “Patient in an intermediate care facility I” means a resident who requires 24-hour supervision under the care of a licensed vocational nurse but needs only periodic professional treatment, observation and evaluation. [Bd. of Health, Intermediate Care Facilities Reg. § 1.1.3, eff. 12-5-75] NAC 449.656 “Patient in an intermediate care facility II” defined. ( NRS 449.0302 ) “Patient in an intermediate care facility II” means a resident who requires 24-hour supervision under the care of a registered nurse. The resident requires observation, evaluation and assistance with personal care continuously. [Bd. of Health, Intermediate Care Facilities Reg. § 1.1.4, eff. 12-5-75] NAC 449.657 “Person with a developmental disability” defined. ( NRS 449.0302 ) “Person with a developmental disability” means a person who has a condition manifested in childhood which is attributable to an intellectual disability, cerebral palsy, epilepsy or other neurological conditions similar to or requiring treatment similar to that required by an intellectual disability. [Bd. of Health, Intermediate Care Facilities Reg. § 1.3, eff. 12-5-75]—(Substituted in revision for NAC 449.620) NAC 449.658 “Person with an intellectual disability” defined. ( NRS 449.0302 ) “Person with an intellectual disability” means a person having a condition of significantly subaverage intellectual functions existing concurrently with deficits in adaptive behavior. The condition manifests itself during the developmental period before the age of 18. [Bd. of Health, Intermediate Care Facilities Reg. § 1.8, eff. 12-5-75]—(Substituted in revision for NAC 449.641) NAC 449.659 “Resident” defined. ( NRS 449.0302 ) “Resident” means a patient in an intermediate care facility. [Bd. of Health, Intermediate Care Facilities Reg. § 1.12, eff. 12-5-75] Licensing NAC 449.668 Provisional licenses. ( NRS 449.0302 ) The Division may issue a provisional license to a facility which: 1. Is in operation at the time of the adoption of new regulations, to provide a reasonable time, not to exceed 1 year from the effective date of the regulations, within which to comply with the new regulations; or 2. Has failed to comply with NAC 449.614 to 449.743 , inclusive, but which is in the process of making necessary changes or has agreed in writing to effect changes within a reasonable time specified by the Division, not to exceed 1 year. [Bd. of Health, Intermediate Care Facilities Reg. § 2.6, eff. 12-5-75; A 12-27-77] Administration and Personnel NAC 449.671 Financing; liability insurance. ( NRS 449.0302 ) 1. Each facility shall: (a) Have a sound plan for financing which assures sufficient funds to provide proper care for residents and to carry out the stated purposes, programs and services; (b) If it is a new facility, have reasonable expectations of sufficient funds to carry it through the first 4 months of operation and be able to furnish evidence to that effect; (c) Maintain a recognized financial accounting and reporting system which fulfills all requirements established by the Commissioner of Insurance pursuant to chapter 449 of NRS. 2. Liability insurance is required in amounts appropriate for the protection of residents, employees, volunteers and visitors to the facility. A certificate of insurance must be furnished to the Division as evidence that the policy is in force. Each insurance policy must contain an endorsement providing for 30 days notice to the Division of Public and Behavioral Health, 4150 Technology Way, Suite 300, Carson City, Nevada 89706, before the effective date of cancellation or the nonrenewal of the policy. [Bd. of Health, Intermediate Care Facilities Reg. §§ 3.9-3.10.2, eff. 12-5-75] NAC 449.674 Administrator: Qualifications. ( NRS 449.0302 ) 1. A facility must be administered by a person licensed in Nevada as a nursing home administrator, except in the case of intermediate care facilities for persons with an intellectual disability or persons with a developmental disability. 2. If a hospital is qualifying as a facility, it must be administered by the administrator of the hospital. 3. The administrator shall have the necessary authority and responsibility for the management of the facility and the implementation of administrative policies. 4. The administrator may be designated as the resident services director pursuant to NAC 449.677 . [Bd. of Health, Intermediate Care Facilities Reg. §§ 5.1-5.3, eff. 12-5-75] NAC 449.677 Employees: General requirements. ( NRS 449.0302 ) 1. A facility must maintain methods of administrative management which assure that: (a) There are on duty, all hours of each day, members of the staff sufficient in number and qualifications to carry out the policies, responsibilities and programs of the facility; and (b) The numbers and categories of personnel are adequate for the number of residents and their particular needs. 2. There must be an orientation program for all new employees that includes the review of all policies of the facility. An educational program must be planned and conducted for the development and improvement of skills of all of the facility’s personnel. Records must be maintained which indicate the content of and participation in all orientation and developmental programs. 3. The administrator or any person on the professional staff of the facility must be designated as resident services director and assigned the responsibility for the coordination and monitoring of the overall plan of care for the residents. 4. The facility must maintain effective arrangements for required institutional services. There must be written agreements with outside resources in those instances where the facility does not employ a qualified professional person to render a required institutional service. The responsibilities, functions, objectives and terms of the agreement with each outside resource must be delineated in writing and signed by the administrator or authorized representative and the outside resource. These services may include physical, occupational or speech therapy and social, dental or dietetic services. 5. A designated member of the staff who is suited by training or experience must be responsible for arranging social services and for the integration of social services with other elements of the overall plan of care. 6. A member of the staff who is qualified by experience or training in directing group activities must be responsible for the program of activities. 7. A designated member of the staff who is suited by training or experience in food management or nutrition must be responsible for planning and supervising menus and meals. 8. The facility must furnish the Division with such information from payroll records as may be requested regarding staffing patterns. [Bd. of Health, Intermediate Care Facilities Reg. §§ 6.1-6.8, eff. 12-5-75] NAC 449.680 Maintenance of evidence of screenings for communicable diseases. ( NRS 439.200 , 449.0302 ) A facility must maintain evidence that each employee or independent contractor of the facility has been screened for communicable diseases as required by NAC 441A.375 . [Bd. of Health, Intermediate Care Facilities Reg. §§ 12.1 & 12.2, eff. 12-5-75]—(NAC A by R048-22, 12-29-2022) NAC 449.681 Employees of facility which provides care to persons with dementia: Continuing education. ( NRS 449.0302 , 449.094 ) 1. Except as otherwise provided in subsection 4, each person who is employed by a facility which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, who has direct contact with and provides care to persons with any form of dementia and who is licensed or certified by an occupational licensing board must complete the following number of hours of continuing education specifically related to dementia: (a) In his or her first year of employment with a facility, 8 hours which must be completed within the first 30 days after the employee begins employment; and (b) For every year after the first year of employment, 3 hours which must be completed on or before the anniversary date of the first day of employment. 2. The hours of continuing education required to be completed pursuant to this section: (a) Must be approved by the occupational licensing board which licensed or certified the person completing the continuing education; and (b) May be used to satisfy any continuing education requirements of an occupational licensing board and do not constitute additional hours or units of required continuing education. 3. Each facility shall maintain proof of completion of the hours of continuing education required pursuant to this section in the personnel file of each employee of the facility who is required to complete continuing education pursuant to this section. 4. A person employed by a facility which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, is not required to complete the hours of continuing education specifically related to dementia required pursuant to subsection 1 if he or she has completed that training within the previous 12 months. 5. As used in this section, “continuing education specifically related to dementia” includes, without limitation, instruction regarding: (a) An overview of the disease of dementia, including, without limitation, dementia caused by Alzheimer’s disease, which includes instruction on the symptoms, prognosis and treatment of the disease; (b) Communicating with a person with dementia; (c) Providing personal care to a person with dementia; (d) Recreational and social activities for a person with dementia; (e) Aggressive and other difficult behaviors of a person with dementia; and (f) Advising family members of a person with dementia concerning interaction with the person with dementia. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) Construction and Operation: Generally NAC 449.685 Design, construction, equipment and maintenance: General requirements; prerequisites to approval of facility for licensure. ( NRS 439.200 , 449.0302 ) 1. A facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the facility and members of the general public. 2. Except as otherwise provided in this section and NAC 449.732 to 449.743 , inclusive: (a) A facility shall comply with the provisions of NFPA 101: Life Safety Code , adopted by reference pursuant to NAC 449.0105 . (b) Any new construction, remodeling or change in the use of a facility must comply with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 , unless the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting the area, replacing the flooring in the area, repairing windows in the area, and replacing window or wall coverings in the area. 3. A facility shall be deemed to be in compliance with the provisions of subsection 2 if the facility is licensed on February 1, 2004, the use of the physical space in the facility is not changed and there are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the public health and welfare. 4. Except as otherwise provided in subsection 5, a facility shall comply with all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Life safety, environmental, health, fire and local building codes, Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply. 5. A facility which is inspected and approved by the State Public Works Division of the Department of Administration in accordance with the provisions set forth in chapter 341 of NRS and chapter 341 of NAC is not required to comply with any applicable local building codes relating to the construction and maintenance of the facility. 6. A facility shall submit building plans for new construction or remodeling to the entity designated to review such plans by the Division of Public and Behavioral Health pursuant to NAC 449.0115 . The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the facility. Before the construction or remodeling may begin, the plans for the construction or remodeling must be approved by the Division of Public and Behavioral Health. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004; A by R122-16, 9-21-2017; R048-22, 12-29-2022) NAC 449.692 Sanitary requirements. ( NRS 449.0302 ) 1. A facility must meet all state and local environmental health standards. 2. The quality and type of food service equipment must be appropriate to the type of food service program and approved by fire and health authorities. 3. Environmental health inspection reports must be on file in the facility and note the date and nature of the correction of any deficiency within a reasonable period following the report not to exceed 3 months. Copies of reports must be sent by the inspector to the Division. 4. Cleaning of the premises and equipment must be performed as needed to protect the health of the residents and staff. The facility must have the necessary cleaning and maintenance equipment with storage facilities and appropriate procedures for regular cleaning and routine maintenance as evidenced by a clean establishment maintained in good repair. Cleaning equipment, cleaning agents, aerosol cans and other hazardous chemical agents must be stored in areas separate from clean linen, food and other supplies and be inaccessible to residents. Dirty linen storage must be separate from the storage of clean linen, food and other supplies. Items for personal use, such as combs, toothbrushes, towels, bar soap and other similar items, must not be used in common. 5. Soap dispensers and individual disposable towels must be provided at all lavatories and bathrooms designated for use by the staff or the public. [Bd. of Health, Intermediate Care Facilities Reg. §§ 11.1-11.4, eff. 12-5-75] NAC 449.695 Laundry requirements. ( NRS 449.0302 ) 1. Adequate facilities must be provided for the proper and sanitary washing and finishing of linen and other washable goods laundered in the intermediate care facility. The laundry must be situated in an area which is separate and apart from any room where food is stored, prepared or served. The laundry area must be well lighted and ventilated, adequate in size for the needs of the facility, maintained in a sanitary manner and kept in good repair. 2. The temperature of water entering the washer must be 140 ° F to 150 ° F (60 ° C to 65 ° C). 3. All soiled linen must be collected and transported to the laundry in washable containers in a sanitary manner. Soiled laundry must not be transported through areas used for preparing or serving food. Soiled linen must be handled and stored in such a manner as to prevent contamination of clean linen. A secure area must be provided for the storage of laundry supplies. 4. Clean linen to be stored, dried, ironed or folded must be handled in a sanitary manner. Clean linen must be transferred, stored and distributed in a sanitary manner. Closets which are conveniently located must be provided on each floor for the storage of clean linen and must not be used for any other purpose. [Bd. of Health, Intermediate Care Facilities Reg. §§ 11.5-11.7.2, eff. 12-5-75] NAC 449.698 Fire inspections; hazardous conditions; operation of other business. ( NRS 449.0302 ) 1. At the time of application for a license and at least annually, all facilities must be inspected by the fire or building authority having jurisdiction to ensure that fire and safety requirements are being met. The Division may request a fire inspection at any time it deems appropriate. 2. No facility may be located where surrounding conditions may be hazardous to the physical or mental well-being of residents. 3. No other business detrimental to the facility may be conducted on the premises. [Bd. of Health, Intermediate Care Facilities Reg. §§ 13.4-13.6, eff. 12-5-75] NAC 449.701 Preparations for emergencies; reporting of fire or disaster. ( NRS 449.0302 ) 1. A facility must have a written and regularly rehearsed disaster preparedness plan for members of the staff and residents to follow in case of fire, explosion or other emergency. 2. There must be written procedures for personnel to follow in an emergency, including: (a) The care of the residents and emergency coverage by physicians; (b) The notification of attending physicians and other persons responsible for the residents; (c) Arrangements for transportation for hospitalization or other appropriate services; and (d) Arrangements to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water. 3. A facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster. [Bd. of Health, Intermediate Care Facilities Reg. §§ 3.6-3.7.3, eff. 12-5-75]—(NAC A by R066-04, 8-4-2004) NAC 449.704 Written policies and procedures for facility; admission agreements; transfer agreements. ( NRS 449.0302 ) 1. A facility must have written policies and procedures available to the members of the staff, residents and the public which govern all areas of services provided by the facility. 2. The policies for the admission, transfer and discharge of residents must assure that: (a) Only those persons are accepted whose needs can be met by the facility directly, in cooperation with community resources or other providers of care with which it is affiliated or has contracts; (b) As changes occur in their physical or mental condition, necessitating service or care which cannot be adequately provided by the facility, residents are transferred promptly to hospitals, skilled nursing facilities or other appropriate facilities; and (c) Except in the case of an emergency, the resident, his or her next of kin, attending physician and the responsible agency, if any, are consulted in advance of the transfer or discharge of any resident, and casework services or other means are utilized to assure that adequate arrangements exist for meeting his or her needs through other resources. 3. An admission agreement may not provide the licensee the right to act in behalf of the resident in legal matters or be given general power of attorney, except in the case of a person remanded to the custody of the Division. 4. The written policies of the facility must set forth the rights of residents, prohibit their mistreatment or abuse, and provide for the registration and disposition of complaints without threat of discharge or other reprisal against any employee or resident. 5. Every facility must have in effect a transfer agreement with one or more hospitals sufficiently close to the facility to make feasible the transfer between them of residents and their records. Any facility which does not have such an agreement in effect but has attempted in good faith to enter into such an agreement with a hospital is considered to have an agreement if it is in the public interest and essential to assuring services for eligible persons in the community. [Bd. of Health, Intermediate Care Facilities Reg. §§ 3.1-3.4.1, eff. 12-5-75] NAC 449.707 Money of residents. ( NRS 449.0302 ) 1. A written account, available to residents and their families, must be maintained on a current basis for each resident with written, signed and dated receipts for: (a) All personal possessions and money received by or deposited with the facility. (b) All disbursements made to or on behalf of the resident. The purpose of the disbursement must be noted on the receipt. 2. Receipts for each resident must be kept in each resident’s personal needs envelope or otherwise safely and systematically filed. 3. A ledger must be maintained for the handling of residents’ personal money. The beginning ledger sheet must be credited with the resident’s money on hand. The ledger must be kept current. Personal needs money is for the exclusive personal use of the resident. The ledger and receipts for each resident must be made available for review upon the request of the Division. 4. If the resident is managing his or her own personal money, the money must be turned over to anyone at the request of the resident. A signed, itemized and dated receipt from anyone receiving the resident’s personal money is required for deposit in the resident’s personal envelope or other file. 5. If a resident is unable to manage his or her own money, there must be legal authority, such as appointment as conservator, guardian or trustee, for a relative or other person to carry out these acts for the resident. 6. Except as otherwise provided in this subsection, no licensee or employee of a facility may accept appointment as guardian, or conservator, of the estate of any resident or become a substitute payee for any payments made to any resident, or accept power of attorney. If a resident is legally determined to be unable to manage his or her money, his or her sole source of money is in the form of monthly benefit checks, and documentary evidence can be produced which shows that efforts to obtain a legal guardian for the resident have failed, this requirement may be waived to the extent that the facility may be the substitute payee on the checks. 7. All money held by the facility on behalf of residents must be maintained in a financial institution in the community where the facility is located in a separate trustee account apart from the operating accounts of the facility and must be clearly designated. Small amounts may be kept on hand by the facility for the incidental personal use of a resident. Upon the death of a resident, a receipt must be obtained from the resident’s personal representative or from a relative who presents an affidavit under the provisions of NRS 146.080 before releasing the balance of the personal needs money. [Bd. of Health, Intermediate Care Facilities, Reg. §§ 3.5-3.5.8.2, eff. 12-5-75] NAC 449.710 Inventory of residents’ belongings. ( NRS 449.0302 ) 1. There must be an inventory of the personal belongings of a resident upon admission which is made a part of the resident’s record and updated as needed. All personal belongings, especially items of clothing, must carry permanent identification of ownership. 2. Provision must be made on the premises for the temporary safe storage of a resident’s valuables. Residents must be encouraged to store their valuables off the premises, such as in a safe-deposit box. Every facility must take appropriate measures to safeguard and account for the personal articles of residents and any cash entrusted to the care or control of the licensee. [Bd. of Health, Intermediate Care Facilities Reg. §§ 3.14-3.15.1, eff. 12-5-75] NAC 449.713 Program requirements. ( NRS 449.0302 ) 1. A facility must maintain arrangements through which medical, dental and remedial services, such as laboratory services or X-ray, required by the resident but not regularly provided within the facility, may be obtained when needed. 2. The facility must provide, according to the needs of each resident, specialized and supportive rehabilitative services either directly or through arrangements with qualified outside resources. 3. These services must be provided under a written plan of care: (a) Based on the attending physician’s orders; (b) Based on an assessment of the resident’s needs; (c) Which is reviewed regularly, noting a resident’s progress; and (d) Which is altered or revised as necessary. 4. Services must be provided in accordance with accepted professional practices by qualified therapists or by qualified assistants or other supportive personnel under appropriate supervision. 5. Areas utilized to provide therapy services must be of sufficient size and appropriate design to accommodate necessary equipment, conduct examinations and provide treatment. 6. The facility must provide social services as needed by the residents either directly or by written arrangement with an outside source. A designated member of the staff who is qualified by training or experience must be responsible for implementing and coordinating social services. A plan for social services must be recorded in the patient’s record and must be periodically evaluated in conjunction with the total plan of care for the resident. 7. The facility must provide a program of activities. 8. A plan for independent and group activities must be developed for each resident in accordance with his or her needs and interests. The program of activities must be incorporated in the overall plan of care for the resident. The program must be reviewed with the participation of the resident at least quarterly and altered as needed. 9. Adequate recreational areas must be provided and sufficient equipment and materials must be available. [Bd. of Health, Intermediate Care Facilities Reg. §§ 4.1-4.4.2.1, eff. 12-5-75] NAC 449.716 Dietary services. ( NRS 449.0302 ) 1. At least three meals or their equivalent must be served daily at regular times with not more than 14 hours between a substantial evening meal and breakfast. A second serving must be provided for those residents who desire one. 2. Therapeutic diet menus must be planned by a licensed dietitian or be reviewed and approved by the attending or staff physician. 3. Menus must be planned and followed to meet the nutritional needs of the residents in accordance with the orders of a physician and, to the extent medically possible, in accordance with the recommended dietary allowances of the Food and Nutrition Board of the Institute of Medicine of the National Academies. Menus must be in writing, planned at least a week in advance, dated, posted and kept on file for 90 days. Any substitutions on a menu must be noted on the written menu so that the menu on file reflects what was actually served. 4. Adequate facilities and equipment for the preparation, serving, refrigeration and storage of food in a sanitary manner must be provided. 5. A facility with more than 10 clients shall: (a) Comply with all applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto; (b) Obtain the necessary permits from the Division; (c) Maintain a report of each inspection concerning the sanitation of the facility for at least 1 year after the date of the inspection; and (d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action. 6. Residents needing special equipment, implements or utensils to assist them when eating must have those items provided. 7. Where a facility operates on the cottage plan, provision must be made for food service that ensures hot, palatable meals. If the cottage plan provides for a central dining area, walkways to the dining area providing protection from the elements must be provided. 8. A qualified professional person must be used as a consultant on meal planning and food service. Four hours of consultation each month is the minimum requirement. A qualified person is: (a) A person who is a licensed dietitian; or (b) A graduate from an accredited college with a major in food and nutrition who has 2 years of supervisory experience in health care institutions or who has participated in a food service supervisor’s course. [Bd. of Health, Intermediate Care Facilities Reg. §§ 8.1-8.7.1.2, eff. 12-5-75]—(NAC A by R066-04, 8-4-2004; R155-10, 12-16-2010; R090-12, 12-20-2012) NAC 449.719 Health services. ( NRS 449.0302 ) 1. A facility must provide health services which assure that each resident receives treatments, medications, diets and other health services as prescribed and planned, all hours of each day. 2. Immediate supervision of the health services of the facility on all days of each week must be provided by a registered nurse employed full-time on all day shifts. The nurse must be licensed to practice in Nevada. In the case of facilities which serve less than 20 intermediate care facility II patients, a licensed practical or vocational nurse may serve as the supervisor of health services, if consultation is provided by a registered nurse, licensed to practice in Nevada, through formal contract, at regular intervals, but not less than 4 hours weekly. Either a registered nurse or a licensed practical or vocational nurse licensed to practice in Nevada must be employed on the night shift on all days of each week. Intermediate care facilities for persons with an intellectual disability or persons with a developmental disability are exempt from this requirement. 3. At least two members of the staff must be on duty and awake at all times to assure prompt, appropriate action in cases of injury, illness, fire or other emergencies. Intermediate care facilities for persons with an intellectual disability or persons with a developmental disability with less than 16 beds are exempt from this requirement. 4. A written health care plan must be developed and implemented by appropriate members of the staff for each resident. The levels of care must be no less than those stated in section 501.3 of Chapter V of the Welfare Division Medicaid Manual . The plan must be reviewed and revised at least quarterly. 5. Nursing services, including restorative nursing, must be provided in accordance with the needs of the residents. 6. Hours for nursing care must be at least 0.25 hours per resident for an intermediate care facility I and at least 1.25 hours per resident for intermediate care facility II. 7. Immediate supervision in an intermediate care facility for persons with an intellectual disability or persons with a developmental disability which is licensed for 16 or more beds must be by a currently licensed registered nurse or licensed practical nurse on all day shifts. Facilities in which a licensed practical nurse serves as the supervisor of health services must contract with a registered nurse for at least 4 hours of weekly consultation. Facilities with not more than 15 beds with residents certified by a physician as not in need of professional nursing services must have a formal contract with a registered nurse to visit as required for minor illnesses, injuries or emergencies. There must be a responsible member of the staff immediately available to all residents at all times. [Bd. of Health, Intermediate Care Facilities Reg. §§ 7.1-7.6.1.1, eff. 12-5-75] NAC 449.722 Pharmaceutical services. ( NRS 449.0302 ) 1. If a facility does not employ a licensed pharmacist, it must have formal arrangements with a licensed pharmacist to provide consultation on methods and procedures for ordering, storage, administration, disposal and recording of drugs and biologicals. 2. Medications administered to a resident must be ordered either in writing or orally by the resident’s attending or staff physician. Oral orders by a physician for prescription drugs must be given only to a licensed nurse, pharmacist or physician. All oral orders for medication must be recorded, signed by the person receiving them and countersigned by the attending physician within 72 hours. 3. Medications not specifically limited as to time or number of doses when ordered must be controlled by automatic stop orders or other methods in accordance with written policies. The attending physician must be notified. 4. Self-administered medication is allowed only with the permission of the attending physician of the resident. 5. The pharmacist and a registered nurse shall review each drug regimen of a resident monthly and shall notify the physician if problems occur or changes are appropriate. 6. Drug regimens must be reviewed quarterly by the attending or staff physician. [Bd. of Health, Intermediate Care Facilities Reg. §§ 9.1-9.5.1, eff. 12-5-75] NAC 449.725 Records. ( NRS 449.0302 ) 1. A facility must maintain an organized system for keeping residents’ records. A resident’s records must be available to professionals and other members of the staff who are directly involved with the resident. The records must be available to representatives of the Division. 2. The record for each resident must include the following: (a) Information, relating to the resident’s identification. (b) Admission data, including past medical and social history. (c) Copies of initial and periodic examinations, evaluations and progress notes. (d) Assessments and goals of each plan of care and modifications to the plan. (e) Discharge summaries. (f) An overall plan of care describing the goals to be accomplished through individually designed activities, therapies and treatments. (g) The plan of care must indicate which professional service or person is responsible for the care or service. (h) Entries describing treatments and services rendered. (i) Medications administered. (j) All symptoms and other indications of illness or injury, including the date, time and action taken regarding each such incident. 3. Records must be adequately safeguarded against destruction, loss or unauthorized use. 4. Records must be retained for a minimum of 3 years following the discharge of a resident. [Bd. of Health, Intermediate Care Facilities Reg. §§ 10.1-10.4, eff. 12-5-75] NAC 449.728 Supervision by physician; volunteers; advertising. ( NRS 449.0302 ) 1. A facility must maintain policies and procedures to assure that each resident’s health and care is under the continuing supervision of a physician who sees the resident as needed and in no case less often than every 60 days unless justified otherwise and documented by the attending physician. 2. Volunteers and volunteer groups may be used to supplement the services and programs of the facility. Volunteers may not be used to provide basic services to residents. 3. Residents may perform such duties and tasks as are consistent with their plans of care. 4. Advertising and promotional materials must be accurate and must not misrepresent accommodations, services or programs offered by the facility. [Bd. of Health, Intermediate Care Facilities Reg. §§ 3.8, 3.11-3.13, eff. 12-5-75] Construction and Operation: Facilities for Persons With an Intellectual Disability or Persons With a Developmental Disability NAC 449.732 Definitions. ( NRS 449.0302 ) As used in NAC 449.732 to 449.743 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.7322 and 449.7324 have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7322 “Facility” defined. ( NRS 449.0302 ) “Facility” means an intermediate care facility for persons with an intellectual disability or persons with a developmental disability with 17 or more beds. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7324 “New facility” defined. ( NRS 449.0302 ) “New facility” means a facility which is newly built or a facility which is under new ownership. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7326 Standards for construction, remodeling or change in use of facility; fire alarms; emergency radio system; submission and approval of building plans. ( NRS 449.0302 ) 1. The construction of a new facility or the remodeling or change in use of an existing facility must be in accordance with the most recently adopted local building codes and NFPA 101: Life Safety Code adopted by reference pursuant to NAC 449.0105 . 2. Fire alarms must be manually operated and connected to an electrically supervised system. Each alarm signal must be coded to indicate the location of the station of origin. 3. The facility must contain a device for emergency radio communications to be prepared for disasters. 4. The radio system must be self-sufficient in an emergency and be capable of operation without reliance on the building’s service or the emergency power system. The radio system must be linked with state and community communication networks. 5. Building plans for the construction of a new facility, for remodeling or for the change in use of an existing facility must be submitted to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 . The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the facility. 6. The Division shall not approve the plans for licensing until all construction has been completed and a survey is conducted at the site. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7328 Elevators. ( NRS 449.0302 ) 1. All facilities with services for patients or bedrooms located on floors other than the floor of the main entrance must have elevators. 2. At least one elevator of the type used in hospitals must be provided if 1 to 59 patients are located on floors other than the floor of the main entrance. Two elevators must be provided if 60 to 200 patients are located on floors other than the floor of the main entrance. Three elevators must be provided if 201 to 350 patients are located on floors other than the floor of the main entrance. For facilities with more than 350 beds, the number of required elevators will be determined by a study of the plan of the hospital and the estimated need for vertical transportation. 3. The cars of the elevators must have inside dimensions that will accommodate a patient’s bed and attendants and must be at least 5 feet (1.52 meters) wide and 7 1/2 feet (2.29 meters) deep. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.733 Electrical systems. ( NRS 449.0302 ) 1. All electrical installations and systems must be tested to show that the equipment is installed and operates as planned or specified. A written record of tests on electrical systems and equipment must be supplied to the owner. 2. All spaces occupied by people, machinery and equipment within buildings, approaches to buildings and parking lots must have lighting. Rooms for patients must have general lighting. All switches for lighting in patient areas must operate quietly. 3. If fuel is stored for an emergency generator, the storage capacity must be sufficient for at least 24 hours of continuous operation. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7332 Mechanical systems. ( NRS 449.0302 ) 1. Before the completion and acceptance of a facility, all mechanical systems must be tested, balanced and operated to demonstrate to the owner or his or her representative that the installation and performance of the systems conform to the requirements of the plans and specifications. 2. The owner must be furnished with a complete set of operating maintenance and preventative maintenance instructions and parts listed with numbers and descriptions for each piece of equipment. 3. Facilities must be built and maintained in accordance with NFPA 101: Life Safety Code adopted by reference pursuant to NAC 449.0105 . 4. All air supply and air exhaust systems must be mechanically operated. 5. Hot water must be: (a) Maintained at a temperature of: (1) Not more than 125 ° F (52°C) for clinical use; (2) Not more than 180 ° F (82 ° C) for dishwashing; (3) Not more than 110°F (43°C) for toilet, bath and shower areas and any lavatories equipped for washing hands which are used by patients; and (4) At least 150 ° F (66 ° C) for use in the laundry. (b) Provided with at least 25 pounds of pressure. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7334 Doors, windows, ceilings, walls and floors. ( NRS 439.200 , 449.0302 ) 1. All rooms for occupancy by patients must be equipped with doors and hardware which permit access from the outside in any emergency. 2. The minimum width of all doors to those rooms must be 3.66 feet (111.7 centimeters). Doors to the toilet rooms of patients and other rooms needing access for wheelchairs must have a minimum width of 3 feet (91.44 centimeters). Doors opening onto corridors must not swing into the corridor unless they lead to spaces that are not occupied. 3. Windows and outer doors which may frequently be left open must be provided with screens for protection against insects. 4. Safety glass or plastic glazing materials must be used for shower doors, bath enclosures and in doors and windows of rooms for patients. 5. The height of a ceiling must be 8 feet (2.44 meters) in rooms which are occupied. Ceilings in storage rooms, corridors, toilet rooms and other minor rooms may have a height of 7.5 feet (2.29 meters) but may not have any projection lower than 7 feet (2.13 meters). 6. Flooring materials must be easily cleaned and maintained in good repair. Floors in areas subject to wet cleaning must not be physically affected by germicidal and cleaning solutions. Nonslip surfaces must be provided for areas subject to traffic while wet. Wall bases in kitchens and operating and delivery rooms must be integrated with the floor. 7. Wall finishes must be washable. Walls around plumbing fixtures must be resistant to moisture. Walls and floors must be free from cracks and holes. 8. Ceilings must be easily cleaned. Areas for preparing food must have ceilings which cover all overhead piping and ductwork. Acoustical ceilings must be provided in corridors in patient areas, nurses’ stations, dayrooms, dining areas and waiting rooms. If acoustical ceilings cannot be provided, other methods of eliminating excessive noise and echoing must be used. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004; A by R048-22, 12-29-2022) NAC 449.7336 Entrances and lobbies; miscellaneous space. ( NRS 449.0302 ) 1. The entrance to administrative and public areas must be at grade level, sheltered from the weather and capable of accommodating wheelchairs if no other access for wheelchairs is available. 2. The lobby must include a reception or information counter, waiting space for the public, toilet facilities, public telephones, a drinking fountain and storage space for wheelchairs. 3. The area used for interviews must be conveniently available to the lobby. 4. A space for a business office, a multipurpose room and adequate storage space must be provided. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7338 Dining and storage space. ( NRS 449.0302 ) 1. Dining space of 15 square feet (1.39 square meters) per seated person must be provided for ambulatory patients, staff and visitors. 2. Storage space must be provided for housekeeping equipment and supplies. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7342 Facilities for employees and volunteers. ( NRS 449.0302 ) In addition to the facilities for employees required in certain departments, all employees and volunteers must have lockers, lounges and toilets to accommodate their needs. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7344 Areas for engineering and maintenance. ( NRS 449.0302 ) 1. A room or separate building for boilers, mechanical equipment and electrical equipment must be provided. 2. An area for an engineer’s office and maintenance shop must be provided. 3. A toilet and emergency shower must be provided in the engineering area. 4. Storage for supplies for the maintenance of the building must be provided. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7346 Janitors’ closets. ( NRS 449.0302 ) 1. In addition to the janitors’ closets required in certain departments, janitors’ closets must be provided throughout the facility to maintain a clean and sanitary environment. 2. At least one janitors’ closet must be provided for each nursing unit and for each floor. 3. A janitors’ closet must contain a floor receptor or service sink and storage space for housekeeping equipment and supplies. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7348 Linen service. ( NRS 449.0302 ) 1. If linen is processed at the facility, there must be equipment which can process a 7-day supply within a regularly scheduled workweek. 2. There must be a room for receiving, holding and sorting soiled linen, with facilities for washing hands immediately available. An area for storing clean linen must be provided. Areas for inspecting, mending and issuing clean linen must be provided. Storage areas for laundry supplies must be provided. 3. If linen is processed outside the facility, only a holding room for soiled linen and a storage room for receiving, holding and inspecting clean linen need to be provided. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.735 Area for medical records. ( NRS 449.0302 ) An area for working on and storing medical records must be provided. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7352 Nursing units. ( NRS 449.0302 ) 1. Nursing units must be limited to 60 beds. The maximum room capacity is two patients. 2. The minimum area for a room, exclusive of toilet rooms, closets, lockers, wardrobes and vestibules of less than one-half of the width of a room, is 100 square feet (9.29 square meters) in rooms with one bed and 80 square feet (7.43 square meters) per bed in multibed rooms. In multibed rooms, there must be at least 3.66 feet (1.12 meters) of clear area at the foot of each bed and at least 5 feet (1.5 meters) of clear area between each bed. No more than two beds may be beside one another, parallel to the wall with a window. 3. Each patient must have access to a toilet and lavatory without entering the general corridor. One toilet and lavatory may serve no more than four beds and no more than two patients’ rooms. 4. Each patient must have a wardrobe, locker or closet with clear internal dimensions of at least 1.83 feet (55.9 centimeters) by .83 feet (25.4 centimeters) with a shelf and enough vertical height to hang full-length garments. 5. A patient’s room must not be located more than 120 feet (36.58 meters) from: (a) The nurses’ station; and (b) The clean and soiled workrooms. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7354 Service areas. ( NRS 449.0302 ) 1. Space must be provided at the nursing station for charting, communication systems and necessary equipment and storage. 2. Lavatories and toilets for the staff must be conveniently located near the nursing station. 3. A clean workroom must be provided for the storage and assembly of supplies for nursing procedures. The room must contain a work counter and a sink equipped with blade-type faucets. 4. A soiled workroom must be provided and contain a clinical sink, work counter and receptacles for waste and soiled linen. 5. A medicine room conveniently located near the nursing station must contain a sink equipped with blade-type faucets, a refrigerator, locked storage and facilities for the preparation and dispensing of medication. A double-locked area must be provided for controlled substances. The clean workroom and medicine room may be combined. The medicine room may be a self-contained cabinet located in the clean workroom. 6. A nourishment station or carts for supplying nourishment and ice to the patients must be provided. 7. A bathtub or shower must be provided at the rate of one for each 12 beds which are not otherwise served by bathing facilities within the patients’ rooms. Each central bathing tub or shower must be in a room or enclosure which provides space for private use of the bathing fixture, drying and dressing. The tub and shower must have a nonskid floor. At least one bathing area on each floor must have space for a wheelchair and an attendant. A toilet must be accessible from each central bathing area without entering a general corridor. This toilet may be used as a training toilet. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.7356 Processing of waste. ( NRS 449.0302 ) Space and facilities must be provided for the sanitary storage and disposal of waste by mechanical destruction, compaction, containerization or removal by a combination of these techniques. (Added to NAC by Bd. of Health by R066-04, eff. 8-4-2004) NAC 449.736 Personnel. ( NRS 449.0302 ) 1. A facility for persons with an intellectual disability or persons with a developmental disability must be administered by a person with sufficient authority and responsibility to manage the facility and implement administrative policy. The administrator must be a currently licensed nursing home administrator, a qualified professional in intellectual disabilities or a hospital administrator if a hospital is qualifying as an intermediate care facility for persons with an intellectual disability or persons with a developmental disability. 2. A qualified professional in intellectual disabilities must be one of the following: (a) A psychologist with at least a master’s degree from an accredited program with specialized training or 1 year of experience in treating persons with intellectual disabilities; (b) A currently licensed physician or osteopath with the training or experience described in paragraph (a); (c) An educator with a degree from an accredited program with the training or experience described in paragraph (a); (d) A social worker with either a bachelor’s degree in social work or a bachelor’s degree in a field other than social work and with the training or experience described in paragraph (a); (e) A qualified physical or occupational therapist with the training or experience described in paragraph (a); (f) A speech-language pathologist or audiologist with the training or experience described in paragraph (a); (g) A registered nurse with the training or experience described in paragraph (a); or (h) A therapeutic recreational specialist who is a graduate of an accredited program and with the training or experience described in paragraph (a). 3. Each facility shall retain a qualified professional in intellectual disabilities who is responsible for: (a) Supervising the implementation of each resident’s plan of care; (b) Integrating the facility’s total program; (c) Recording each resident’s progress; and (d) Initiating a quarterly review of each resident’s plan of care. [Bd. of Health, Intermediate Care Facilities Reg. §§ 16.2-16.4.4, eff. 12-5-75]—(Substituted in revision for NAC 449.734) NAC 449.737 Plan of care. ( NRS 449.0302 ) 1. Each resident in a facility for persons with an intellectual disability or persons with a developmental disability must be a regular participant in an individual plan of care which must be prepared in written form by an interdisciplinary team consisting of at least a physician, a social worker, a qualified professional in intellectual disabilities and such other professional specialists indicated in unusual cases. 2. The plan of care must: (a) Contain a complete medical, social and psychological evaluation of the resident; (b) Indicate the resident’s need for institutional care; (c) Be stated in quantifiable terms and made available to the members of the staff who implement its provisions; and (d) Prescribe an individually designed integrated program of therapies, experiences, activities or training. Ê The ultimate goal of any plan of care is the maximal normalization of the resident. 3. Each resident’s plan of care must be reviewed at least quarterly by the interdisciplinary team. This review must include: (a) A review of the resident’s progress toward the objectives of the plan; (b) An evaluation of the appropriateness of the elements of the plan; (c) An assessment of the need for continuing institutional care; and (d) A consideration of alternate methods of care. 4. If an interdisciplinary team determines that a resident no longer requires institutional care, a postinstitutional plan must be written by a qualified professional in intellectual disabilities and other appropriate professionals providing for appropriate services, protective supervision where necessary, and other follow-up services in the resident’s new environment. A summary must be placed in the resident’s file. 5. The facility must provide or arrange for the provision of the services of qualified professionals as indicated in the resident’s individualized plan of care. Available services must include, but are not limited to: (a) Physical and occupational therapy; (b) Psychological services; (c) Social services; (d) Speech-language pathology and audiology; (e) Organized recreational activities; and (f) Physician’s services, including: (1) An annual physical examination; and (2) Formal arrangements for 24-hour emergency treatment every day of the week. [Bd. of Health, Intermediate Care Facilities Reg. §§ 16.5-16.7 & 16.14-16.14.6.2, eff. 12-5-75] NAC 449.740 Corporal punishment; restraints. ( NRS 449.0302 ) 1. Corporal punishment of residents in a facility for persons with an intellectual disability or persons with a developmental disability by members of the staff or other residents is prohibited. 2. Physical restraints may not be used except as absolutely necessary for the safety of the resident, his or her peers or the staff and then only under the following conditions: (a) The facility shall have a written policy clearly stating the conditions under which restraint may be employed and enumerating which members of the staff may authorize its use; (b) No restraint may remain in force for more than 12 hours; (c) A resident in restraint must be checked at least every 30 minutes by trained members of the staff and a written record of these checks must be maintained; (d) The restraint file must be reviewed daily by the administrator or his or her appointee and a copy of the record placed in the resident’s file; and (e) The restraints used must be designed so as not to cause physical injury or great discomfort to the resident. A resident must be released from restraint for at least 10 minutes of every 2-hour period they are restrained. 3. Any totally enclosed crib or other barred enclosure is considered a restraining device. 4. Excessive chemical restraints must not be employed for the convenience of members of the staff. [Bd. of Health, Intermediate Care Facilities Reg. §§ 16.10-16.13, eff. 12-5-75] NAC 449.743 Records. ( NRS 449.0302 ) 1. A file must be maintained for each resident in a facility for persons with an intellectual disability or persons with a developmental disability which contains: (a) Identification information; (b) The resident’s legal status; (c) Admission data; (d) Past medical, developmental and social history; (e) Copies of all facility examinations and evaluations of the resident or his or her plan of care; and (f) A discharge summary. Ê Entries must be made noting any treatments or services rendered, medications administered or symptoms of illness or injury. 2. Residents’ records must be secured against loss, destruction or unauthorized use. The records must be made available to licensing and certification authorities upon request. [Bd. of Health, Intermediate Care Facilities Reg. §§ 16.8 & 16.9, eff. 12-5-75] COMMUNITY TRIAGE CENTERS NAC 449.74311 Definitions. ( NRS 449.0302 ) As used in NAC 449.74311 to 449.74373 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.74313 to 449.74325 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006; A by R016-20, 11-2-2020) NAC 449.74313 “Administrator” defined. ( NRS 449.0302 ) “Administrator” means the person who is appointed by the governing body of a facility who has primary responsibility for the overall operations of the facility. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74315 “Facility” defined. ( NRS 449.0302 ) “Facility” means a community triage center as defined in NRS 449.0031 . (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74317 “Governing body” defined. ( NRS 449.0302 ) “Governing body” means a body that has the ultimate authority for the administration of a facility pursuant to NAC 449.74327 . (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74321 “Patient” defined. ( NRS 449.0302 ) “Patient” means any person who is under observation or receiving care or treatment in a facility. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74322 “Person with mental illness” defined. ( NRS 449.0302 ) “Person with mental illness” has the meaning ascribed to it in NRS 433A.115 . (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006)—(Substituted in revision for NAC 449.74319) REVISER’S NOTE. Ch. 66, Stats. 2019 replaced the term “person with a mental illness” in NRS 433A.115 with the term “person in a mental health crisis.” The definition of the term “person in a mental health crisis” is now codified at NRS 433A.0175 . NAC 449.74323 “Program” defined. ( NRS 449.0302 ) “Program” means a program described in NAC 449.74339 . (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74325 “Psychologist” defined. ( NRS 449.0302 ) “Psychologist” has the meaning ascribed to it in NRS 641.027 . (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74327 Governing body; bylaws and policies. ( NRS 449.0302 ) 1. Each facility must have a governing body which has the ultimate authority for the administration of the facility. 2. The governing body shall: (a) Adopt written bylaws and policies that define the powers and duties of the governing body, its committees, the administrator and any advisory group; (b) Review and revise annually the bylaws, policies and procedures of the governing body; (c) Appoint an administrator of the facility who is qualified by education, experience and training to manage the facility; (d) Establish policies governing the responsibilities, authority and duties of the administrator that are designed to enable the administrator to perform the administrative and treatment functions of the facility; (e) Appoint a medical director of the facility who is responsible for the medical services provided at the facility; (f) Adopt controls designed to achieve and maintain maximum standards of service; (g) Review and approve an annual budget to carry out the objectives of each program; and (h) Review and approve annually the program goals and objectives set forth in NAC 449.74339 . 3. The bylaws and policies adopted pursuant to subsection 2 must: (a) Identify the overall goals of the facility; (b) Include, without limitation, an organizational chart of the facility; (c) Define the major lines of authority and areas of responsibility within the program of treatment provided by the facility; (d) Define the membership of the governing body, the types of membership, the method of selection or appointment of members, officers or committees and their terms of office; and (e) Define the frequency of meetings of the governing body and attendance requirements. 4. The governing body shall meet at least semiannually. Minutes must be kept of the meetings and must include, without limitation: (a) The date of the meeting; (b) A list of the persons who attended the meeting; (c) A list of the topics discussed at the meeting; and (d) A list of all decisions made by the governing body and any actions taken. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74329 Policies and procedures for services and operation of facility. ( NRS 449.0302 ) 1. The governing body shall adopt written policies and procedures that govern the operation of the facility and the services provided by the facility. 2. The policies and procedures adopted pursuant to subsection 1 must: (a) Ensure that only those persons are accepted as patients whose needs can be met by the facility directly or in cooperation with community resources or other providers of treatment with which it is affiliated or has contacts; (b) Ensure that a patient whose physical or mental condition has changed to such an extent that he or she can no longer be adequately served by the facility will be transferred promptly to an appropriate facility; (c) Set forth the rights of patients and members of the staff, including, without limitation, the rights of patients set forth in NRS 449A.100 to 449A.118 , inclusive, and provide for the registration and disposition of complaints without threat of discharge or reprisal against an employee or patient; (d) Ensure that the admission agreement between the administrator and the patient specifically prohibits the administrator, his or her designee or any member of the staff of the facility from being given durable power of attorney for health care for the patient; and (e) Be available to members of the staff, patients and the public. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74331 Transfer of patient. ( NRS 449.0302 ) 1. Except in the case of an emergency: (a) The transfer of a patient must not be effected until the patient, attending physician of the patient, if any, and responsible agency are consulted in advance. (b) If a patient is transferred to a hospital or other medical facility, a summary of discharge containing a plan for continuation of care must be prepared and forwarded to the receiving facility if the patient or his or her guardian consents to release such information to the receiving facility. 2. If a patient is transferred to a hospital or other medical facility as a result of a medical emergency, information required for appropriate continuation of care must be released to the receiving facility in compliance with the standards set forth in 42 C.F.R. Part 2. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74333 Handling of money of patient. ( NRS 449.0302 ) 1. If a facility handles the money of a patient, a written ledger account of all deposits, disbursements and other transactions must be maintained. A record must be made available to the patient. 2. If the amount of money of a patient which the facility handles is $75 or more, the money must be maintained in a financial institution in the community where the facility is located in a separate trustee account apart from the operational accounts of the facility and must be clearly designated. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74335 Inventory of belongings of patient. ( NRS 449.0302 ) If a facility holds or stores the belongings of a patient, there must be an inventory of the belongings on admission, made a part of the record of the patient and updated as needed. These belongings must be returned to the patient upon his or her exit. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74337 Liability insurance. ( NRS 449.0302 ) Liability insurance in a sufficient amount to protect patients, members of the staff, volunteers and visitors must be maintained by each facility. A certificate of insurance must be furnished to the Division. The certificate must include, without limitation, provision for 30 days’ notice to the Division of the cancellation or the nonrenewal of a policy of liability insurance. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74339 General requirements for programs and services. ( NRS 449.0302 ) 1. Each program for the provision of detoxification services, each social model detoxification program or its equivalent and each modified medical detoxification program or its equivalent of a facility must be certified in accordance with the provisions of chapter 458 of NRS and chapter 458 of NAC. 2. Each component of each program described in subsection 1 must develop objectives that complement the goals of the program. 3. The facility shall provide for the medical, emergency dental and psychological services needed to fulfill the goals of each program and meet the needs of all of its patients to the extent that is possible, with assistance from available community resources. 4. Patients who are admitted and receive detoxification services must be provided such services under the direction of a qualified physician licensed in accordance with the provisions of chapter 630 or 633 of NRS. 5. If a facility provides services through outside sources, formal, written arrangements must be made ensuring that the services are supplied directly by, or under the supervision of, qualified persons. 6. A facility shall provide case management services as needed by a patient through a social worker or a registered nurse or by written agreement with a social worker or a registered nurse. 7. A plan for case management must be recorded in the records of a patient and must be periodically evaluated in conjunction with the treatment plan of the patient. 8. Each facility shall review each program described in subsection 1 at least annually. The review must include, without limitation, an evaluation of: (a) The appropriateness of the admission of patients; (b) The lengths of stay of patients; (c) Planning for the discharge of patients; (d) The use of services and utilization of the components of the program; (e) The use of outside services; and (f) Any unusual incidents that resulted or may have resulted in harm to a patient. 9. Written reports of the annual reviews conducted pursuant to subsection 8 must be evaluated by the governing body and the administrator. Documentation of the evaluation process must be maintained at the facility. Outcome reports and reports of actions taken must be maintained for a period of at least 6 years. 10. As used in this section: (a) “Detoxification” means the process of eliminating the toxic effects of alcohol and drugs from the body. (b) “Social model detoxification program” means a treatment program that concentrates on providing psychosocial services and nonmedical detoxification. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74341 Responsibilities and duties of administrator. ( NRS 449.0302 ) 1. The administrator of a facility is responsible to the governing body of the facility for the operation of the facility in accordance with the policies and procedures of the facility. 2. The administrator shall: (a) Organize the administrative functions of each program, delegate duties and establish a formal means of accountability on the part of subordinates. (b) Ensure that a written manual defining the policies and procedures of each program is prepared, regularly revised, and updated at least annually. The manual must: (1) Contain all policies and procedures of the facility, including, without limitation, definitions and other documentation required by NAC 449.74311 to 449.74373 , inclusive; and (2) Be available to members of the staff of the facility at all times at designated and convenient locations. (c) Appoint a person who is qualified by education, experience and training to act as administrator in his or her absence. (d) Notify the Bureau within 24 hours after the administrator becomes aware of: (1) The death of a patient at the facility; or (2) The elopement from the facility of an at-risk patient. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006; A by R016-20, 11-2-2020) NAC 449.74343 Policies and procedures concerning employees. ( NRS 449.0302 ) 1. The administrator or his or her appointee must be present and responsible for the operations of the facility during normal hours. 2. All members of the counseling staff of a facility must be authorized by state law to provide counseling. 3. Each person employed in a facility must have a preemployment physical examination or certification of a 3-year health record from a physician, and be tested for tuberculosis as required in chapter 441A of NAC. 4. Each facility shall: (a) Have on duty, at all hours of the day, members of the staff sufficient in number and qualifications to carry out policies, responsibilities and program continuity. (b) Provide an orientation session to new employees. Documentation of the session must be maintained in the personnel file of the employee. (c) Have written policies and procedures: (1) For the recruitment, selection, promotion and termination of members of the staff; (2) Concerning rules of conduct, and training and development of the staff; and (3) Governing disciplinary actions that clearly define the mechanism for the suspension or dismissal of members of the staff. (d) Maintain a written job description for each position at the facility. The job description must accurately reflect the actual job situation and must be reviewed annually or whenever a change in the responsibilities of the job or qualifications occurs. Job descriptions must be available on request to all members of the staff. Each job description must include, without limitation: (1) The title of the job; (2) The tasks and responsibilities of the job; (3) The skills, education and experience necessary for the job; (4) The relationship of the job to other jobs within each program; and (5) The working conditions, location and shift of the job, and the materials and equipment to be used on the job. (e) Maintain a personnel record for each employee of the facility. The record must include, without limitation: (1) The employment application; (2) Letters of recommendation; (3) Records from any investigation of the employee; (4) Verification of training, experience and certification; (5) Job performance evaluations; (6) Incident reports; and (7) Disciplinary actions taken. (f) Maintain personnel records in a secure manner and make them available only to those persons authorized to receive personnel records in the written policies and procedures of the facility. An employee must have access to his or her own file upon request. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74345 Nursing services. ( NRS 449.0302 ) 1. Each facility shall have an organized plan for nursing service that provides nursing services 24 hours per day. The nursing services must be provided or supervised by a registered nurse in compliance with state law, including, without limitation, chapter 632 of NRS and chapter 632 of NAC. 2. The nursing service shall have a sufficient number of registered nurses, licensed practical nurses and other personnel to provide care in general medical nursing, psychiatric nursing and nursing related to treatment of alcohol or other substance use disorders. 3. The administrator shall ensure that the nursing staff develops and keeps current a plan for nursing care for each patient. 4. The administrator shall appoint a chief administrative nurse to direct the nursing service. The chief administrative nurse must: (a) Be a registered nurse; (b) Be knowledgeable, skilled and competent in clinical practice and the management of nurses; and (c) Comply with the provisions of chapter 632 of NRS and chapter 632 of NAC and follow professional standards established for organized nursing services. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74347 Health services. ( NRS 449.0302 ) 1. Each facility shall provide health services which ensure that each patient receives treatment, prescribed medication, adequate diets and other health services consistent with each program administered by the facility. 2. There must be policies and procedures designed to ensure the early detection of complications or conditions considered to be common among persons with alcohol or other substance use disorders and persons with mental illness. 3. The policies and procedures must be developed with assistance from and approved by the medical director of the facility. 4. Policies and procedures must be developed and implemented to ensure the early detection of patients at risk for suicide. The policies and procedures must be developed with assistance from and approved by the medical director of the facility and a psychiatrist. 5. Before a patient is admitted to a facility, a general medical and psychological assessment, including an assessment of suicide risk and a drug history of the patient, must be taken by a physician, a physician assistant, an advanced practice registered nurse or a designated member of the nursing staff of the facility who has psychiatric experience. The drug history of the patient must include, without limitation: (a) Drugs used in the past; (b) Drugs used recently; (c) Drugs of preference; (d) Frequently used drugs; (e) Drugs used in combination; (f) Dosages used; (g) Date of first usage; (h) Incidents of overdose, withdrawal or adverse drug reactions; (i) Previous history of treatment; and (j) History of mental illness and treatment. 6. Except as otherwise provided in subsection 7, a physical examination and review of the medical and drug history of a patient must be conducted by a physician, nurse practitioner or physician assistant within 24 hours after the patient is admitted to a facility. 7. If the assessment conducted in accordance with subsection 5 concludes that a physical examination of the patient should be completed within less than 24 hours after the patient is admitted, the physical examination must be conducted within the time recommended in the assessment. 8. Each facility shall have written policies and procedures defining the appropriate action to be taken when a medical emergency arises. The policies and procedures must be reviewed and approved by the medical director of the facility. 9. Staff providing patient care must be qualified by the American Red Cross or another similar nationally recognized agency to administer cardiopulmonary resuscitation. 10. Each patient of a facility must be tested for tuberculosis as required by the provisions of chapter 441A of NAC. 11. First-aid supplies must be maintained and readily available at each facility. 12. A facility that provides laboratory testing shall do so in compliance with the provisions of chapter 652 of NRS and chapter 652 of NAC. 13. If a facility has no provisions for the isolation of a patient diagnosed with an infectious disease, the patient must be transferred to a facility that provides such service. The decision to transfer the patient must be made by the medical director of the facility or his or her designee. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74349 Mental health services. ( NRS 449.0302 ) 1. Mental health services provided by a facility must be supervised by a psychiatrist or a psychologist who has a master’s degree in clinical or counseling psychology. The mental health staff of the facility must be adequate in number and qualified to carry out their assigned responsibilities. 2. The mental health staff may assist in: (a) Diagnosis and testing; (b) Program development and evaluation; (c) In-service training; and (d) Therapeutic activity in group settings or one-on-one therapeutic activity. 3. Mental health services must be provided by a staff member of the facility who: (a) Has a master’s degree in clinical or counseling psychology; (b) Is an advanced practice registered nurse with at least 2 years of clinical practice in the field of psychiatric nursing or nursing related to the treatment of alcohol or other substance use disorders; or (c) Is licensed as a clinical social worker in accordance with the provisions of chapter 641B of NRS. 4. A psychiatrist licensed in accordance with the provisions of chapter 630 of NRS must be available at each facility to approve mental health service policies and procedures and to provide consultation for patients who need mental health services. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74351 Pharmaceutical services. ( NRS 449.0302 ) 1. Each facility shall have: (a) A pharmacy directed by a registered pharmacist; (b) A drug room supervised by no less than a currently licensed professional nurse; or (c) A contract for 24-hour pharmaceutical service with a licensed pharmacy. 2. If a facility maintains a pharmacy or drug room, the pharmacy or drug room must be administered in accordance with all applicable state and federal laws and must have a full-time, part-time or consulting pharmacist who is responsible for developing, supervising and coordinating all of the activities of the pharmaceutical service. 3. Each facility shall have and implement policies and procedures that minimize errors in the administration of drugs. The medical director of the facility and the pharmacist who is responsible for the pharmaceutical service must approve the policies and procedures. 4. Drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice and state and federal laws. 5. When a pharmacist is not available at the facility, drugs and biologicals may be removed from the pharmacy or drug area only by a member of the staff who is authorized to remove such substances by the policies and procedures of the facility, which must be established in accordance with state and federal laws. 6. Errors in administering a drug, adverse reactions by a patient to a drug and any incompatibility between a drug and a patient must be reported immediately to the attending physician of the patient or the medical director of the facility. 7. Misuses and losses of controlled substances must be reported to the pharmacist who is responsible for the pharmaceutical service, the administrator and the chief administrative nurse of the facility, in accordance with all applicable state and federal laws. 8. Information relating to drug interactions and information on drug therapy, side effects, toxicology, dosage indications for use and routes of administration must be available to the professional members of the staff of the facility. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74353 Medication and biologicals. ( NRS 449.0302 ) 1. Except as otherwise provided in subsection 2, an order for medication or biologicals for a patient must be in writing and signed by the practitioner, or other appropriate professional person authorized by state or federal law to order the medication or biological, who is responsible for the care of the patient. 2. When a telephone or verbal order is used to order medications or biologicals, the order must be: (a) Accepted only by a person who is authorized by the policies and procedures of the facility, which must be consistent with state law, to accept such an order; and (b) Signed or initialed by the prescribing practitioner in accordance with the policies and procedures of the facility. 3. Each order for a medication or biological must include, without limitation, the name of the medication or biological, and the dosage, time or frequency of administration and route of administration of the medication or biological. 4. Only a member of the staff of the facility who is authorized by state law to administer medication or biologicals may administer medication or biologicals at the facility. 5. Each facility shall have a system to monitor and improve the process of administering medication and biologicals. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74355 Records of patients. ( NRS 449.0302 ) 1. Each facility shall maintain an organized system for the records of patients. 2. The records of a patient must be available to professional members of the staff of the facility who are directly involved with the patient. 3. The records of patients must be available to representatives of the Division. 4. The records of a patient must include, without limitation: (a) Identification information; (b) Past medical and social history; (c) Copies of all initial and periodic examinations; (d) Evaluations and progress notes; and (e) Assessments and goals of the plan of treatment of the patient. 5. The plan of treatment must state who is responsible for providing treatment or services to the patient. 6. Entries must be made describing treatments and services rendered, medications administered, and any symptoms or other indications of illness or injury, including, without limitation, the date, time and action taken regarding each incident. 7. Records must be adequately safeguarded against destruction, loss or unauthorized use. 8. A discharge plan, as determined by a case management assessment of the patient, must be documented for each patient discharged from the facility. 9. Records must be retained for at least 5 years after the discharge of a patient from a facility. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74357 Laundry requirements. ( NRS 449.0302 ) 1. Each facility shall have the proper equipment for the sanitary washing and finishing of linen and other washable goods or shall maintain a written agreement with a commercial establishment to provide proper laundry services. 2. The laundry area of a facility must be situated in an area of the facility that is separate and apart from any room where food is stored, prepared or served. The laundry area must be well-lighted, ventilated, adequate in size to house equipment, maintained in a sanitary manner and kept in good repair. 3. Soiled linen must be collected and transported to the laundry in washable or disposable containers in a sanitary manner. Soiled linen must not be transported through areas of the facility used for preparing or serving food. 4. Clean linen to be dried, ironed, folded, transferred or distributed must be handled in a sanitary manner in accordance with a written plan maintained by the facility. 5. Closets for storing linen and laundry supplies must be provided and must not be used for any other purpose. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74359 Dietary services. ( NRS 449.0302 ) 1. Each facility shall serve at least three meals or their equivalent daily, at regular times, with not more than 14 hours between a substantial evening meal and breakfast. 2. Additional food and between-meal nourishment must be provided to a patient when needed, based on an assessment of the medical condition of the patient. 3. Menus must be planned and followed to meet the nutritional needs of the patients in accordance with the recommended dietary allowances of the Food and Nutrition Board of the Institute of Medicine of the National Academies. 4. Therapeutic menus must be planned by a licensed dietitian or must be reviewed and approved by the attending physician of the patient or the medical director of the facility. 5. Menus must be in writing, planned in advance, dated and posted, and kept on file at the facility for at least 90 days. Any substitution must be noted on the written menu so that the menu on file reflects what was actually served. 6. A licensed dietitian must be used as a consultant on planning meals and serving food. This person shall consult at least monthly with the staff of the facility. 7. The facility shall provide: (a) Adequate facilities and equipment for the preparation, serving, refrigeration and storage of food in a sanitary manner; (b) Storage space for dry foods, refrigerated food and frozen food; (c) Any special equipment, implements or utensils that are needed by a patient to assist the patient in eating; (d) Dining space for ambulatory patients, staff and visitors that is separate from sleeping areas, food preparation areas and distribution areas; (e) Tables and chairs in the dining space that are sturdy and cleanable; and (f) In each kitchen area: (1) Sinks for washing hands with blade-type faucets, soap and paper towels for drying hands; and (2) A separate janitors’ closet for the storage of housekeeping chemicals and supplies which contains a floor sink with backflow prevention. 8. A facility with more than 10 patients shall: (a) Comply with all applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto; (b) Obtain the necessary permits from the Division; (c) Maintain a report of each inspection concerning the sanitation of the facility for at least 1 year after the date of the inspection; and (d) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (c) for at least 1 year after the date of the corrective action. 9. A facility that contracts with a food management company shall comply with all applicable regulations of the State Board of Health. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006; A by R155-10, 12-16-2010; R090-12, 12-20-2012) NAC 449.74361 New construction or remodeling: Submission and approval of building plans; prerequisites to approval of facility for licensure. ( NRS 449.0302 ) 1. Except as otherwise provided in subsection 4, before any new construction of a facility or any remodeling of an existing facility is begun: (a) The facility shall submit a copy of the building plans for the new construction or remodeling to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 . The entity’s review of those plans is advisory only and does not constitute approval for licensure of the facility. (b) The building plans must be approved by the Division. 2. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility. 3. The Division shall not issue a license to operate a facility until the Bureau has approved the construction of the facility. 4. The provisions of subsection 1 do not apply to plans for remodeling a facility if the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting in the area, replacing flooring in the area, repairing windows in the area or replacing window and wall coverings in the area. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74363 Design, construction, equipment and maintenance of facility. ( NRS 449.0302 ) 1. Each facility must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the facility and members of the general public. 2. Each facility shall comply with all applicable: (a) State and federal laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Environmental, life safety, fire, health and local building codes, Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply. 3. Each facility shall comply with the provisions of NFPA 101: Life Safety Code , as adopted by reference pursuant to NAC 449.0105 . (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74365 Entrances, lobbies and offices; storage space. ( NRS 449.0302 ) Each facility shall provide: 1. A covered entrance to protect patients from the elements; 2. A lobby which measures not less than 100 square feet, has access to toilet facilities and may be used for multiple purposes; 3. Offices for the administrator or his or her designee; 4. Offices for social services which may be used for more than one purpose if the offices are large enough to accommodate multiple use and patient privacy can be maintained; 5. A storage space for office supplies and equipment; and 6. Medical record storage that is adequate to protect patients’ health care records in accordance with federal requirements for the protection of medical information. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74367 Patients’ rooms; toilet and bathing facilities. ( NRS 449.0302 ) 1. Each facility shall provide separate patient rooms for male and female patients. Each patient room must: (a) Be at least 80 square feet per bed, exclusive of toilet facilities, closets or entryways; (b) Include a bed with clean linens and blankets; and (c) Have storage for patient belongings. 2. Each facility shall provide: (a) Toilet and bathing facilities to patients in a manner that ensures their privacy while bathing and in adequate number to meet the needs of the patients; (b) Fixtures in toilet and bathing facilities designed to minimize the possibility of injury or suicide; and (c) Mirrors in toilet and bathing facilities which are constructed of safety glass. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74369 Service areas; miscellaneous requirements. ( NRS 449.0302 ) 1. Each facility shall provide: (a) A nursing station which includes, without limitation: (1) Space for computer and printer equipment and for writing; (2) A medication room or storage space for a medication dispensing unit; (3) A separate utility room for clean materials; (4) A separate utility room for soiled materials; (5) A break room for staff; (6) Separate toilet facilities for staff; and (7) Lockers or secured storage for staff belongings; (b) A separate room for secured storage of patient belongings that have been determined to be hazardous; (c) A separate room for the storage of clean linen; (d) A separate room for nourishments that contains an ice machine, which must be self-dispensing if it is accessible to patients or visitors; (e) A treatment room which is at least 120 square feet and which includes, without limitation: (1) A hand-washing sink with blade-type handles or hands-free operation; (2) A writing space; (3) Sufficient lighting; (4) Storage space for clean and sterile supplies; (5) Locked storage for medications and double-locked storage for controlled substances in schedules I to IV, inclusive, as described in chapter 453 of NRS; (6) Cabinets for the storage of equipment; and (7) An examination table and a chair for the use of patients; (f) Flooring which is easy to clean and intact, without cracks or holes; (g) Insulation within the building to conserve energy, protect personnel, prevent vapor condensation and reduce noise; (h) Air conditioning, heating and ventilation to maintain a comfortable interior temperature; and (i) Laundry facilities to meet the needs of the patients or, if the facility has a contract for linen services, a room for receiving laundry. If the facility provides laundry facilities, then those laundry facilities must be located in a room that is at least 100 square feet. The room must be constructed of 1-hour fire-resistant-rated construction, be fully equipped with sprinklers and have a 45-minute fire-resistant-rated door. The vents in the room must have fire and smoke dampers installed in accordance with the requirements of NFPA 101: Life Safety Code , as adopted by reference pursuant to NAC 449.0105 . 2. Each nursing station and each floor of the facility must have a janitors’ room with a floor sink and backflow prevention. The janitors’ room must: (a) Provide sufficient storage space for housekeeping chemicals and supplies, housekeeping mops, brooms, service carts and cleaning supplies; and (b) Be separate from any storage space used for the storage of food. 3. Each facility shall have a procedure for the safe disposal of hazardous biological materials. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74371 Safety and sanitation. ( NRS 449.0302 ) 1. The premises and equipment of each facility must be maintained in a safe, functional and sanitary condition. Each facility shall have the necessary cleaning and maintenance equipment with sufficient storage areas and appropriate procedures to maintain a clean and orderly establishment. Janitorial supplies, including, without limitation, aerosols, must be stored in areas separate from clean linen, food and other supplies. The storage of dirty linen must be separate from the storage of clean linen, food and other supplies. 2. Items for personal use, including, without limitation, combs, toothbrushes, towels and bar soap, must not be shared by patients. 3. All toilet facilities in a facility must be provided with soap and individual, disposable towels. 4. Each facility shall ensure that the environment of the facility is free of hazards that may cause accidents. 5. Each facility shall maintain an effective program to control pests and rodents in order to ensure that the facility is free from pests and rodents. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) NAC 449.74373 Preparations for disasters; reporting of fire or disaster. ( NRS 449.0302 ) 1. Each facility shall develop a written plan for internal and external disasters which outlines procedures for members of the staff and patients to follow in case of fire or other emergency and provides for meeting the needs of patients if the facility must be evacuated or is damaged or destroyed. 2. Each facility shall conduct fire drills at least monthly, and a written record of each drill conducted must be retained in the facility for not less than 1 year after the drill is conducted. 3. A simple floor plan showing the routes for evacuating must be posted in prominent locations on each floor of the facility. 4. The facility shall notify the Bureau of the occurrence of a fire or disaster in the facility within 24 hours after the facility becomes aware of the fire or disaster. 5. Each facility shall conduct a disaster drill annually for each shift and retain a written record of the drill in the facility for not less than 12 months after the drill is conducted. 6. Each facility shall adopt procedures to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water. 7. No room or space of a facility may be occupied for sleeping, living or dining that is accessible only by a ladder, by folding stairs or through a trapdoor. 8. If a basement of a facility is used for living or dining, at least one exit must be provided directly to the outside at ground level. No facility may: (a) Be situated more than one story below the ground; and (b) Use any basement or space in a basement for sleeping. 9. Each facility shall prohibit smoking within the facility and within 25 feet of the facility. (Added to NAC by Bd. of Health by R051-06, eff. 7-14-2006) FACILITIES FOR SKILLED NURSING General Provisions NAC 449.744 “Facility for skilled nursing” defined. ( NRS 449.0302 ) As used in NAC 449.744 to 449.74549 , inclusive, unless the context otherwise requires, “facility for skilled nursing” has the meaning ascribed to it in NRS 449.0039 . (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R067-04, 8-4-2004) Licensing and Administration of Facility NAC 449.74411 Applicability of license; limitation on number of patients; coverage against certain liabilities. ( NRS 449.0302 ) 1. A facility for skilled nursing must be operated and conducted in the name designated on the license for the facility, with the name of the person responsible for its operation also appearing on the face of the license. The license is not transferable. 2. A facility for skilled nursing shall not admit more patients to the facility than the number of beds for which it is licensed, except in emergencies. A facility that admits more patients to the facility than the number of beds for which it is licensed shall immediately notify the Bureau of the additional admissions. 3. A facility for skilled nursing shall retain proof that it is adequately covered against liabilities resulting from claims incurred in the course of its operation. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R119-05, 11-17-2005) NAC 449.74413 Change in ownership, use or construction of facility. ( NRS 439.200 , 449.0302 ) The owner of a facility for skilled nursing shall, at least 30 days before there is a change of ownership, change of use or change in the construction of the facility, notify the Bureau of that change. If the facility is not in compliance with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 , the notice must identify those provisions of the guidelines with which the facility has failed to comply. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R067-04, 8-4-2004; R122-16, 9-21-2017; R048-22, 12-29-2022) NAC 449.74415 Responsibilities of governing body. ( NRS 449.0302 ) A facility for skilled nursing must have a governing body that is legally responsible for establishing and carrying out policies regarding the management and operation of the facility. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74417 Administrator of facility. ( NRS 449.0302 ) 1. The governing body of a facility for skilled nursing shall appoint a qualified administrator for the facility. 2. The administrator: (a) Must be licensed under the provisions of chapter 654 of NRS; and (b) Is responsible for the management of the facility. 3. A facility for skilled nursing must be administered in a manner that enables it to use its resources effectively and efficiently in order to attain and maintain the highest practicable physical, mental and psychosocial well-being of each patient. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74419 Committee for quality assurance. ( NRS 449.0302 ) 1. A facility for skilled nursing shall establish a committee for quality assurance. 2. The committee must be composed of: (a) The chief administrative nurse; (b) A member of the staff who is a physician and appointed by the administrator; and (c) At least three other members of the staff who are appointed by the administrator. 3. The committee shall: (a) Meet at least quarterly to identify problems and concerns related to the care provided to patients for which corrective actions are necessary; and (b) Adopt and carry out appropriate plans of action to correct the problems and concerns that are identified. 4. The Bureau may not require the disclosure of the records of the committee unless such disclosure is required to ensure compliance with the provisions of this section. 5. Good faith efforts made by a committee to identify problems and concerns related to the care provided to patients and to correct the problems and concerns that are identified may not be used as grounds for imposing administrative sanctions against a facility for skilled nursing. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74421 Procedures for emergency or disaster. ( NRS 449.0302 ) 1. A facility for skilled nursing shall adopt written procedures to be followed by the members of the staff and patients in the case of an emergency or disaster, including, without limitation, fires, severe weather and locating missing patients. 2. The facility shall provide training to an employee regarding these procedures upon his or her employment by the facility and periodically review the procedures with members of the staff. 3. The facility shall periodically conduct unannounced drills to practice carrying out the procedures adopted pursuant to subsection 1. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) Admission, Transfer and Discharge of Patient NAC 449.74423 Certain conditions for admission prohibited. ( NRS 449.0302 ) A facility for skilled nursing shall not, as a condition of admitting or providing for the expedited admission of a patient to, or allowing a patient to remain in, the facility: 1. Require a patient to waive his or her rights to benefits under any state or federal program that is available to assist patients in the payment of services provided by the facility, including, without limitation, Medicaid and Medicare. 2. Require a patient to provide a written or oral confirmation that he or she is not eligible for or will not apply for benefits under such a program. 3. Charge, solicit, accept or receive any gift, money, contribution or other consideration on behalf of a patient who is eligible for benefits under such a program in addition to any amount otherwise required to be paid to the facility under the program. The provisions of this subsection do not prohibit a facility from: (a) Charging such a patient for an item or service not covered under the program if: (1) The item or service is requested by the patient; (2) The facility does not require the patient to request the item or service as a condition of admission to or remaining in the facility; and (3) The facility informs the patient that there will be a charge for the item or service and the amount of the charge. (b) Soliciting, accepting or receiving a charitable, religious or philanthropic contribution from an organization or a person who is unrelated to the patient, but only to the extent that the contribution is not a condition of admitting or providing for the expedited admission of the patient to, or allowing the patient to remain in, the facility. 4. Require a third person to guarantee the payment of fees charged by the facility for services provided to the patient. The provisions of this subsection do not prohibit the facility from requiring a person who has legal control over the income or other resources of the patient to enter into a contract, without incurring personal liability, for the payment of fees charged by the facility for services provided to the patient. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74425 Admission of patient with mental illness or an intellectual disability. ( NRS 449.0302 ) 1. On or after September 27, 1999, a facility for skilled nursing shall not admit a patient with a mental illness or with an intellectual disability unless the Division has determined, based on an independent evaluation of the physical and mental health of the patient, that he or she requires: (a) The level of services provided by a facility for skilled nursing; and (b) Specialized services that the facility is able to provide. 2. The independent evaluation required by subsection 1 must be performed by a person or organization other than the Division. 3. As used in this section: (a) “Intellectual disability” has the meaning ascribed to it in NRS 0.036 . (b) “Mental illness” has the meaning ascribed to it in NRS 433.164 . (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74427 Agreement with hospital for transfer of patients. ( NRS 449.0302 ) 1. A facility for skilled nursing shall have in effect an agreement with at least one licensed hospital that provides for the transfer of patients from the facility to the hospital. The agreement must provide that: (a) A patient transferred from the facility will be admitted to the hospital in a timely manner if the transfer is medically appropriate as determined by the patient’s attending physician; and (b) Medical and other information required for the care and treatment of the patient is transferred with the patient. Such information may include information for determining whether the patient may be cared for adequately in a setting that is less expensive than the facility or the hospital. 2. A facility for skilled nursing that does not have such an agreement in effect but has attempted in good faith to enter into such an agreement with a hospital sufficiently close to the facility to make transfers feasible shall be deemed to have such an agreement. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74429 Transfer or discharge of patient. ( NRS 449.0302 ) 1. A facility for skilled nursing may transfer or discharge a patient from the facility only if: (a) The facility can no longer provide for the needs of the patient and the transfer or discharge is necessary for the patient’s welfare; (b) The health of the patient has improved sufficiently so that the patient no longer requires the services provided by the facility; (c) The health or safety of other persons in the facility is endangered if the patient remains in the facility; (d) The charges for services provided to the patient by the facility have not been paid after the facility has given notice of those charges; or (e) The facility ceases to operate. 2. Before a facility for skilled nursing may transfer or discharge a patient from the facility, the facility shall: (a) Record the reasons for the transfer or discharge in the medical records of the patient. If a patient is transferred or discharged under the circumstances described in: (1) Paragraph (a) or (b) of subsection 1, the reasons for the transfer or discharge must be recorded by the patient’s physician. (2) Paragraph (c) of subsection 1, the reasons for the transfer or discharge must be recorded by any physician. (b) Give notice of the transfer or discharge to the patient and, if known, to the legal representative of the patient or a member of the patient’s family. The notice must: (1) Be in writing; (2) Be in a language that is understood by the patient and his or her legal representative or a member of his or her family; (3) Except as otherwise provided in subsection 3, be given at least 30 days before the effective date of the transfer or discharge; (4) Include the reasons for the transfer or discharge; (5) Include the effective date of the transfer or discharge; (6) Specify the location to which the patient will be transferred or discharged; (7) Include a statement that the patient has a right to appeal the transfer or discharge; (8) Include the name, address and telephone number of the advocates for residents of facilities for long-term care appointed pursuant to chapter 427A of NRS; and (9) If the patient is developmentally disabled or mentally ill, include the name, address and telephone number of persons who advocate for and are responsible for the protection of such persons. 3. The notice required by paragraph (b) of subsection 2 may be given less than 30 days before the effective date of the transfer or discharge if: (a) The health or safety of other persons in the facility is endangered if the patient remains in the facility; (b) The health of the patient has improved sufficiently to allow a more immediate transfer or discharge of the patient; (c) The medical needs of the patient require a more immediate transfer or discharge; or (d) The patient has not resided in the facility for at least 30 days. 4. Upon admission of a patient to a facility for skilled nursing and at the time the facility transfers the patient for hospitalization or therapeutic leave, the facility shall provide to the patient and to the legal representative of the patient or to a member of the patient’s family, in writing: (a) The time within which the patient may resume his or her residency in the facility without waiting for readmission; and (b) The policy of the facility for readmitting a patient whose hospitalization or therapeutic leave exceeds the time within which he or she may resume his or her residency in the facility without waiting for readmission upon the first availability of a bed in a semiprivate room. 5. A facility for skilled nursing shall prepare a patient for his or her transfer or discharge in such a manner as to ensure the safe and orderly transfer or discharge of the patient from the facility. 6. As used in this section, “transfer” or “discharge” means the movement of a patient to a location outside of a facility for skilled nursing, whether or not that location is within the same physical area of the facility. The term does not include the movement of a patient to a bed located within the facility for skilled nursing. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74431 Summary of discharge. ( NRS 449.0302 ) 1. A facility for skilled nursing shall prepare a summary of discharge for each patient discharged from the facility. 2. A summary of discharge must include: (a) A summary of the pertinent information relating to the patient’s stay at the facility; (b) A final summary of the patient’s physical, mental and psychosocial health at the time of discharge, including, without limitation, the information required to be included in a comprehensive assessment of the patient pursuant to subsection 2 of NAC 449.74433 ; and (c) A plan of care for the patient after his or her discharge that assists the patient in adjusting to his or her new living environment. The plan of care must be developed with the participation of the patient and members of his or her family. 3. A facility for skilled nursing may release a summary of discharge to persons and under the circumstances approved by the patient who is the subject of the summary or his or her legal representative. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) Assessment of Patients and Plan of Care NAC 449.74433 Comprehensive assessment of needs of patient. ( NRS 449.0302 ) 1. A facility for skilled nursing shall conduct a comprehensive assessment of the needs of each patient in the facility using the assessment instrument specified by the Bureau. 2. A comprehensive assessment must include, without limitation: (a) Demographic and other pertinent information required to identify the patient; (b) The customary routine of the patient; (c) The cognitive patterns of the patient; (d) An analysis of the communication skills of the patient; (e) An analysis of the vision of the patient; (f) The mood and behavior patterns of the patient; (g) An analysis of the psychosocial well-being of the patient; (h) Any problems related to the functional or structural physical condition of the patient; (i) The patient’s pattern of continence; (j) The physical condition of the patient, including the diagnosis of any diseases which the patient may have; (k) An analysis of the nutritional needs of the patient; (l) The dental condition of the patient; (m) The condition of the patient’s skin; (n) Activities in which the patient is interested; (o) Medications required to be taken by the patient; (p) Any special treatments and procedures required by the patient; (q) The probability of discharging the patient from the facility and any other information related to the discharge of the patient from the facility; (r) Documentation of summary information relating to any additional assessment performed in accordance with the patient’s assessment protocols; and (s) Documentation of the patient’s participation in the assessment. 3. The information to be included in a comprehensive assessment must be obtained from the direct observation of and communication with the patient and from communications with the members of the staff who care for the patient. 4. A comprehensive assessment must be conducted: (a) Within 14 days after the patient’s admission to the facility. The provisions of this paragraph do not require a comprehensive assessment of a patient who is readmitted to the facility following a temporary absence from the facility for hospitalization or therapeutic leave if there is not a significant change in the physical or mental condition of the patient. (b) Within 14 days after there has been a significant decline or improvement in the physical or mental condition of the patient that: (1) Requires intervention by a member of the facility’s staff or further medical treatment; (2) Has affected more than one aspect of the patient’s health; and (3) Requires review by an interdisciplinary team or a revision of the patient’s plan of care, or both. (c) At least once every 12 months, but in no event later than 365 days after the completion of the most recent comprehensive assessment. 5. A comprehensive assessment must accurately reflect the physical, mental and psychosocial health of the patient. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74435 Quarterly assessment of patient. ( NRS 449.0302 ) 1. A facility for skilled nursing shall, not less than every 3 months, conduct an assessment of each patient in the facility using the quarterly assessment instrument approved by the Bureau. 2. Each quarterly assessment must accurately reflect the physical, mental and psychosocial health of the patient. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74437 Conduct of assessments. ( NRS 449.0302 ) 1. The assessments required by NAC 449.74433 and 449.74435 must be conducted by a registered nurse or coordinated by a registered nurse with the participation of other appropriate health care professionals. Each person who completes a portion of the assessment shall certify the accuracy of that portion. The registered nurse shall certify that the assessment is completed. 2. A facility for skilled nursing shall coordinate the assessments required by NAC 449.74433 and 449.74435 with other screening programs required to be conducted upon the patient’s admission to the facility to the extent practicable to avoid the duplication of efforts. 3. Each assessment required by NAC 449.74433 and 449.74435 must be: (a) Maintained in the medical record of the patient for at least 15 months after the assessment is conducted. (b) Used to develop, review and revise the patient’s plan of care. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74439 Comprehensive plan of care. ( NRS 449.0302 ) 1. A facility for skilled nursing shall develop for each patient in the facility a comprehensive plan of care. 2. A comprehensive plan of care must include: (a) Measurable objectives and timetables to meet the physical, mental and psychosocial needs of the patient that are identified in the comprehensive assessment required by NAC 449.74433 ; (b) A description of the services that will be provided to the patient to attain or maintain his or her highest practicable physical, mental and psychosocial well-being; and (c) A description of the services that would otherwise be provided to the patient, but will not be provided because of the patient’s refusal to accept those services. 3. A comprehensive plan of care must be: (a) Developed within 7 days after the completion of the initial comprehensive assessment required by NAC 449.74433 and periodically reviewed and revised after each subsequent assessment; and (b) Prepared by an interdisciplinary team that includes the patient’s attending physician, a registered nurse who is responsible for the care of the patient and such other members of the staff of the facility as are appropriate to provide services in accordance with the needs of the patient. To the extent practicable, the patient, his or her legal representative and members of his or her family must be allowed to participate in the development of the plan of care. 4. Services provided to a patient in a facility for skilled nursing must: (a) Comply with the professional standards of quality applicable to those services; and (b) Be provided by qualified persons in accordance with the patient’s plan of care. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) Medical Records NAC 449.74441 Maintenance. ( NRS 449.0302 ) 1. A facility for skilled nursing shall maintain medical records for each patient in the facility in accordance with accepted professional principles. 2. A medical record must be: (a) Complete; (b) Accurate; (c) Organized; and (d) Readily accessible to those persons who are authorized to review the records. 3. A medical record must include: (a) Sufficient information to identify the patient; (b) A record of the assessments of the patient conducted pursuant to NAC 449.74433 and 449.74435 ; (c) The patient’s plan of care and the services provided to the patient; (d) The results of any assessment of the patient conducted by a state agency before his or her admission to the facility; and (e) Periodic progress notes prepared by appropriate members of the staff. 4. A facility for skilled nursing shall maintain the medical records of a patient: (a) For at least 5 years after the discharge of the patient, unless state law requires otherwise; and (b) For at least 3 years after the patient reaches 18 years of age if the patient is a minor. 5. A facility for skilled nursing shall ensure that: (a) Information contained in a medical record is not lost, destroyed or used in an unauthorized manner. (b) No person willfully and knowingly falsifies or causes another person to falsify information contained in a medical record. 6. Information contained in a medical record is confidential and must not be released without the written consent of the patient except: (a) As required by law; (b) Under a contract involving a third-party payor; or (c) As required upon the transfer of the patient to another medical facility. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74443 Inspection. ( NRS 449.0302 ) 1. A patient in a facility for skilled nursing or his or her legal representative may submit an oral or written request to the facility to inspect all records relating to the patient maintained by the facility. The facility shall, within 24 hours after the receipt of such a request, excluding weekends and holidays, allow the patient or his or her legal representative to inspect the patient’s records. 2. Upon request, the facility shall furnish to the patient or his or her legal representative a copy of the records or any portion thereof at the cost of obtaining records from a provider of health care set forth in NRS 629.061 . The copy must be furnished within 48 hours after the receipt of the request, excluding weekends and holidays. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) Rights of Patients NAC 449.74445 Generally. ( NRS 449.0302 ) 1. A facility for skilled nursing shall protect and promote the rights of each patient in the facility. 2. In addition to the rights set forth in NRS 449A.106 and 449A.112 , a patient in a skilled nursing facility has the right to: (a) Receive care in a manner and environment that maintains and enhances each patient’s dignity with respect to each patient’s individuality. (b) Exercise his or her rights without the threat of interference, coercion, discrimination or reprisal. (c) Choose his or her attending physician. (d) Be fully informed, in a language that the patient understands, of his or her total health status, including, without limitation, his or her medical condition. (e) Participate in decisions relating to the patient’s health care, unless he or she is unable to do so because he or she is incompetent or incapacitated. (f) Receive services with reasonable accommodation for the patient’s individual needs and preferences, unless the health or safety of the patient or other patients would be endangered. (g) Privacy in relation to his or her accommodations, personal care, written and oral communications and meetings with other persons. The provisions of this paragraph do not require a facility for skilled nursing to provide a private room to each patient. (h) File grievances with the facility without the threat of discrimination or reprisal and to the prompt resolution of those grievances. Such grievances include, without limitation, complaints relating to treatment that has been furnished or not furnished and the behavior of other patients. (i) Use a telephone where calls can be made without being overheard. (j) Retain and use personal possessions as space allows, including, without limitation, furniture and clothing, unless to do so would infringe upon the rights or threaten the health and safety of other patients. (k) Share a room with his or her spouse if both spouses reside in the facility and consent to the arrangement. (l) Manage his or her financial affairs. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74447 Communications with other persons; examination of records by advocate. ( NRS 449.0302 ) 1. A facility for skilled nursing shall not prohibit a patient in the facility from contacting, receiving information from or speaking to: (a) A representative of the Bureau. (b) The patient’s physician. (c) Any person who advocates for the rights of the patients of the facility, including, without limitation: (1) Advocates for residents of facilities for long-term care appointed pursuant to chapter 427A of NRS; and (2) Persons who advocate for and are responsible for the protection of persons with developmental disabilities or who are mentally ill. (d) Any person who provides health care, social, legal or other services to the patient. (e) The relatives of the patient. (f) Any other persons with whom the patient wishes to visit. 2. The provisions of this section do not prohibit a facility for skilled nursing from adopting reasonable restrictions relating to the visitation of patients. 3. A facility for skilled nursing shall not prohibit an advocate for residents of facilities for long-term care appointed pursuant to chapter 427A of NRS from examining the medical records of a patient of the facility in accordance with state law and with the permission of the patient or the patient’s legal representative. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74449 Notice to patients of rights, services and charges. ( NRS 449.0302 ) 1. A facility for skilled nursing shall give notice to each patient admitted to the facility of: (a) His or her rights as a patient and of the policies of the facility relating to the conduct and responsibilities of patients in the facility; and (b) The services available at the facility and the charges for those services, including, without limitation, charges for services that are not covered by the facility’s per diem rate. 2. The notice required by subsection 1 must be given: (a) Orally and in writing; (b) In a language that the patient understands; and (c) Before or upon admission of the patient to the facility and periodically during the patient’s stay at the facility. 3. The written notice of the patient’s rights must include, without limitation: (a) A summary of the provisions of NAC 449.74461 and 449.74463 ; (b) The names, addresses and telephone numbers of: (1) The Bureau; (2) Advocates for residents of facilities for long-term care appointed pursuant to chapter 427A of NRS; (3) The Medicaid Fraud Control Unit within the Office of the Attorney General; and (4) Any other persons who advocate for the rights of patients in the facility; and (c) A statement that the patient may file a complaint with the Bureau concerning the abuse or neglect of any patient or the misappropriation of any patient’s money. 4. The patient must acknowledge in writing the receipt of each notice provided. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74451 Charges to be consistent with notice of charges. ( NRS 449.0302 ) Any amount charged for services provided by a facility for skilled nursing must be consistent with the notice of charges provided by the facility pursuant to NAC 449.74449 . (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74453 Notice to patients of programs available for assistance in payment of services. ( NRS 449.0302 ) A facility for skilled nursing shall: 1. Provide to applicants for admission to the facility and to the patients in the facility oral and written information concerning state and federal programs that are available to assist patients in the payment of services provided by the facility, including, without limitation, Medicaid and Medicare; and 2. Display in a prominent place within the facility the written information provided pursuant to subsection 1. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74457 Policies and procedures for advance directives by patient; information to be furnished regarding physicians. ( NRS 449.0302 ) 1. A facility for skilled nursing shall adopt written policies and procedures authorizing the patients in the facility to establish advance directives for their treatment. 2. The policies and procedures must require that written information be given to adult patients concerning their right to accept or refuse treatment and to establish advance directives for their treatment. 3. A facility for skilled nursing shall inform each patient in the facility of the name and specialty of the physician responsible for his or her care and the manner in which the physician may be contacted. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74459 Examination by patient of survey of facility and plan of correction. ( NRS 449.0302 ) 1. A patient of a facility for skilled nursing may examine the results of the most recent survey of the facility conducted by the Bureau or a federal regulatory agency and any plan of correction required to be carried out by the facility as a result of the survey. 2. A facility for skilled nursing shall: (a) Make such surveys and plans of correction available for examination at a place that is readily accessible to the patients of the facility; and (b) Post in a prominent location within the facility a notice of the places where the surveys and plans of correction are available for examination. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74461 Finances of patient: System for maintenance and accounting. ( NRS 449.0302 ) 1. A facility for skilled nursing: (a) Shall not require a patient to deposit any amount of money with the facility to be held by the facility on behalf of the patient. (b) Shall hold, safeguard, manage and account for money deposited with the facility on behalf of a patient if requested to do so in writing by the patient, in accordance with the provisions of this section and NAC 449.74463 . 2. If money held by a facility for skilled nursing on behalf of a patient is greater than $50, the money must be maintained in a financial institution in an account that: (a) Bears interest; (b) Is separate from the facility’s operating accounts; and (c) Credits all interest earned on the money in the account to the account. 3. If money held by a facility for skilled nursing on behalf of a patient is not more than $50, the money must be maintained in: (a) A financial institution in an account that bears interest; (b) A financial institution in an account that does not bear interest; or (c) A petty cash fund. 4. A facility for skilled nursing shall establish and maintain a system that provides a complete and separate accounting of the money held by the facility on behalf of a patient that is prepared according to generally accepted principles of accounting. The system must prohibit the commingling of the patient’s money with the facility’s money or the money of any person other than another patient. An accounting must be made available to the patient on a quarterly basis and upon the request of the patient or his or her legal representative. 5. A facility for skilled nursing shall obtain a surety bond or provide to the Bureau other assurances that are satisfactory to the Bureau to ensure the security of all money held by the facility on behalf of its patients. 6. A facility for skilled nursing shall, within 30 days after the death of a patient who has deposited money with the facility to hold on his or her behalf, deliver the money and a final accounting to the proper court or person administering the patient’s estate. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74463 Finances of patient: Authorization to withhold money. ( NRS 449.0302 ) 1. A facility for skilled nursing shall not withhold from money held by the facility on behalf of a patient any amount for: (a) Services related to the maintenance of the patient’s room or bed; (b) Supplies and services for routine personal hygiene that are required by the patient, including, without limitation: (1) Shampoo, a comb and a brush; (2) Bath soap, disinfecting soap or specialized cleansing agents required to treat the medical condition of the patient or to treat infection; (3) A razor and shaving cream; (4) A toothbrush, toothpaste, denture adhesive, dental cleaner and dental floss; (5) Moisturizing lotion; (6) Tissues, cotton balls and cotton swabs; (7) Deodorant; (8) Supplies and services for incontinence; (9) Sanitary napkins and related supplies; (10) Towels and washcloths; (11) Hospital gowns; (12) Nonprescription drugs; (13) Supplies and services for the patient’s nails; and (14) Supplies and services for the patient’s laundry; and (c) Medically-related social services required by NAC 449.74523 . 2. Except as otherwise provided in subsection 3, a facility for skilled nursing may withhold from money held by the facility on behalf of a patient amounts for the following items and services: (a) A telephone; (b) A television and radio for the patient’s personal use; (c) Personal comfort items, including, without limitation, smoking materials, notions, novelties and confections; (d) Cosmetic and grooming items and services that are not required for routine personal hygiene; (e) Clothing; (f) Reading material; (g) Gifts purchased on behalf of the patient; (h) Flowers and plants; (i) Items for social events and entertainment that are in addition to the program of activities required by NAC 449.74495 ; (j) Special services required for the care of the patient, including, without limitation, the services of a private nurse or aide; (k) A private room, unless a private room is required because of the medical condition of the patient; and (l) Food that is specially prepared for the patient or requested in lieu of food that is regularly prepared by the facility as required by NAC 449.74525 . 3. A facility for skilled nursing shall not: (a) Charge a patient any amount for an item or service that has not been requested by the patient. (b) Require a patient or his or her representative to request an item or service as a condition of the patient being admitted to or remaining in the facility. 4. If an item or service is requested by a patient or his or her representative for which there will be a charge, a facility for skilled nursing shall inform the patient or representative of the amount of the charge. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74465 Sending and receiving mail. ( NRS 449.0302 ) A facility for skilled nursing shall not prohibit a patient in the facility from: 1. Sending and promptly receiving mail. A patient’s mail must not be opened by the facility. 2. Obtaining stationery, postage and writing instruments at the patient’s expense. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74467 Performance of services for facility by patient. ( NRS 449.0302 ) 1. A facility for skilled nursing shall not require a patient in the facility to perform services for the facility. 2. A patient may perform services for the facility only if: (a) The facility has included in the patient’s plan of care his or her need or desire to perform services for the facility; (b) The plan of care describes the nature of the services to be performed and the compensation, if any, to be paid for those services; (c) The compensation to be paid for the services is at or above the prevailing wage; and (d) The patient agrees to perform the services described in the plan of care. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) Quality of Care NAC 449.74469 Standards of care. ( NRS 449.0302 ) A facility for skilled nursing shall provide to each patient in the facility the services and treatment that are necessary to attain and maintain the patient’s highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment conducted pursuant to NAC 449.74433 and the plan of care developed pursuant to NAC 449.74439 . (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74471 Administration of drugs. ( NRS 449.0302 ) 1. A facility for skilled nursing shall not administer a drug to a patient in the facility: (a) In excessive doses, including duplicate drug therapy; (b) For an excessive duration; (c) Without monitoring the patient properly; (d) Without adequate indications for the use of the drug; or (e) If there are any adverse reactions which indicate that the dosage should be reduced or discontinued. 2. Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433 , a facility for skilled nursing shall ensure that a patient who: (a) Has not used an antipsychotic drug is not given such a drug unless it is required to treat a condition of the patient that has been diagnosed and documented in the medical record of the patient. (b) Uses an antipsychotic drug receives gradual reductions in the dosage, in conjunction with behavioral intervention, in an attempt to discontinue the use of the drug, unless the medical condition of the patient requires otherwise. 3. A facility for skilled nursing shall ensure that patients are not subjected to significant errors in their medication and that the rate of error in the administration of medication is less than 5 percent. 4. A facility for skilled nursing shall not prohibit a patient from administering medication to himself or herself if the interdisciplinary team responsible for the care of the patient determines that this practice is safe. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74473 Program for control of infections. ( NRS 449.0302 ) 1. A facility for skilled nursing shall establish and maintain a program for the control of infections within the facility. 2. The program must: (a) Be designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of disease and infection. (b) Include procedures for the investigation, control and prevention of infections in the facility. (c) Establish the procedures that will be followed if a patient becomes infectious, including, without limitation, the circumstances under which a patient may be isolated. A facility shall isolate any patient if required to prevent the spread of infection. (d) Provide for the maintenance of records of infections and the corrective actions taken when infections occurred. 3. A facility shall ensure that: (a) An employee with a communicable disease or an infected skin lesion does not come into direct contact with patients in the facility or their food if such contact may result in the transmission of the disease. (b) Employees wash their hands after any direct contact with a patient if required by accepted professional practices. 4. Linens must be handled, stored, processed and transported in a manner which prevents the spread of infection. 5. The medical records of each patient in the facility must include documentation that the patient has been tested for tuberculosis in accordance with the provisions of NAC 441A.380 . (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74475 Vision and hearing. ( NRS 449.0302 ) A facility for skilled nursing shall: 1. Ensure that each patient in the facility receives proper treatment and devices for his or her vision and hearing. 2. Assist a patient, if necessary, in making appointments for the treatment of his or her vision and hearing. 3. If necessary, arrange transportation for a patient to visit a practitioner for the treatment of the patient’s vision or hearing or to obtain devices needed for his or her vision or hearing. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74477 Pressure sores. ( NRS 449.0302 ) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433 , a facility for skilled nursing shall ensure that a patient: 1. Who is admitted to the facility without pressure sores does not develop pressure sores unless the development of pressure sores is unavoidable because of the medical condition of the patient; and 2. With pressure sores receives the services and treatment needed to promote healing, prevent infection and prevent new sores from developing. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74479 Urinary problems. ( NRS 449.0302 ) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433 , a facility for skilled nursing shall ensure that a patient: 1. Who is admitted to the facility without an indwelling catheter is not required to use a catheter unless catheterization is unavoidable because of the medical condition of the patient; and 2. Who is incontinent receives the services and treatment needed to prevent the infection of the patient’s urinary tract and restore the normal function of his or her bladder. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74481 Range of motion. ( NRS 449.0302 ) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433 , a facility for skilled nursing shall ensure that: 1. The range of motion of a patient admitted to the facility is not reduced unless the reduction is unavoidable because of the medical condition of the patient; and 2. A patient with a limited range of motion receives the services and treatment needed to increase the patient’s range of motion and to prevent any further loss in his or her range of motion. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74483 Mental or psychosocial behavior. ( NRS 449.0302 ) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433 , a facility for skilled nursing shall ensure that a patient: 1. Who is having difficulty adjusting to his or her environment and is exhibiting abnormal mental or psychosocial behavior receives the services and treatment needed to correct the assessed problem; and 2. Whose assessment does not indicate any difficulty adjusting to the patient’s environment or abnormal mental or psychosocial behavior does not become withdrawn, angry or depressed or decrease his or her social interaction unless such behavior is unavoidable because of the medical condition of the patient. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74485 Nasogastric tubes. ( NRS 449.0302 ) Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433 , a facility for skilled nursing shall ensure that a patient who is: 1. Able to feed himself or herself with or without assistance is not fed with a nasogastric tube unless a nasogastric tube is unavoidable because of the medical condition of the patient; and 2. Fed with a nasogastric tube receives the services and treatment needed to: (a) Prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers; and (b) Restore, if possible, normal eating skills. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74487 Nutritional health; hydration. ( NRS 449.0302 ) 1. Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433 , a facility for skilled nursing shall ensure that: (a) The nutritional health of the patient is maintained, including, without limitation, the maintenance of his or her weight and levels of protein, unless the nutritional health of the patient cannot be maintained because of his or her medical condition. (b) The patient receives a therapeutic diet if such a diet is required by the patient. 2. A facility for skilled nursing shall provide each patient in the facility with sufficient fluids to maintain proper hydration and health. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74489 Physical or chemical restraint of patients. ( NRS 449.0302 ) 1. A facility for skilled nursing shall not use physical or chemical restraints on a patient to discipline the patient or for the convenience of members of the staff. 2. Physical or chemical restraints may be used only if required to treat a patient’s medical symptoms. 3. As used in this section: (a) “Chemical restraints” means a psychopharmacologic drug that is not required to treat the medical symptoms of a patient, but is used to discipline a patient or for the convenience of members of the staff of a facility for skilled nursing. (b) “Physical restraints” means any manual method or physical or mechanical device, material or equipment attached or adjacent to a patient’s body that cannot be removed easily by the patient and restricts the freedom of movement of the patient or normal access to the patient’s body. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74491 Prohibition of certain practices regarding patients; investigation of certain violations and injuries to patients; unfit employees. ( NRS 449.0302 ) 1. A facility for skilled nursing shall adopt and carry out written policies and procedures that prohibit: (a) The mistreatment and neglect of the patients in the facility; (b) The verbal, sexual, physical and mental abuse of the patients in the facility; (c) Corporal punishment and involuntary seclusion; and (d) The misappropriation of the property of the patients in the facility. 2. A facility for skilled nursing shall adopt procedures which ensure that all alleged violations of the policies adopted pursuant to subsection 1 and injuries to patients of unknown origin are reported immediately to the administrator of the facility, to the Bureau and to other officials in accordance with state law, and are thoroughly investigated. The procedures must ensure that further violations are prevented while the investigation is being conducted. 3. The results of any investigation must be reported: (a) To the administrator of the facility or his or her designated representative and to the Bureau within 5 working days after the alleged violation is reported. (b) In the manner prescribed in NRS 200.5093 and 432B.220 and chapter 433 of NRS. Ê The administrator of the facility shall take appropriate action to correct any violation. 4. A facility for skilled nursing: (a) Shall not employ a person if: (1) The person has been convicted of abusing, neglecting or mistreating a patient; or (2) A finding that he or she has abused, neglected, mistreated or misappropriated the property of a patient has been entered in the state nursing assistants registry maintained by the State Board of Nursing. (b) Shall report to the State Board of Nursing, the Bureau or another appropriate occupational licensing board any judicial action taken against an employee or former employee of the facility which would indicate that the employee is unfit to be employed as a member of the staff of a facility for skilled nursing. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74493 Notification of changes or condition of patient. ( NRS 449.0302 ) 1. A facility for skilled nursing shall immediately notify a patient, the patient’s legal representative or an interested member of the patient’s family, if known, and, if appropriate, the patient’s physician when: (a) The patient has been injured in an accident and may require treatment from a physician; (b) The patient’s physical, mental or psychosocial health has deteriorated and resulted in medical complications or is threatening the patient’s life; (c) There is a need to discontinue the current treatment of the patient because of adverse consequences caused by that treatment or to commence a new type of treatment; (d) The patient will be transferred or discharged from the facility; (e) The patient will be assigned to another room or assigned a new roommate; or (f) There is any change in federal or state law that affects the rights of the patient. 2. A facility for skilled nursing shall maintain in its records and periodically revise the address and telephone number of a patient’s legal representative and interested members of the patient’s family. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74495 Development of program of activities. ( NRS 449.0302 ) 1. A facility for skilled nursing shall provide for each patient in the facility a program of activities that is developed in accordance with the comprehensive assessment of the patient conducted pursuant to NAC 449.74433 . 2. The program of activities must be directed by a member of the staff who: (a) Is a therapeutic recreational specialist or activities specialist and is eligible for certification by an organization for accrediting such specialists; (b) Within the preceding 5 years, has at least 2 years of experience working in a social or recreational program, 1 year of which was as a full-time employee in a patient activities program in a health care setting; (c) Is a licensed occupational therapist or occupational therapy assistant; or (d) Has completed a course of training for directing programs of activities for patients in a health care setting. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74497 Daily activities of patient. ( NRS 449.0302 ) 1. Based on the comprehensive assessment of a patient conducted pursuant to NAC 449.74433 , a facility for skilled nursing shall ensure that: (a) The patient’s ability to carry out his or her daily activities does not diminish unless such diminution is unavoidable because of the medical condition of the patient; (b) The patient receives the services and treatment needed to maintain or improve the patient’s ability to carry out his or her daily activities; and (c) The patient receives the services needed to maintain his or her grooming and personal and oral hygiene, and to ensure good nutrition, if the patient is unable to carry out his or her daily activities. 2. As used in this section, “daily activities” includes, without limitation: (a) Bathing, dressing and grooming oneself; (b) The ability to be ambulatory; (c) Using the toilet without assistance; (d) Feeding oneself; and (e) Using speech, language and other communication systems. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74499 Participation in activities. ( NRS 449.0302 ) 1. A facility for skilled nursing shall not prohibit a patient in the facility from: (a) Participating in activities and maintaining a schedule that are consistent with the patient’s interests, assessments and plan of care; (b) Making choices relating to the patient’s health care that are consistent with his or her plan of care; (c) Interacting with persons inside and outside of the facility; (d) Participating in social, religious and community activities that do not interfere with other patients in the facility; and (e) Making such other choices relating to his or her activities within the facility that are of significance to the patient. 2. A patient in a facility for skilled nursing may organize and participate in groups formed to interact with other patients in the facility and with the members of their families. A facility for skilled nursing shall provide a private area within the facility in which the members of such a group may meet. 3. A member of the staff of the facility or a visitor to the facility may attend a meeting of such a group if granted permission to do so by the members of the group. 4. A facility for skilled nursing shall designate a member of its staff to provide assistance for and respond to the requests of such a group. 5. The administrator of a facility for skilled nursing shall ensure that any grievances or recommendations submitted by the members of such a group relating to the operation of the facility are given consideration and acted upon appropriately. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) Staff and Attending Physicians NAC 449.74511 Personnel policies; personnel records. ( NRS 449.0302 ) 1. A facility for skilled nursing shall adopt written policies for the personnel employed at the facility. 2. The written policies must: (a) Include the duties and responsibilities of, and the qualifications required for, each position at the facility; (b) Include the conditions of employment for each position at the facility; (c) Include the policies and objectives of the facility related to training while on the job and requirements for continuing education; and (d) Be periodically reviewed and made available to each employee of the facility. 3. A current and accurate personnel record for each employee of the facility must be maintained at the facility. The record must include, without limitation: (a) Evidence that the employee has obtained any license, certificate or registration, and possesses the experience and qualifications, required for the position held by the employee; (b) Such health records as are required by chapter 441A of NAC which include evidence that the employee has had a skin test for tuberculosis in accordance with NAC 441A.375 ; and (c) Documentation that the facility has not received any information that the employee has been convicted of a crime listed in paragraph (a) of subsection 1 of NRS 449.174 . 4. A facility shall make its personnel records available to the Bureau for inspection upon request. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74513 Medical director. ( NRS 449.0302 ) 1. A facility for skilled nursing shall employ a medical director who is licensed to practice medicine in this State. 2. The medical director shall: (a) Carry out the policies of the facility related to the medical care of its patients; and (b) Coordinate the medical care provided by the facility. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74515 Physicians. ( NRS 449.0302 ) 1. A patient may be admitted to a facility for skilled nursing only upon the written approval of a physician. Upon a patient’s admission to the facility, the facility shall ensure that orders for the immediate care of the patient have been received from the patient’s attending physician. 2. Each patient admitted to a facility for skilled nursing must remain under the care of a physician. 3. A facility for skilled nursing shall ensure that: (a) The medical care of each patient in the facility is supervised by a physician; and (b) A physician other than the attending physician of a patient supervises the care of that patient when the attending physician is not available. 4. A patient in a facility for skilled nursing must be visited by a physician at least once every 30 days for the first 90 days after his or her admission to the facility, and at least once every 60 days thereafter. For the purposes of this subsection, a visit from a physician shall be deemed to be timely if it occurs not later than 10 days after the date on which the visit is required. Except as otherwise provided in this section, each visit required by this subsection must be made by the physician. 5. At each visit to a patient required by subsection 4: (a) The patient’s plan of care must be reviewed, including, without limitation, the medications and treatments prescribed for the patient; (b) Progress notes of the visit must be prepared, signed and dated; and (c) Any orders for the treatment of the patient must be signed and dated. 6. After the initial visit to a patient is made by a physician, every other visit to the patient may be made by a physician assistant, nurse practitioner or clinical nurse specialist on behalf of the physician if the physician assistant, nurse practitioner or clinical nurse specialist is acting: (a) Within the authorized scope of his or her practice and under the supervision of the physician; and (b) In accordance with state law and the policies of the facility for skilled nursing. 7. A facility for skilled nursing shall provide or arrange for the provision of physicians’ services 24 hours a day in the case of an emergency. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74517 Nursing staff. ( NRS 449.0302 ) 1. A facility for skilled nursing shall ensure that there is a sufficient number of members of the nursing staff on duty at all times to provide nursing care to and attain and maintain the highest practicable physical, mental and psychosocial well-being of each patient in the facility in accordance with his or her plan of care. 2. A facility for skilled nursing shall employ a full-time registered nurse to act as the chief administrative nurse. The chief administrative nurse must have: (a) At least 3 years of experience providing nursing care in a hospital or facility for long-term care; and (b) Experience supervising other employees. 3. A licensed practical nurse must be designated on each shift as the nurse in charge. The chief administrative nurse may be designated as the nurse in charge only if the facility has an average daily occupancy of not more than 60 patients. 4. A registered nurse must be on duty at a facility for skilled nursing for at least 8 consecutive hours per day, 7 days a week. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74519 Nursing assistants and nursing assistant trainees. ( NRS 449.0302 ) 1. A facility for skilled nursing shall not employ a person as a nursing assistant trainee, full-time, temporarily or under contract: (a) Until the facility obtains from the training program required for certification as a nursing assistant in which the person is enrolled, verification that the person has completed 16 hours of instruction in the classroom or is awaiting the results of a certification examination. (b) For more than 4 months. 2. A facility for skilled nursing shall ensure that each nursing assistant employed by the facility is able to demonstrate competency in skills and techniques that are necessary to care for the patients in the facility in accordance with each patient’s plan of care. 3. A performance review must be completed for each nursing assistant employed by a facility for skilled nursing at least annually. Based on the results of the review, a facility shall provide training to a nursing assistant to ensure his or her competency. The training must: (a) Comply with any requirements for training adopted by the State Board of Nursing pursuant to chapter 632 of NRS; (b) Be at least 12 hours per year; (c) Address any areas of weakness indicated in the review and may address the special needs of the patients in the facility as determined by the personnel of the facility; and (d) If the nursing assistant provides services to patients with cognitive impairments, address the care of such patients. 4. A facility for skilled nursing shall not employ a nursing assistant if, for a period of 24 consecutive months after his or her completion of the training program required for certification as a nursing assistant, the nursing assistant has not provided nursing services or services related to nursing for monetary compensation. 5. As used in this section: (a) “Nursing assistant” has the meaning ascribed to it in NRS 632.0166 . (b) “Nursing assistant trainee” has the meaning ascribed to it in NRS 632.0168 . (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74521 Other health care professionals. ( NRS 449.0302 ) 1. A facility for skilled nursing shall employ full-time, part-time or as consultants such health care professionals as are necessary to provide adequate care for each patient in the facility and to carry out the provisions of NAC 449.744 to 449.74549 , inclusive. 2. A health care professional employed by a facility for skilled nursing shall comply with accepted professional standards applicable to the services provided by the health care professional. 3. If a facility for skilled nursing does not employ a person to furnish a service required by the facility, the facility shall obtain that service from a qualified outside source. An agreement for obtaining such services must specify, in writing, that the facility assumes responsibility for: (a) Obtaining services that comply with accepted professional standards applicable to the services being obtained; and (b) The timely delivery of such services. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74522 Employees of facility which provides care to persons with dementia. ( NRS 449.0302 , 449.094 ) 1. Except as otherwise provided in subsection 4, each person who is employed by a facility for skilled nursing which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, who has direct contact with and provides care to persons with any form of dementia and who is licensed or certified by an occupational licensing board must complete the following number of hours of continuing education specifically related to dementia: (a) In his or her first year of employment with a facility for skilled nursing, 8 hours which must be completed within the first 30 days after the employee begins employment; and (b) For every year after the first year of employment, 3 hours which must be completed on or before the anniversary date of the first day of employment. 2. The hours of continuing education required to be completed pursuant to this section: (a) Must be approved by the occupational licensing board which licensed or certified the person completing the continuing education; and (b) May be used to satisfy any continuing education requirements of an occupational licensing board and do not constitute additional hours or units of required continuing education. 3. Each facility for skilled nursing shall maintain proof of completion of the hours of continuing education required pursuant to this section in the personnel file of each employee of the facility who is required to complete continuing education pursuant to this section. 4. A person employed by a facility for skilled nursing which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer’s disease, is not required to complete the hours of continuing education specifically related to dementia required pursuant to subsection 1 if he or she has completed that training within the previous 12 months. 5. As used in this section, “continuing education specifically related to dementia” includes, without limitation, instruction regarding: (a) An overview of the disease of dementia, including, without limitation, dementia caused by Alzheimer’s disease, which includes instruction on the symptoms, prognosis and treatment of the disease; (b) Communicating with a person with dementia; (c) Providing personal care to a person with dementia; (d) Recreational and social activities for a person with dementia; (e) Aggressive and other difficult behaviors of a person with dementia; and (f) Advising family members of a person with dementia concerning interaction with the person with dementia. (Added to NAC by Bd. of Health by R067-04, eff. 8-4-2004) Provision of Services NAC 449.74523 Social services. ( NRS 449.0302 ) 1. A facility for skilled nursing shall provide medically-related social services that are designed to assist the patients in the facility in enhancing or restoring their ability to function physically, socially and economically. 2. The social services provided must: (a) Identify and meet the social and emotional needs of each patient in the facility. (b) Assist each patient and the members of his or her family in adjusting to the effects of the patient’s illness or disability, to the patient’s treatment and to his or her stay in the facility. (c) Include adequate planning upon the patient’s discharge from the facility to ensure that appropriate community and health resources are used. 3. A facility for skilled nursing shall employ full-time or under contract an adequate number of social workers and other personnel who are appropriately trained, experienced and qualified to plan, provide and evaluate the social services provided to the patients in the facility. Each social worker employed by the facility must be licensed to engage in social work as a social worker pursuant to chapter 641B of NRS. The facility shall adopt and carry out a plan requiring any social worker employed by the facility who has not completed at least 1 year of training or experience related to providing social services to patients in a facility for skilled nursing to consult with a social worker with such training or experience. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74525 Dietary services. ( NRS 439.200 , 449.0302 , 449.1915 ) 1. A facility for skilled nursing shall employ full-time, part-time or as a consultant, a person who is a licensed dietitian. If a licensed dietitian is not employed full-time, the facility shall designate a person to serve as the director of food service who receives frequently scheduled consultations from a licensed dietitian. 2. A facility shall employ an adequate number of qualified and competent personnel to provide food service to the patients in the facility. 3. Menus must be planned in advance and followed to meet the nutritional needs of the patients in the facility in accordance with the recommended dietary allowances of the Food and Nutrition Board of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine. 4. A facility shall provide to each patient in the facility: (a) Food that is prepared to conserve the nutritional value and flavor of the food. (b) Food that is nourishing, palatable, attractive and served at the proper temperature. (c) A well-balanced diet that meets the daily nutritional and special dietary needs of the patient. (d) Who refuses the food that is regularly served by the facility, a substitute of similar nutritional value. 5. A therapeutic diet served to a patient by a facility must be prescribed by the attending physician, physician assistant, dentist, advanced practice registered nurse or podiatric physician of the patient or ordered by a licensed dietitian. 6. A facility shall serve to each patient in the facility at least three meals daily, at such times as are comparable to regular mealtimes within the community in which the facility is located. A snack must be offered to each patient daily at bedtime. Except as otherwise provided in this subsection, breakfast must be served not more than 14 hours after the previous evening meal. If a nourishing snack is served at bedtime, breakfast may be served not more than 16 hours after the previous evening meal if approved by a group of patients organized pursuant to NAC 449.74499 . 7. A facility shall provide special eating equipment and utensils to each patient who requires them. 8. A facility shall: (a) Comply with the applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto and obtain such permits as are necessary from the Division for the preparation and service of food; (b) Maintain a report of each inspection concerning the sanitation of the facility for at least 1 year after the date of the inspection; (c) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (b) for at least 1 year after the date of the corrective action; (d) Procure food from sources that are approved or considered satisfactory by federal, state and local authorities; (e) Store, prepare and serve food under sanitary conditions; and (f) Dispose of refuse and garbage properly. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R067-04, 8-4-2004; R155-10, 12-16-2010; R090-12, 12-20-2012; R048-22, 12-29-2022) NAC 449.74527 Specialized rehabilitative services. ( NRS 449.0302 ) 1. A facility for skilled nursing shall provide to a patient in the facility, according to his or her plan of care, specialized rehabilitative services, including, without limitation, physical therapy, speech-language pathology, occupational therapy and services for mental illness and intellectual disabilities. Such services must be provided by the facility or obtained from qualified outside sources pursuant to NAC 449.74521 . 2. Specialized rehabilitative services may be provided to a patient in a facility only upon the written order of a physician. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74529 Dental services. ( NRS 449.0302 ) A facility for skilled nursing shall: 1. Provide or obtain from qualified outside sources pursuant to NAC 449.74521 , routine and emergency dental services required to meet the needs of each patient in the facility; 2. Assist patients in the facility with obtaining routine and emergency dental care by: (a) Making appointments; and (b) Arranging for transportation to and from a dentist’s office; and 3. Promptly refer a patient with lost or damaged dentures to a dentist. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74531 Pharmaceutical services. ( NRS 449.0302 ) 1. A facility for skilled nursing shall provide such pharmaceutical services, including, without limitation, acquiring, receiving, dispensing and administering drugs and biologicals, as are required to meet the needs of the patients in the facility. The facility shall provide such drugs and biologicals as are needed or obtain them from qualified outside sources pursuant to NAC 449.74521 . 2. A facility for skilled nursing shall employ or otherwise obtain the services of a registered pharmacist. The registered pharmacist shall: (a) Provide consultations on all matters relating to the pharmaceutical services provided by the facility; (b) Establish a system of records for the receipt and disposition of all controlled substances in the facility in sufficient detail to ensure an accurate reconciliation; and (c) Ensure that those records are in order and that an account of all controlled substances in the facility is maintained and periodically reconciled. 3. The regimen of drugs for each patient in the facility must be reviewed at least once each month by a registered pharmacist. The pharmacist shall report any irregularities he or she discovers to the patient’s attending physician and the chief administrative nurse of the facility. The physician and chief administrative nurse shall take such actions as they deem necessary in response to the report. 4. Drugs and biologicals used by a facility must be: (a) Labeled in accordance with state and federal law and accepted professional standards. Each label must include the appropriate accessory and cautionary instructions and the expiration date, if applicable. (b) Stored in accordance with state and federal law in locked compartments with proper controls for the temperature. Only authorized personnel may have access to the keys to unlock the compartments. Substances listed as schedule II controlled substances pursuant to chapter 453 of NRS and other drugs that have the potential for misuse must be stored separately in a locked compartment that is immovable, unless the facility uses a system to distribute the substances or drugs in single-unit packages, the quantity stored is minimal and a dosage that is missing can be readily detected. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74533 Laboratory services. ( NRS 449.0302 ) 1. A facility for skilled nursing shall provide laboratory services to meet the needs of the patients in the facility or contract with a laboratory to obtain such services. 2. If a facility for skilled nursing has its own laboratory, it must be a licensed clinical laboratory under the provisions of chapter 652 of NRS and comply with the provisions of 42 C.F.R. Part 493. The provisions of this subsection do not prohibit a licensed nurse from performing laboratory tests pursuant to NRS 652.217 . 3. If the facility contracts with a laboratory for its services, that laboratory must be: (a) A licensed clinical laboratory under the provisions of chapter 652 of NRS; and (b) Certified in the specialties and subspecialties required by the facility in accordance with the provisions of 42 C.F.R. Part 493. 4. A facility for skilled nursing shall: (a) Provide or obtain only such laboratory tests as are ordered by the attending physician of a patient in the facility; (b) Promptly notify the attending physician of the results of those tests; (c) Arrange transportation for a patient to obtain laboratory tests ordered by the patient’s attending physician, if the patient requires such assistance; and (d) Include in the medical records of a patient all reports of the results of laboratory tests ordered for the patient. The reports must include: (1) The date on which the tests were performed; and (2) The name and address of the laboratory performing the tests. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74535 Radiological and other diagnostic services. ( NRS 449.0302 ) 1. A facility for skilled nursing shall provide radiological and other diagnostic services to meet the needs of the patients in the facility or contract with qualified outside sources to obtain such services. 2. If a facility for skilled nursing provides radiological and other diagnostic services, it shall comply with applicable state law related to the provision of such services. 3. A facility for skilled nursing shall: (a) Provide or obtain only such radiological and other diagnostic tests as are ordered by the attending physician of a patient in the facility; (b) Promptly notify the attending physician of the results of those tests; (c) Arrange transportation for a patient to obtain radiological and other diagnostic tests ordered by the patient’s attending physician, if the patient requires such assistance; and (d) Include in the medical records of a patient all reports of the results of radiological and other diagnostic tests ordered for the patient. The reports must: (1) Include the date on which the tests were performed; and (2) Be signed by the person performing the tests. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74537 Special services. ( NRS 449.0302 ) A facility for skilled nursing shall ensure that a patient in the facility receives the following special services if needed: 1. Injections. 2. Parenteral and enteral fluids. 3. Colostomy, ureterostomy and ileostomy care. 4. Tracheostomy care. 5. Tracheal suctioning. 6. Respiratory care. 7. Foot care. 8. Prostheses. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) Physical Environment NAC 449.74539 General requirements. ( NRS 449.0302 ) A facility for skilled nursing shall: 1. Provide a safe, functional, sanitary and comfortable environment for the patients in the facility, the members of its staff and members of the general public; 2. Care for each patient in the facility in a manner that promotes the dignity of the patient and his or her quality of life; 3. Ensure that the environment of the facility is free of hazards that would cause accidents; 4. Ensure that each patient in the facility receives adequate supervision and devices to prevent accidents; 5. Provide such housekeeping and maintenance services as are necessary to maintain a sanitary, orderly and comfortable environment; 6. Adopt procedures to ensure that water is available to the essential areas of the facility if there is an interruption in the facility’s normal supply of water; 7. Equip corridors with firmly secured handrails on each side; 8. Provide adequate and comfortable levels of lighting in all areas of the facility; 9. Provide comfortable levels of sound in all areas of the facility; 10. Maintain an effective program to control pests in order to ensure that the facility is free from pests and rodents; 11. Have adequate outside ventilation by means of windows or mechanical ventilation, or both; and 12. Provide safe and comfortable levels of temperature in the facility. The temperature of the facility must be maintained at a level that is not less than 71 degrees Fahrenheit and not more than 81 degrees Fahrenheit. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99) NAC 449.74543 Design, construction, equipment and maintenance: General requirements; prerequisites to approval of facility for licensure. ( NRS 439.200 , 449.0302 ) 1. A facility for skilled nursing must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the facility and members of the general public. 2. Except as otherwise provided in this section: (a) A facility for skilled nursing shall comply with the provisions of NFPA 101: Life Safety Code , adopted by reference pursuant to NAC 449.0105 . (b) Any new construction, remodeling or change in use of a facility for skilled nursing must comply with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 , unless the remodeling is limited to refurbishing an area within the facility, including, without limitation, painting the area, replacing the flooring, repairing windows, or replacing window and wall coverings. 3. A facility for skilled nursing shall be deemed to be in compliance with the provisions of subsection 2 if: (a) The facility is licensed on January 1, 1999, the use of the physical space in the facility is not changed and there are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the public health and welfare; or (b) The facility has submitted building plans to the Bureau before February 1, 1999, and: (1) The Bureau determines that the plans comply with standards for construction in effect before December 11, 1998; (2) The facility is constructed in accordance with those standards; (3) Construction of the facility is begun before August 1, 1999; and (4) There are no deficiencies in the construction of the facility that are likely to cause serious injury, harm or impairment to the public health and welfare. 4. Except as otherwise provided in subsection 5, a facility for skilled nursing shall comply with all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Life safety, environmental, health, fire and local building codes, Ê related to the construction and maintenance of the facility. If there is a difference between state and local requirements, the more stringent requirements apply. 5. A facility for skilled nursing which is inspected and approved by the State Public Works Division of the Department of Administration in accordance with the provisions set forth in chapter 341 of NRS and chapter 341 of NAC is not required to comply with any applicable local building codes related to the construction and maintenance of the facility. 6. A facility for skilled nursing shall submit building plans for new construction or remodeling to the entity designated to review such plans by the Division of Public and Behavioral Health pursuant to NAC 449.0115 . The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the facility. Before the construction or remodeling may begin, the plans for the construction or remodeling must be approved by the Division of Public and Behavioral Health. The Bureau shall not approve a facility for licensure until all construction is completed and a survey is conducted at the site of the facility. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R076-01, 10-18-2001; R067-04, 8-4-2004; R122-16, 9-21-2017; R048-22, 12-29-2022) NAC 449.74549 Patients’ rooms. ( NRS 449.0302 ) 1. A patient’s room within a facility for skilled nursing must be designed and equipped in a manner that allows adequate nursing care to be provided and provides comfort and privacy for the patient. 2. A facility for skilled nursing shall provide to each patient in the facility: (a) A separate bed of proper size and height for the convenience of the patient; (b) A clean, comfortable mattress; (c) Bedding that is appropriate for the weather and climate; (d) Clean linens for his or her bed and bath that are in good condition; and (e) Furniture that is appropriate for the patient’s needs. (Added to NAC by Bd. of Health by R051-99, eff. 9-27-99; A by R067-04, 8-4-2004) NURSING POOLS General Provisions NAC 449.747 Definitions. ( NRS 449.0302 ) As used in NAC 449.747 to 449.7481 , inclusive, unless the context otherwise requires: 1. “License” means a document issued by the Division permitting the operation of a nursing pool. 2. “Licensee” means a person to whom a license has been issued. 3. “Nursing pool” has the meaning ascribed to it in NRS 449.0153 . (Added to NAC by Bd. of Health, eff. 1-31-90; A 8-1-91; R044-97, 10-30-97) Licensing NAC 449.7471 License required. ( NRS 449.0302 ) No person, state or local government, or agency thereof, may establish, conduct or maintain in this State a nursing pool without first obtaining a license from the Division. (Added to NAC by Bd. of Health, 1-31-90, eff. 7-1-90) NAC 449.7473 Location to which license applies; persons named in license; restrictions on use of license. ( NRS 449.0302 ) 1. Each license is separate and distinct and is issued to a specific person to operate a nursing pool at a specific location. A nursing pool must be operated and conducted under the name and within the area of service designated on the license. The name of the person who is designated as responsible for its conduct must appear on the face of the license. 2. A separate license is required for each nursing pool owned and controlled by a central organization, corporate entity or home office, but operated and directed by governing and administrative bodies separate from the central organization or any other unit owned and controlled by the central organization. (Added to NAC by Bd. of Health, eff. 1-31-90; A by R044-97, 10-30-97) NAC 449.7474 Duties of licensee or applicant for license. ( NRS 449.0302 ) 1. A licensee or applicant for a license shall: (a) Designate a person who is responsible for the conduct of the nursing pool; and (b) Disclose the ownership of the nursing pool to the Division. 2. A licensee or applicant for a license is responsible for: (a) Compliance by the nursing pool with all applicable local, state and federal laws, regulations and similar requirements. (b) Periodic administrative and professional evaluations of the nursing pool. The licensee or applicant shall receive, review and take action on recommendations made by the evaluating groups and maintain a record of that action. (c) The appointment of a qualified administrator and the delegation of his or her responsibility and authority. The licensee or applicant shall ensure that the administrator has sufficient freedom from his or her other responsibilities to permit his or her adequate attention to the overall direction and management of the nursing pool. (d) The appointment of a director of professional services. 3. A licensee or applicant for a license shall adopt policies, including policies relating to the care of patients, and bylaws for the nursing pool. The bylaws must be written, revised as needed and made available to the Division. The bylaws must contain not less than the following: (a) A description of the persons to whom responsibilities for the administration and supervision of the program and the evaluation of practices may be delegated, and the methods by which the licensee or applicant will hold those persons responsible. (b) A provision requiring the establishment of personnel policies. (c) A statement of the objectives of the nursing pool. (Added to NAC by Bd. of Health, eff. 1-31-90) Administration and Personnel NAC 449.7475 Administrator: Qualifications and duties. ( NRS 449.0302 ) 1. The administrator of a nursing pool must be a physician or professional registered nurse, licensed to practice in this State, or a person having at least 1 year of supervisory or administrative experience in a field related to the provision of health care. 2. The administrator of a nursing pool shall represent the licensee in the daily operation of the nursing pool and appoint a person to exercise his or her authority in his or her absence. The administrator’s responsibilities include: (a) Keeping the licensee fully informed of the activities of the nursing pool through regularly written reports; (b) Employing qualified personnel and arranging for their orientation and continuing education; (c) Developing and implementing an accounting and reporting system that reflects the fiscal experience and current financial position of the nursing pool; (d) Negotiating for services provided by contract in accordance with legal requirements and established policies of the nursing pool; (e) Holding periodic meetings to maintain a liaison between the licensee and members of the staff of the nursing pool; and (f) Performing such other duties as may be assigned. (Added to NAC by Bd. of Health, eff. 1-31-90) NAC 449.7476 Director of professional services: Qualifications and duties. ( NRS 449.0302 ) 1. The director of professional services must be a physician, or a professional registered nurse, who is licensed to practice in this State. The director must be readily available through the office of the nursing pool to advise members of the staff of the nursing pool. 2. The director of professional services shall: (a) Direct, supervise and coordinate the skilled nursing services provided by the nursing pool; (b) Develop and revise written objectives, policies and procedural manuals for the care of patients; (c) Assist in the development of descriptions of jobs; (d) Assist in the recruitment and selection of personnel; (e) Recommend to the administrator the number and levels of members of the nursing staff; (f) Plan and conduct orientations and continuing education for members of the staff engaged in the care of patients; (g) Evaluate the performance of the nursing staff; and (h) Assist in planning and budgeting for the provision of services. (Added to NAC by Bd. of Health, eff. 1-31-90) NAC 449.7477 Personnel policies: Maintenance and availability. ( NRS 449.0302 ) A nursing pool shall maintain written policies concerning the qualifications, responsibilities and conditions of employment for each category of personnel, including licensure when required by law. The written policies must be reviewed as needed, made available to the members of the staff of the nursing pool and provide for: 1. Wages and hours; 2. Eligibility for vacations, sick leave and other benefits; 3. Maintenance of a current record of the health of each member of the staff; 4. Orientation of all health personnel to the policies and objectives of the nursing pool, training while on the job and continuing education; 5. Periodic evaluations of the performance of members of the staff; 6. Descriptions of jobs for each category of personnel which are specific and include the types of activities each category may perform; and 7. Maintenance of current personnel records which confirm that the policies are followed. (Added to NAC by Bd. of Health, eff. 1-31-90) NAC 449.7478 Requirements for contracts to provide nursing services. ( NRS 449.0302 ) If a nursing pool provides nursing services under a contract with another entity, other than a licensed medical facility, the services must be furnished in accordance with the terms of a written contract. The contract must: 1. Provide for retention by the nursing pool of responsibility for and control of the services. 2. Designate the services to be provided, including the setting and geographical area to be served. Services provided must be within the scope and limitations set forth in a physician’s plan of treatment for his or her patient, and must not be altered with regard to type, amount, frequency or duration, unless the patient suffers an adverse reaction to that treatment. 3. Describe the means of supervision of the personnel performing the services. 4. Describe the method of coordinating the services with the nursing pool. 5. Specify the method of determining charges by and reimbursement of the nursing pool for specific services provided under the contract. Only the nursing pool may bill or collect for services rendered. 6. Specify the period the contract will be effective and the frequency with which the contract will be reviewed. The contract must be reviewed not less than annually. 7. Ensure that the personnel and services which are the subject of the contract meet the requirements of NAC 449.747 to 449.7481 , inclusive, including those requirements concerning licensure, qualifications, medical examinations, functions, supervision, orientation and continuing education. 8. Provide that only the nursing pool may accept patients for nursing services. 9. Ensure that the personnel and services which are the subject of the contract will provide treatment to referred patients without regard to race, creed or national origin. (Added to NAC by Bd. of Health, eff. 1-31-90; A by R044-97, 10-30-97) NAC 449.7479 Referral of patients when services not available; provision of services; bonding of staff. ( NRS 449.0302 ) 1. If services needed by a patient are not available from a nursing pool, it must assist in directing the patient to other resources in the community. 2. Services must be provided only by qualified personnel under the supervision of a physician who is licensed to practice in this State. Necessary qualifications include licensure, registration, certification or the equivalent, as required by state and federal law, for professional registered nurses, practical nurses and nursing assistants. 3. A nursing pool must secure an appropriate bond for each member of its staff who provides care directly to patients. (Added to NAC by Bd. of Health, eff. 1-31-90) NAC 449.748 Duties of registered nurse; provision of nursing care by practical nurse or nursing assistant. ( NRS 449.0302 ) 1. A registered nurse employed by a nursing pool shall: (a) Provide nursing guidance and care to patients; (b) If care is to be provided to a patient at his or her home, evaluate the home regarding its suitability for the provision of that care; (c) Teach patients and those who provide them with care regarding the appropriate methods of providing that care; (d) Supervise and evaluate the care given to patients on a continuing basis; and (e) Provide any necessary professional nursing care. 2. A practical nurse or nursing assistant employed by a nursing pool may provide nursing care if he or she is authorized to practice in this State and supervised by a registered nurse. (Added to NAC by Bd. of Health, eff. 1-31-90) NAC 449.7481 Annual evaluation of nursing pool by licensee. ( NRS 449.0302 ) 1. A licensee shall perform an overall evaluation of the nursing pool annually. The purpose of the evaluation is to audit the financial condition of the nursing pool, to review its policies and procedures, to recommend additions or changes to those policies and procedures, and to ensure compliance with those policies and with applicable regulations. 2. A committee shall: (a) Review the medical and personnel policies of the nursing pool to see that they are being fulfilled and that necessary additions or changes are effected; and (b) Submit its report to the licensee, together with any recommendations for changes and any pertinent observations it deems necessary. (Added to NAC by Bd. of Health, eff. 1-31-90) HOME HEALTH AGENCIES General Provisions NAC 449.749 Definitions. ( NRS 439.200 , 449.0302 ) As used in NAC 449.749 to 449.800 , inclusive, unless the context otherwise requires: 1. “Branch office” means an office, other than the home office, from which a home health agency provides services. 2. “Home health agency” means an agency to provide nursing in the home as defined in NRS 449.0015 . 3. “Home health aide” means a nursing assistant as defined in NRS 632.0166 . 4. “Home office” means the central administrative office of a home health agency. [Bd. of Health, Home Health Agencies Part I Chap. II, eff. 1-10-74]—(NAC A 11-13-96; R048-22, 12-29-2022) NAC 449.750 Adoption of publication by reference; revision of publication after adoption. ( NRS 439.200 , 449.0302 ) 1. “Appendix B - Guidance to Surveyors: Home Health Agencies” of the State Operations Manual , issued February 21, 2020, published by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services, is hereby adopted by reference. The publication is available at no cost on the Internet at https://www.hhs.gov/guidance/document/state-operations-manual-appendix-b-guidance-surveyors-home-health-agencies , or, if that Internet website ceases to exist, from the Division. 2. If the publication adopted by reference in subsection 1 is revised, the Division shall review the revision to determine its suitability for this State. If the Division determines that the revision is not suitable for this State, the Division shall hold a public hearing to review its determination and give notice of that hearing within 90 days after the date of the publication of the revision. If, after the hearing, the Division does not revise its determination, the Division shall give notice that the revision is not suitable for this State within 90 days after the hearing. If the Division does not give such notice, the revision becomes part of the publication adopted by reference in subsection 1. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) Licensing and Inspection NAC 449.752 License required. ( NRS 449.0302 ) No person, state, local government or any agency thereof may establish, conduct or maintain in this State a home health agency without first obtaining a license issued by the Division. [Bd. of Health, Home Health Agencies Part II Chap. I § A, eff. 1-10-74] NAC 449.758 Applicability of license; coverage against certain liabilities. ( NRS 439.200 , 449.0302 ) 1. Each license is separate and is issued to a specific person to operate a home health agency at a specific location. The home health agency must be operated and conducted in the name designated on the license with the designated service area and the name of the person responsible for its operation also appearing on the face of the license. The license is not transferable. 2. Copies of the original license must be issued for each agency or branch of an agency which is maintained on separate premises under the same management. 3. Each home health agency must have proof that it is adequately covered against liabilities resulting from claims incurred in the course of operation. [Bd. of Health, Home Health Agencies Part II Chap. I § D; Part II Chap. II, eff. 1-10-74]—(NAC A 11-13-96; R044-97, 10-30-97; R121-05, 11-17-2005; R048-22, 12-29-2022) NAC 449.761 Periodic inspections. ( NRS 449.0302 ) Every home health agency for which a license has been issued will be periodically inspected by an authorized representative of the Division. Reports of each inspection in which deficiencies were found will be prepared by the representative conducting the inspection. A copy of the report will be provided to the administrator of the home health agency within 10 days after the representative who conducted the inspection has conferred with the agency concerning the deficiencies found during the inspection. The administrator shall prepare a plan to correct the deficiencies set forth in the report and submit the plan to the Division within 10 days after receipt of the report from the Division. [Bd. of Health, Home Health Agencies Part II Chap. I § E, eff. 1-10-74]—(NAC A 11-13-96) NAC 449.767 Action to enjoin operation without license. ( NRS 449.0302 ) 1. The Division may bring an action in the name of the State to enjoin any person, partnership, corporation or association, or any state or local governmental unit or agency thereof, from establishing or maintaining a home health agency: (a) Without first obtaining a license therefor; or (b) After his or her license has been revoked or suspended by the Division. 2. It is sufficient in the action to allege that the defendant did, on a certain date and in a certain place, operate and maintain an agency without a license. [Bd. of Health, Home Health Agencies Part II Chap. I §§ H & I, eff. 1-10-74] NAC 449.768 Applicant or licensee to maintain home office in Nevada. ( NRS 449.0302 ) A person who applies for a license to operate a home health agency or a person who holds such a license shall maintain a home office in this State. (Added to NAC by Bd. of Health, eff. 11-13-96) Administration and Personnel NAC 449.782 Personnel policies. ( NRS 449.0302 ) A home health agency shall establish written policies concerning the qualifications, responsibilities and conditions of employment for each type of personnel, including licensure if required by law. The written policies must be reviewed as needed and made available to the members of the staff and the advisory groups. The personnel policies must provide for: 1. Wage and hour policies; 2. Eligibility for vacation, sick leave and other fringe benefits; 3. The orientation of all health personnel to the policies and objectives of the agency, training while on the job, and continuing education; 4. Periodic evaluation of employees’ performances; 5. Job descriptions for each category of personnel which are specific and include the type of activity each may carry out; 6. The maintenance of employee records which confirm that personnel policies are followed; and 7. The maintenance of a health record for each employee as required by chapter 441A of NAC. [Bd. of Health, Home Health Agencies Part II Chap. III § F subsec. 1, eff. 1-10-74]—(NAC A 11-13-96; R121-05, 11-17-2005; R121-14, 10-27-2015) NAC 449.788 Licensure, registration or certification of certain personnel. ( NRS 439.200 , 449.0302 ) 1. A person providing services on behalf of a home health agency must possess any licensure, registration, certification or their equivalent required by state or federal law. 2. A nutritionist providing services on behalf of a home health agency must be a dietitian licensed pursuant to chapter 640E of NRS. [Bd. of Health, Home Health Agencies Part II Chap. III § G subsecs. 1-3, eff. 1-10-74]—(NAC A 11-13-96; R048-22, 12-29-2022) NAC 449.793 Periodic review of patient and clinical records by appointed committee; minutes of meetings. ( NRS 439.200 , 449.0302 ) 1. The governing body or other entity responsible for the operation of a home health agency shall appoint a committee to provide for a quarterly review of 10 percent of the records of patients who have received services from the agency during the preceding 3 months in each service area. The members of the committee must include an administrative representative, a physician, a registered nurse and a clerk or librarian who keeps records. 2. The clerk or librarian of the committee shall review the clinical records to ensure that they are complete, that all forms are properly filled out and that documentation complies with good medical practices. 3. The committee shall: (a) Determine whether the services have been provided to the patients in an adequate and appropriate manner by all levels of service; and (b) Record any deficiencies and make necessary recommendations to the administrator. 4. If the branch offices of a home health agency are small, two or more offices may establish one committee to review cases from each area. 5. The committee shall ensure that minutes of the committee’s meetings are documented and make the minutes available to personnel of the Division for review upon request. [Bd. of Health, Home Health Agencies Part II Chap. III § J, eff. 1-10-74]—(NAC A 11-13-96; R048-22, 12-29-2022)—(Substituted in revision for NAC 449.803) NAC 449.7935 Compliance with certain federal requirements; exception; provision of data to Division; application of certain provisions to physician assistants and advanced practice registered nurses. ( NRS 439.200 , 449.0302 ) 1. Except as otherwise provided in this subsection, a home health agency shall comply with the provisions of 42 C.F.R. §§ 484.1 to 484.115, inclusive, and the publication adopted by reference in NAC 449.750 . A home health agency that is not certified by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services is not required to comply with: (a) 42 C.F.R. § 484.45 and any associated guidance prescribed by the publication adopted by reference in NAC 449.750 , except that the home health agency shall: (1) Collect the data prescribed by 42 C.F.R. § 484.55(c)(8); and (2) Update and revise that data at the frequency required by 42 C.F.R. § 484.55(d); (b) 42 C.F.R. § 484.50(c)(7)(i) and (ii) and any associated guidance prescribed by the publication adopted by reference in NAC 449.750 ; or (c) The requirement prescribed by 42 C.F.R. § 484.50(c)(8) that a home health agency must comply with the requirements of 42 C.F.R. §§ 405.1200 to 405.1204, inclusive, and any associated guidance prescribed by the publication adopted by reference in NAC 449.750 . 2. A home health agency shall provide the data described in 42 C.F.R. § 484.55(c)(8) to the Division upon the request of the Division. Such data must accurately reflect the status of the patient at the time that the relevant assessment is conducted. 3. For the purposes of this section, any provision of 42 C.F.R. §§ 484.1 to 484.115, inclusive, or the publication adopted by reference in NAC 449.750 that refers to a physician shall be deemed to apply equally to a physician assistant licensed pursuant to chapter 630 or 633 of NRS or an advanced practice registered nurse. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) Medical Services and Medical Records NAC 449.794 Clinical records: Maintenance. ( NRS 439.200 , 449.0302 , 629.051 ) A home health agency shall maintain clinical records in the manner prescribed by NRS 629.051 . [Bd. of Health, Home Health Agencies Part II Chap. III § H subsecs. 1-3, eff. 1-10-74]—(NAC A 11-13-96; R048-22, 12-29-2022) NAC 449.797 Clinical records; contents. ( NRS 439.200 , 449.0302 ) The clinical records of a home health agency must contain: 1. Information as to whether home health services are after hospitalization in a hospital, skilled nursing facility or other health service facility and, if so, the dates of admission and discharge from these facilities. 2. A clinical summary from the hospital, skilled nursing facility or other health service facility from which the patient is transferred to the home health agency. 3. A copy of: (a) The patient’s durable power of attorney for health care, if the patient has executed such a power of attorney pursuant to NRS 162A.700 to 162A.870 , inclusive; and (b) A declaration governing the withholding or withdrawal of life-sustaining treatment, if the patient has executed such a declaration pursuant to NRS 449A.433 . 4. A record of the termination of services, including the date and reason for termination and the time when the physician was notified of the termination. [Bd. of Health, Home Health Agencies Part II Chap. III § H subsec. 4, eff. 1-10-74]—(NAC A 11-13-96; R048-22, 12-29-2022) NAC 449.800 Orders of a physician, physician assistant or advanced practice registered nurse. ( NRS 439.200 , 449.0302 ) 1. A complete diagnosis must be included with the orders of a physician, physician assistant or advanced practice registered nurse as well as any relevant problems. 2. Initial orders of a physician, physician assistant or advanced practice registered nurse, renewals and changes of orders for skilled nursing and other therapeutic services submitted by telephone must be recorded before they are carried out. All orders must bear the signature of the physician, physician assistant or advanced practice registered nurse who initiated the order within 20 working days after the receipt of the oral order. 3. Orders must be specific regarding the level of care and the service given. 4. Medication orders must include: (a) The name of the drug. (b) The exact dosage in units, milligrams, grams or other measurements. (c) Frequency. (d) The duration of treatment. (e) The method of administration. (f) Any special precautions, including requests for orders of a physician, physician assistant or advanced practice registered nurse for the use of adrenaline for possible anaphylaxis. 5. The agency must have an established policy regarding the administration of injectable narcotics and other drugs subject to the controlled substance law. If the policy allows the administration of injectable narcotics and other dangerous drugs subject to controlled substance law, they must be prescribed according to state regulations. 6. Specific orders must be given for: (a) Rehabilitative and restorative care such as physiotherapy; (b) Skilled nursing and home health aide care; (c) Nutritional needs; (d) The degree of activity permitted; (e) Dressings and the frequency of change; (f) The instruction of a member of the family in technical nursing procedures; and (g) Any other items necessary to complete a specific plan of treatment for the patient. 7. An order must be renewed in writing by the physician, physician assistant or advanced practice registered nurse who issued the order at least every 62 days. 8. New orders are required when there is a change in diagnosis, a change in orders, a change of physician, physician assistant or advanced practice registered nurse or following hospitalization. [Bd. of Health, Home Health Agencies Part II Chap. III § I, eff. 1-10-74]—(NAC A 11-1-88; 11-13-96; R048-22, 12-29-2022) COMMUNITY-BASED LIVING ARRANGEMENT SERVICES General Provisions NAC 449.801 Definitions. ( NRS 433.324 , 439.200 , 449.0302 ) As used in NAC 449.801 to 449.861 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.802 to 449.816 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018; R048-22, 12-29-2022)—(Substituted in revision for NAC 433.300) NAC 449.802 “Certificate” defined. ( NRS 433.324 , 433.607 , 433.609 , 439.200 , 449.0302 ) “Certificate” has the meaning ascribed to it in NRS 433.603 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.303) NAC 449.804 “Community-based living arrangement services” or “services” defined. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) “Community-based living arrangement services” or “services” has the meaning ascribed to it in NRS 433.605 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.306) REVISER’S NOTE. Ch. 51, Stats. 2019 repealed NRS 433.605 and moved the substance of the definition of “community-based living arrangement services” to NRS 449.0026 . NAC 449.805 “Facility” defined. ( NRS 439.200 , 449.0302 ) “Facility” means a home operated by a provider in which services are provided. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) NAC 449.807 “Individual support team” defined. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) “Individual support team” means a team of persons, other than a provider, who provide health care and perform other duties for the benefit of a person with a mental illness. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.309) NAC 449.808 “Individualized plan” defined. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) “Individualized plan” means a plan prescribing the services that will be provided to a person with mental illness, the frequency with which the services will be provided and the manner in which those services will be provided. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.312) NAC 449.810 “Mental illness” defined. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) “Mental illness” has the meaning ascribed to it in NRS 433.164 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.315) NAC 449.811 “Provider” defined. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) “Provider” means a natural person or a partnership, firm, corporation, association, state or local government or agency thereof that is issued a provisional license or license. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.318) NAC 449.813 “Provisional license” defined. ( NRS 433.324 , 439.200 , 449.0302 ) “Provisional license” means a temporary license to provide services that is issued pursuant to NAC 449.820 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.321) NAC 449.814 “Quality assurance review” defined. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) “Quality assurance review” means a review of the provision of services conducted by the Division pursuant to NAC 449.853 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.324) NAC 449.816 “Resident” defined. ( NRS 439.200 , 449.0302 ) “Resident” means a person who resides at and receives services from a facility. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) Issuance and Renewal of Provisional Licenses and Licenses NAC 449.817 Provisional license or license required to provide services; exception. ( NRS 433.324 , 439.200 , 449.0302 ) Except as otherwise provided in NRS 433.607 , a person or governmental entity must hold a provisional license or license to provide services or receive payment from the Division for services. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.327) NAC 449.818 Contents of application for provisional license; fee; bond. ( NRS 433.324 , 439.150 , 439.200 , 449.0302 ) 1. An application for a provisional license must be submitted to the Division on a form furnished by the Division accompanied by a nonrefundable fee of $100 and must include: (a) For an applicant who is a natural person: (1) Three or more letters of professional reference; (2) A certification, signed by the applicant, that the applicant will maintain the confidentiality of information relating to any person who receives services; (3) Proof that the applicant has successfully completed a course in cardiopulmonary resuscitation according to the guidelines of the American Red Cross or American Heart Association; (4) Proof that the applicant is currently certified in standard first aid through a course from the American Red Cross or American Heart Association or, if the applicant submits proof that the course meets or exceeds the requirements of the American Red Cross or the American Heart Association, an equivalent course in standard first aid; (5) Written verification, on a form prescribed by the Division, that the fingerprints of the applicant were taken and forwarded electronically or by another means directly to the Central Repository for Nevada Records of Criminal History and that the applicant has given written permission to the law enforcement agency or other authorized entity taking the fingerprints to submit the fingerprints to the Central Repository for submission to the Federal Bureau of Investigation and to such other law enforcement agencies as the Division deems necessary for reports on the applicant’s background to the Division and the applicant; (6) A copy of the social security card of the applicant; (7) A copy of a form of government-issued identification, which may include, without limitation, a passport, identification card or driver’s license; (8) An attestation that the applicant has sufficient working capital to effectively provide services and, if the applicant proposes to provide services in a facility, operate the facility; (9) If applicable, a copy of the applicant’s state business license and a copy of the current business license issued for the applicant’s business by the county, city or town in which the applicant’s business is located or written verification that the applicant is exempt from any requirement to obtain a business license; and (10) Any other information required by the Division. (b) For an applicant other than a natural person: (1) If applicable, a copy of the state business license of the organization and a copy of the current business license issued for the applicant’s business by the county, city or town in which the applicant’s business is located or written verification that the applicant is exempt from any requirement to obtain a business license; (2) The federal tax identification number of the organization; (3) A copy of the bylaws, articles of incorporation, articles of association, articles of organization, partnership agreement, constitution and any other substantially equivalent documents of the applicant, and any amendments thereto; (4) A list of the members of the governing body of the applicant; (5) If the applicant is an association or a corporation: (I) The name, title and principal business address of each officer and member of its governing body; (II) The signature of the chief executive officer or an authorized representative; and (III) If the applicant is a corporation, the name and address of each person holding more than 10 percent of its stock; (6) For each member of the governing body: (I) Three or more letters of professional reference; and (II) Written verification, on a form prescribed by the Division, that the fingerprints of the member of the governing body were taken and forwarded electronically or by another means directly to the Central Repository for Nevada Records of Criminal History and that the member of the governing body has given written permission to the law enforcement agency or other authorized entity taking the fingerprints to submit the fingerprints to the Central Repository for submission to the Federal Bureau of Investigation and to such other law enforcement agencies as the Division deems necessary for reports on the member’s background to the Division and the applicant; (7) An attestation that the applicant has sufficient working capital to effectively provide services and, if the applicant proposes to provide services in a facility, operate the facility; (8) Copies of any policies and procedures of the applicant relating to the provision of services; and (9) Such other information as may be required by the Division. 2. An applicant for a provisional license shall post a surety bond in an amount equal to the operating expenses of the applicant for 2 months, place that amount in escrow or take another action prescribed by the Division to ensure that, if the applicant becomes insolvent, recipients of community-based living arrangement services from the applicant may continue to receive community-based living arrangement services for 2 months at the expense of the applicant. 3. As used in this section: (a) “Electronic signature” means a user name attached to or logically associated with a record and executed or adopted by a person with the intent to sign an electronic application or other document. (b) “Signature” includes, without limitation, an electronic signature. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018; R048-22, 12-29-2022)—(Substituted in revision for NAC 433.330) NAC 449.819 Review of application for provisional license; actions upon determination that application is incomplete. ( NRS 433.324 , 439.150 , 439.200 , 449.0302 ) 1. The Division shall review each application for a provisional license to determine whether the application is complete. 2. If the Division determines that an application for a provisional license is incomplete, the Division shall notify the applicant that the application is incomplete and authorize the applicant to submit any required information or documentation to complete the application. The applicant must submit any additional information or documentation not later than 30 calendar days after receipt of the notice. The Division may deny the application if the applicant does not submit any required information or documentation in accordance with this subsection. If the application is denied pursuant to this subsection, the applicant may not resubmit an application for a provisional license for at least 12 months after receipt of the notice of the denial given pursuant to NAC 449.822 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.333) NAC 449.820 Training required of applicant for provisional license; inspection of facility; issuance and validity of provisional license. ( NRS 433.324 , 439.200 , 449.0302 ) 1. An applicant for a provisional license must complete 16 hours of training approved or provided by the Division concerning the provision of services. The training must be completed after the application is submitted but not later than 3 months after that date. If the applicant is not a natural person, each officer or employee of the applicant who will oversee the provision of services by the applicant must complete the training required by this subsection. 2. Upon successful completion of the training required by subsection 1, the Division shall: (a) If the applicant proposes to provide services in a facility, inspect the facility and issue a report describing any violations of the provisions of this chapter or chapter 449 of NRS found during the inspection. If the report describes a violation, the Division may require the applicant to submit a plan of correction. The Division shall issue a provisional license: (1) If the Division requires the applicant to submit a plan of correction, upon approval by the Division of the plan of correction. (2) If the Division does not require the applicant to submit a plan of correction, upon issuance of the report. (b) If the applicant does not propose to provide services in a facility, issue a provisional license to the applicant. 3. A provisional license is valid until the Division completes the initial quality assurance review required by NAC 449.823 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.336) NAC 449.822 Grounds for denial of application for provisional license; notice of denial. ( NRS 433.324 , 439.200 , 449.0302 ) 1. Each of the following constitutes a ground for denial of an application for a provisional license: (a) Failure by the applicant to submit a complete application for a provisional license within the time required by NAC 449.819 . (b) Inability of the applicant to provide proper care for the number and types of intended recipients of services. (c) Misrepresentation or failure by the applicant to disclose any material fact in the application submitted to the Division or in any financial record or other document requested by the Division. (d) Conviction of the applicant, an officer or employee of the applicant, an independent contractor of the applicant who oversees the provision of services or an adult who will be present during the provision of services of a crime relevant to any aspect of the provision of services, including, without limitation: (1) Murder, voluntary manslaughter or mayhem; (2) Assault or battery with intent to kill or to commit sexual assault or mayhem; (3) Sexual assault, statutory sexual seduction, incest or lewdness or indecent exposure that is punished as a felony, or any other sexually related felony; (4) A felony involving domestic violence; (5) A misdemeanor involving domestic violence, within the immediately preceding 7 years; (6) A misdemeanor involving assault or battery, within the immediately preceding 7 years; (7) Abuse or neglect of a child or contributory delinquency; (8) A violation of any federal or state law regulating the possession, distribution or use of any controlled substance or any dangerous drug as defined in chapter 454 of NRS, within the immediately preceding 7 years; (9) Abuse, neglect, exploitation, isolation or abandonment of an older person or vulnerable person, including, without limitation, a violation of any provision of NRS 200.5091 to 200.50995 , inclusive, or a law of any other jurisdiction that prohibits the same or similar conduct; (10) A violation of any law relating to the State Plan for Medicaid or a law of any other jurisdiction that prohibits the same or similar conduct, within the immediately preceding 7 years; (11) A violation of any provision of NRS 422.450 to 422.590 , inclusive; (12) A criminal offense under the laws governing Medicaid or Medicare, within the immediately preceding 7 years; (13) Any offense involving fraud, theft, embezzlement, burglary, robbery, fraudulent conversion or misappropriation of property, within the immediately preceding 7 years; (14) Any felony involving the use or threatened use of force or violence against the victim or the use of a firearm or other deadly weapon; or (15) An attempt or conspiracy to commit any of the offenses listed in this paragraph, within the immediately preceding 7 years. (e) Exclusion of the applicant, an officer or employee of the applicant or an independent contractor of the applicant who oversees the provision of services from participation in Medicare, Medicaid or any other federal health care program pursuant to federal law. (f) The existence of any major deficiency in the proposed services to be provided by the applicant which would preclude compliance with any provision of this chapter or chapter 449 of NRS. 2. If an application is denied, the Division shall give the applicant a written notice of the denial in the manner provided by NAC 439.345 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.339) NAC 449.823 Quality assurance review; extension or revocation of provisional license; issuance of license. ( NRS 433.324 , 439.200 , 449.0302 ) 1. Within 12 months after the issuance of a provisional license, the Division shall conduct a quality assurance review as provided in NAC 449.853 . If the Division determines as the result of the quality assurance review that the holder of the provisional license is not in substantial compliance with the provisions of this chapter and chapter 449 of NRS, the Division may revoke or extend the term of the provisional license. The Division may extend the term of the provisional license for any period not to exceed 6 months. 2. If the Division extends the term of a provisional license pursuant to subsection 1, the Division shall, before the expiration of the extended term, conduct another quality assurance review. If the Division determines as the result of the quality assurance review that the holder of the provisional license is not in substantial compliance with the provisions described in subsection 1, the Division shall revoke the provisional license. 3. If the Division determines as the result of a quality assurance review conducted pursuant to subsection 1 or 2 that the holder of a provisional license is in substantial compliance with the provisions of this chapter and chapter 449 of NRS, the Division shall issue a license to the holder of the provisional license. The Division may issue a license to a provider for any period not to exceed 2 years. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.342) NAC 449.825 Renewal of license; fee. ( NRS 439.150 , 439.200 , 449.0302 ) Not less than 45 days before the expiration of a license, the holder of the license must apply to the Division for renewal in the form prescribed by the Division, accompanied by a nonrefundable fee of $100. The Division may renew the license for any period not to exceed 2 years if the Division determines that the holder of the license is in substantial compliance with the provisions of this chapter and chapter 449 of NRS. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.345) Operation of Provider NAC 449.826 Duties of provider. ( NRS 433.324 , 439.200 , 449.0302 ) A provider shall: 1. Comply with any state or federal statute or regulation as required for the Division to receive state or federal money for the provision of services, including, without limitation, any standard of care set forth in: (a) The State Plan for Medicaid; and (b) The Medicaid Services Manual established by the Division of Health Care Financing and Policy of the Department of Health and Human Services. 2. Comply with all applicable state or federal requirements concerning fiscal management, reporting and employment. 3. Comply with the individualized plan prepared pursuant to NAC 449.835 for each person who receives services. 4. Assure the health and welfare of persons receiving services. Any assessment by the Division of a provider’s compliance with the requirements of this subsection must be based upon the self-reporting of persons receiving services from the provider, the observations of members of the staff of the Division and any other information available to the Division. 5. Establish internal procedures for quality assurance. 6. Promptly report to the Division any change in the officers or ownership of the provider. 7. Cooperate with any investigation by the Division. 8. Monitor the living environment of persons receiving services from the provider and establish policies to immediately assist such persons who are living in unsafe or unhealthy environmental conditions to correct those conditions or in finding alternative residences. 9. Develop and implement policies concerning the hiring of persons who will provide services. 10. Maintain a personnel file for each employee or independent contractor who provides services. The personnel file must contain, without limitation: (a) Information concerning the job duties, essential functions, physical capabilities and language proficiency of the employee or contractor; and (b) Proof that the employee or independent contractor is in compliance with the requirements of NAC 449.831 , if applicable. 11. Ensure that each employee or independent contractor who provides services is capable of: (a) Carrying out the responsibilities established in the individualized plan established pursuant to NAC 449.835 for each person to whom the employee or independent contractor provides services and properly qualified by training and experience to do so; and (b) Communicating effectively with each person to whom the employee or independent contractor provides services. 12. Comply with the policies adopted by the Commission on Behavioral Health pursuant to subsection 1 of NRS 433.314 . 13. Maintain a staff sufficient to meet the needs of each person receiving services from the provider in accordance with the individualized plan established for the person pursuant to NAC 449.835 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018; R048-22, 12-29-2022)—(Substituted in revision for NAC 433.348) NAC 449.828 Policies and procedures of governmental or organizational provider. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) If a provider is a governmental entity or an organization, it shall, in conformance with the provisions of this chapter and chapter 449 of NRS, establish policies and procedures for the provision of services and the welfare of the persons it serves. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.351) NAC 449.829 Initial and periodic investigations of employee, independent contractor or adult present during provision of services; termination of employment, contract or authority to be present for conviction of certain crimes; period in which to correct information regarding conviction. ( NRS 439.200 , 449.0302 ) 1. Except as otherwise provided in subsection 2, within 10 days after hiring a new employee, entering into a contract with an independent contractor or determining that an adult who is not a recipient of services, including, without limitation, an adult child of the applicant or an adult child of an employee or independent contractor thereof, will be present during the provision of services, and every 5 years thereafter, a provider shall: (a) Obtain from the employee, independent contractor or other adult one set of fingerprints and a written authorization to forward the fingerprints to the Central Repository for Nevada Records of Criminal History for submission to the Federal Bureau of Investigation for its report; and (b) Submit to the Central Repository for Nevada Records of Criminal History the fingerprints obtained pursuant to paragraph (a) to obtain information on the background and personal history of each employee, independent contractor or other adult to determine whether the person has been convicted of any crime listed in NAC 449.822 . 2. Upon receiving information from the Central Repository for Nevada Records of Criminal History pursuant to subsection 1, or evidence from any other source, that an employee, independent contractor or any other adult who is not a recipient of services and who will be present during the provision of services has been convicted of a crime listed in NAC 449.822 , the provider shall terminate the employment or contract of that person or prohibit that adult from being present during the provision of services after allowing the person time to correct the information as required pursuant to subsection 3. 3. If an employee, independent contractor or other adult believes that the information provided by the Central Repository for Nevada Records of Criminal History or any other source is incorrect, the employee, independent contractor or other adult may immediately inform the provider. The provider that is so informed shall give the employee, independent contractor or other adult a reasonable amount of time of not less than 30 days to correct the information received from the Central Repository or other source before terminating the employment or contract of the person or prohibiting the person from being present during the provision of services pursuant to subsection 2. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) NAC 449.831 Required certifications and courses for employee or independent contractor who provides services. ( NRS 439.200 , 449.0302 ) Each employee or independent contractor of a provider who provides services must: 1. Be currently certified in standard first aid through a course from the American Red Cross or American Heart Association or their successor organizations or, if the applicant submits proof that the course meets or exceeds the requirements of the American Red Cross or the American Heart Association or their successor organizations, an equivalent course in standard first aid; and 2. Have successfully completed a course in cardiopulmonary resuscitation according to the guidelines of the American Red Cross or American Heart Association or their successor organizations. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) NAC 449.832 Arrangements for services from specially trained persons; determination of need for such services. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) 1. A provider shall make arrangements for obtaining services from persons professionally qualified in the field of psychiatric mental health or other specially trained persons, as needed, to assist in planning, carrying out and reviewing the provision of services. Evidence of any use of such services must be on file with the provider. 2. The need for such services must be determined initially by the individual support team established pursuant to NAC 449.835 for the person receiving services and be reviewed by the team on a regular basis, at least annually. 3. As used in this section, “person professionally qualified in the field of psychiatric mental health” has the meaning ascribed to it in NRS 433.209 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.354) NAC 449.834 Financial plan; financial records; financial report. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) A provider shall: 1. Develop and maintain a financial plan which ensures that there are sufficient resources to meet the costs for care of the persons receiving services from the provider; 2. Maintain financial records adequate to determine whether the provider meets all the requirements of NAC 449.801 to 449.861 , inclusive, related to finances; and 3. Submit to the Division any financial report: (a) Which the Division requests in writing; and (b) The need for which is explained by the Division. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.357) NAC 449.835 Assessment of need for services; maintenance of findings of assessment; establishment of individual support team and permanent individualized plan; acceptance of person before assessment in urgent situation. ( NRS 433.324 , 433.609 , 433.806 , 439.200 , 449.0302 ) 1. Except as otherwise provided in subsection 4, a provider may not provide services to a person until there has been an assessment of the need for services for the person. 2. The assessment must be performed or approved by the Division. As part of the assessment, the Division or other entity that performs the assessment must establish an interim individualized plan. 3. Following the assessment, if the person is accepted by the provider: (a) The findings of the assessment must be maintained by the Division and entered into the person’s record kept and maintained by the provider as provided in NAC 449.840 ; and (b) The Division shall establish an individual support team for the person and, in collaboration with the individual support team, establish a permanent individualized plan. 4. In an urgent situation and with the approval of the Division, a provider may accept a person for the provision of services for a period of not more than 5 working days before an assessment is performed. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.360) NAC 449.837 Contract for provision of services. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) A provider shall enter into a written contract for the provision of services with each person who will receive services or his or her parent or guardian, if applicable, and, if the person is being served by the Division or another entity for which the provider is providing services, the Division or other entity. The contract must prescribe the services that will be provided to the person and the payment that the provider will receive for those services. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.363) NAC 449.8385 Training for providers and employees; exception. ( NRS 439.200 , 449.0302 ) 1. Except as otherwise provided in subsection 2, a natural person responsible for the operation of a provider of community-based living arrangement services and each employee of a provider of community-based living arrangement services who supervises or provides support to recipients of community-based living arrangement services shall: (a) Complete not less than 16 hours of training concerning the provision of community-based living arrangement services to persons with mental illness within 30 days after the date of hire or before providing services to a patient, whichever is later; and (b) Annually complete not less than 8 hours of continuing education approved by the Division concerning the particular population served by the provider. 2. If the Board determines that a person described in subsection 1 is required to receive training or continuing education substantially equivalent to that prescribed in that subsection as a condition of licensure or certification under title 54 of NRS, the person is not required to complete the training or continuing education, as applicable, required by subsection 1. 3. If a caregiver assists a recipient of community-based living arrangement services in the administration of any medication, including, without limitation, an over-the-counter medication or dietary supplement, the caregiver must: (a) Before assisting a resident in the administration of a medication, receive not less than 16 hours of training in the management of medication approved by the Division, which must consist of not less than 12 hours of classroom training and not less than 4 hours of practical training, and obtain a certificate attesting to the completion of such training; (b) Receive annually not less than 8 hours of training in the management of medication and provide the provider of community-based living arrangement services with satisfactory evidence of the content of the training and his or her attendance at the training; and (c) Annually pass an examination relating to the management of medication approved by the Bureau. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) NAC 449.840 Record regarding recipient of services: Contents; maintenance; availability for review by recipient or guardian. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) A provider shall keep a separate record regarding each person for whom services are provided. Each such record must include the information needed for providing services, to substantiate billing and for the planning and periodic reevaluation of the needs of the person who is receiving services. The record must be: 1. Kept in a secure location, which, if the provider operates a facility, must be on the premises of the facility; and 2. Made available for review by the person who is receiving services or his or her guardian, if applicable, and the Division. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.369) NAC 449.841 Record regarding recipient of services: Retention; availability for review by representatives of Department of Health and Human Services. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) 1. A provider shall retain the original records of each person who receives services from the provider as provided in NAC 449.840 , or photographic reproductions of such records, for at least 3 years after the provider ceases to provide services to the person. 2. All such records must be complete, current and readily available for review by representatives of the Department of Health and Human Services. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.372) NAC 449.8415 Logs and records of medication; administration of over-the-counter medications and dietary supplements. ( NRS 439.200 , 449.0302 ) 1. A provider who operates a facility that provides assistance to residents in the administration of medications shall maintain: (a) A log for each medication received by the facility for use by a resident of the facility. The log must include: (1) The type and quantity of medication received by the facility; (2) The date of its delivery; (3) The name of the person who accepted the delivery; (4) The name of the resident for whom the medication is prescribed; and (5) The date on which any unused medication is removed from the facility or destroyed. (b) A record of the medication administered to each resident, including, without limitation, any over-the-counter medication or dietary supplement. The record must include: (1) The type of medication administered; (2) The date and time that the medication was administered; (3) The date and time that a resident refuses, or otherwise misses, an administration of medication; and (4) Instructions for administering the medication to the resident that reflect each current order or prescription of the resident’s physician, physician assistant or advanced practice registered nurse. 2. A provider or an employee of a provider may provide or administer an over-the-counter medication or dietary supplement only if the physician, physician assistant or advanced practice registered nurse of the resident has approved the medication or dietary supplement in writing or the provider or employee is ordered by a physician, physician assistant or advanced practice registered nurse to provide or administer the medication to the resident. The over-the-counter medication or dietary supplement must be administered in accordance with the written instructions of the physician, physician assistant or advanced practice registered nurse. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) NAC 449.843 Rights of recipient of services. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) 1. Any person who receives services has the same rights that are afforded to a consumer by chapter 433 of NRS and any regulations adopted pursuant thereto. 2. A person has the right to file a complaint with the Division against a provider in the form prescribed by the Division. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.375) NAC 449.844 Facilities: Ownership or lease by operator; limitation on number of residents; compliance with certain state and local requirements. ( NRS 439.200 , 449.0302 ) 1. A facility must be owned or leased by the provider who operates the facility. 2. A provider who operates a facility shall ensure that the facility: (a) Has not more than 6 residents; and (b) Remains in compliance with all applicable state and local building codes, zoning requirements and business licensing requirements. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) NAC 449.846 Facilities: Occupancy, size, furnishings and use of bedrooms; use of certain rooms or bedrooms prohibited. ( NRS 439.200 , 449.0302 ) 1. A provider shall not authorize a resident to share a room in a facility with more than one other resident. A bedroom that is occupied by: (a) One resident must have at least 80 square feet of floor space. (b) Two residents must have at least 120 square feet of floor space. 2. A provider who operates a facility shall provide for each resident a separate bed that is at least 36 inches wide and has a comfortable and clean mattress, at least two sets of clean sheets, at least one blanket, at least one pillow and at least one bedspread. 3. A provider who operates a facility shall not: (a) Use a bedroom for any other purpose; or (b) Use any of the following as a bedroom for a resident: (1) A hallway, stairway, unfinished attic, garage, storage area, shed or similar area; or (2) A room that can only be reached by passing through a bedroom occupied by another resident. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) NAC 449.847 Facilities: Common areas; dining areas; kitchens; storage of food. ( NRS 439.200 , 449.0302 ) 1. A provider who operates a facility shall: (a) Furnish each common area with comfortable furniture. (b) Provide a dining area with a sufficient number of tables and chairs to provide seating for the number of residents for which the facility is certified. The tables and chairs must be sturdy, of proper height for dining and have surfaces that are easily cleaned. (c) Provide a kitchen that allows for the sanitary preparation of food and is furnished with equipment that is clean and in good working condition. (d) Ensure that all perishable food is refrigerated at a temperature of 41 degrees Fahrenheit or less, all frozen food is kept at a temperature of 0 degrees Fahrenheit or less and all stored foods have not expired. (e) Ensure that food is not stored for longer than the length of time recommended by the United States Department of Health and Human Services in “Storage Times for the Refrigerator and Freezer,” which is hereby adopted by reference. This chart may be obtained: (1) From the United States Department of Health and Human Services for free at 200 Independence Avenue, S.W., Washington, D.C. 20201, and at the Internet address https://www.foodsafety.gov/keep/charts/storagetimes.html ; or (2) Under the circumstances described in subsection 4, on an Internet website maintained by the Division. 2. Except as otherwise provided in this section, the most current version of the guidelines adopted by reference pursuant to paragraph (e) of subsection 1 which is published will be deemed to be adopted by reference. 3. If the Division determines that an update of or revision to the guidelines adopted by reference pursuant to paragraph (e) of subsection 1 are not appropriate for use in the State of Nevada, the Division shall present this determination to the State Board of Health and the State Board of Health will not adopt the update or revision, as applicable. 4. If the guidelines adopted by reference pursuant to paragraph (e) of subsection 1 cease to exist, the last version of the guidelines that was published shall be deemed to be the current version. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) NAC 449.849 Facilities: Maintenance of premises. ( NRS 439.200 , 449.0302 ) A provider who operates a facility shall ensure that: 1. The facility has a safe and sufficient supply of water, adequate drainage and an adequate system for the disposal of sewage. 2. Each faucet for a sink, tub, shower or other similar fixture is operable with hot and cold running water. 3. Each toilet is operational. 4. Each container used to store garbage outside of the facility is kept reasonably clean and covered to prevent rodents from entering the container. 5. Each container used to store garbage in the kitchen is covered with a lid or kept in an enclosed cupboard that is clean and prevents infestation by rodents and insects. 6. The premises of the facility are free of: (a) Offensive odors, insects, rodents and accumulation of dirt, garbage or other refuse; and (b) Hazards, including, without limitation, obstacles that impede the free movement of residents inside and outside of the facility. 7. Each window in the facility that is capable of being opened and each door that is left open to provide ventilation is screened to prevent insects from entering the facility. 8. The facility has sufficient electrical lighting to ensure the comfort and safety of residents. 9. The temperature of the facility does not exceed 82 degrees Fahrenheit or drop below 68 degrees Fahrenheit. 10. The facility remains in compliance with all applicable federal, state and local laws, regulations and ordinances concerning sanitation, safety and accessibility for persons with disabilities. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) NAC 449.850 Facilities: Fire safety. ( NRS 439.200 , 449.0302 ) A provider who operates a facility shall ensure that: 1. Portable multipurpose class ABC fire extinguishers are installed throughout the facility at the direction of the governmental entity that has jurisdiction over fire safety at the facility. 2. Each portable fire extinguisher available at a facility is inspected, recharged and tagged at least once each year by a person certified by the State Fire Marshal to conduct such inspections. 3. Each exit is maintained free of obstructions. 4. Smoke detectors are installed at the facility at the direction of the governmental entity that has jurisdiction over fire safety at the facility and maintained operational. 5. Smoking does not occur in the facility. 6. An extinguishing receptacle approved by the governmental entity that has jurisdiction over fire safety at the facility is placed in each area on the premises of the facility where smoking is allowed. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) NAC 449.852 Facilities: Policy concerning visitation; presence of minor child of provider or employee prohibited; visitation by child of resident. ( NRS 439.200 , 449.0302 ) 1. A provider who operates a facility: (a) Shall maintain a policy concerning visitation by family, friends or acquaintances of residents and employees who enter the facility. (b) Shall not allow a minor child of the provider or an employee of the provider to be present at the facility when services are provided. 2. A child of a resident may visit the resident in accordance with the policy maintained pursuant to subsection 1 and the individualized plan prepared pursuant to NAC 449.835 for the resident. (Added to NAC by Bd. of Health by R134-18, eff. 12-19-2018) Quality Assurance Reviews and Discipline NAC 449.853 Quality assurance review; report and correction of violation. ( NRS 433.324 , 433.609 , 433.613 , 439.200 , 449.0302 ) 1. The Division: (a) May conduct a quality assurance review at any time during the licensure of a provider; and (b) Shall conduct a quality assurance review of each provider that operates a facility at least once each year during the licensure of the provider. A quality assurance review conducted pursuant to this paragraph must include, without limitation, an inspection of the facility. 2. In conducting a quality assurance review, the Division may: (a) Obtain any information or otherwise review any aspect of the provider’s system of delivery of services, including, without limitation, any: (1) Policies and procedures of the provider; (2) Personnel or clinical records maintained by the provider; (3) Documentation regarding any administrative or personnel matter directly related to the health and welfare of any person who is receiving services; (4) Financial information concerning the provider or any person receiving services; and (5) Information concerning the quality of care provided to any person receiving services; (b) Interview or otherwise solicit information from any person receiving services, any employee or independent contractor of any provider or any other agency with knowledge of any person receiving services, and any member of the family or any guardian, friend or advocate of any person receiving services; (c) Observe the services provided to any person receiving services; and (d) Inspect any facility or other premises operated by the provider to determine compliance with the provisions of this chapter and chapter 449 of NRS. 3. After completing a quality assurance review, the Division shall make available to the provider a report that describes each violation. The provider shall correct any violation described in the report. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.378) NAC 449.855 Authorized actions of Division upon determination of deficiencies; plans of correction; grounds for sanctions; authorized sanctions. ( NRS 433.324 , 433.609 , 433.613 , 439.200 , 449.0302 ) 1. If the Division determines pursuant to a quality assurance review that there are any deficiencies in the provision of services by a provider related to the health or welfare of a person receiving such services, the Division may: (a) Deny, suspend or revoke the provisional license or license of the provider; (b) Require the provider to prepare and submit to the Division a written plan of correction, which must be approved by the Division; or (c) Require changes concerning the provision of services by the provider before the Division issues, renews or reinstates a provisional license or license. 2. If the Division requires a provider to prepare and submit to the Division a written plan of correction, the provider shall do so not later than 10 days after the report of violations is made available to the provider pursuant to subsection 3 of NAC 449.853 . Failure to do so constitutes a separate violation for which the Division may deny, suspend or revoke the provisional license or license of the provider or impose any sanction listed in subsection 5. 3. If the Division determines that a written plan of correction is unacceptable, the Division may: (a) Require the provider to resubmit the written plan of correction; or (b) Develop a mandatory directed plan of correction for the provider. 4. The Division may impose any sanction described in subsection 5 upon a provider for: (a) Any aspect of the provision of services by the provider which poses a probable risk of harm to the health or welfare of a person receiving services; (b) Any refusal by the provider to participate in any aspect of a quality assurance review; or (c) The failure or refusal of the provider to implement or maintain any action required by the Division to correct a deficiency identified during a quality assurance review, including, without limitation, failure to submit a timely plan of correction, if required. 5. As a sanction imposed pursuant to subsection 2 or 4, the Division may, without limitation: (a) Require the provider to: (1) Participate in training concerning the provision of services; (2) Comply with additional measures of accountability concerning the provision of services; (3) Comply with additional measures of review by the Division; or (4) Comply with additional performance requirements concerning the provision of services; (b) Terminate or amend any contract that the Division has with the provider; or (c) Suspend or reduce any payment otherwise owed by the Division to the provider. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.381) NAC 449.856 Grounds for revocation of provisional license or license. ( NRS 433.324 , 439.200 , 449.0302 ) Each of the following acts and omissions is a ground for revocation of a provisional license or license: 1. Any misrepresentation of or failure to disclose any material fact in the application for the provisional license or in any financial record or other document requested by the Division. 2. A lack of personnel in sufficient numbers or qualifications to provide proper care and support for the persons receiving services. 3. Conviction of the provider, any employee or independent contractor of the provider or any adult present during the provision of services of a crime listed in NAC 449.822 . 4. Any deficiency of the provider relating to the provision of services that poses an imminent or probable risk of harm to the health or welfare of any person receiving services. 5. Any violation of any requirement set forth in this chapter or chapter 449 of NRS. 6. Any accumulation or pattern of minor violations of the provisions of this chapter or chapter 449 of NRS, if the violations taken as a whole endanger the health or welfare of any person who is receiving services. 7. Any fraudulent activity by the provider or an employee or independent contractor of the provider, including, without limitation, any fraudulent billing, falsification of records or misuse or misappropriation of the property of a person who is receiving services. 8. Failure to comply with any obligation set forth in the contract entered into pursuant to NAC 449.837 . 9. Any refusal to participate in any aspect of a quality assurance review or any other review or investigation by the Division. 10. The failure or refusal of the provider to implement or maintain any action required by the Division to correct a deficiency identified during a quality assurance review or any other review or investigation by the Division. 11. Abuse, neglect, exploitation or coercion of a person who is receiving services. 12. Harassing, coercive, intimidating, insulting, abusive or disruptive language or behavior directed at an employee of the Division, an employee or independent contractor of the provider, another provider or a person or entity providing services other than community-based living arrangement services, a person who is receiving services or a family member or guardian of such a person. 13. Exclusion of the provider, an officer or employee of the provider or an independent contractor of the provider who oversees the provision of services from participation in Medicare, Medicaid or any other federal health care program pursuant to federal law. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017; A by R134-18, 12-19-2018)—(Substituted in revision for NAC 433.384) NAC 449.858 Notice of intent to revoke provisional license or license. ( NRS 433.324 , 439.200 , 449.0302 ) The Division shall give a provider written notice of any intended action to revoke the provisional license or license of the provider as prescribed by NAC 439.345 . (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.387) NAC 449.859 Immediate termination of provision of services. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) If a revocation of the provisional license or the license of a provider is pending and the Division determines that the grounds for the revocation place any person at an imminent or probable risk of harm, the Division may immediately terminate the provision of services by the provider. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.390) NAC 449.861 Appeal. ( NRS 433.324 , 433.609 , 439.200 , 449.0302 ) 1. If a provider is aggrieved by any sanction imposed pursuant to NAC 449.855 or any decision concerning the denial, suspension or revocation of a provisional license or license, the provider may submit a request for an appeal to the Administrator of the Division pursuant to the procedures set forth in NAC 439.300 to 439.395 , inclusive. 2. Except in the case of an immediate termination of the provision of services pursuant to NAC 449.859 , the effective date of a revocation is stayed upon receipt of a request for appeal until the hearing officer renders a decision regarding the appeal. (Added to NAC by Bd. of Health by R090-16, 6-21-2017, eff. 7-1-2017)—(Substituted in revision for NAC 433.393) EMPLOYMENT AGENCIES TO PROVIDE NONMEDICAL SERVICES NAC 449.870 Definitions. ( NRS 439.200 , 449.03005 ) As used in NAC 449.870 to 449.882 , inclusive, the words and terms defined in NAC 449.871 to 449.876 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.871 “Attendant” defined. ( NRS 439.200 , 449.03005 ) “Attendant” means a person who is employed by or retained pursuant to a contract by an employment agency for the purpose of providing nonmedical services to a client. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.873 “Client” defined. ( NRS 439.200 , 449.03005 ) “Client” means an elderly person or a person with a disability who seeks to receive or receives nonmedical services in the home in which the person lives. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.874 “Employment agency” defined. ( NRS 439.200 , 449.03005 ) “Employment agency” means an employment agency to provide nonmedical services. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.876 “Nonmedical services” defined. ( NRS 439.200 , 449.03005 ) “Nonmedical services” means “nonmedical services related to personal care to elderly persons or persons with disabilities,” as that term is defined in NRS 449.01517 . (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.877 Designation of primary place of business on license; operation of multiple work stations; licensee’s name to appear on face of license; liability coverage required. ( NRS 439.200 , 449.03005 ) 1. Except as otherwise provided in this subsection, each license issued to operate an employment agency must be issued to one person and designate the primary place of business of the employment agency. A person may operate an employment agency at multiple work stations if the employment agency maintains the records for the clients, attendants, other members of the staff of the employment agency and operations of the employment agency at the primary place of business designated on the license. 2. The name of the person to whom the license is issued must appear on the face of the license. 3. Each employment agency must retain proof that it has adequate coverage against liabilities to cover claims likely to be incurred in the course of operation. The proof of liability coverage must be verified at the time the employment agency submits its initial application to the Division for a license and upon request by the Division. 4. As used in this section, “work station” means a satellite office of an employment agency that is established for the sole purpose of providing a location: (a) Where copies of records may be sent to an employment agency; and (b) From which an attendant may work to serve a geographic area outside the geographic area in which the attendant normally works. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.879 Qualifications and duties of administrator. ( NRS 439.200 , 449.03005 ) 1. Each employment agency shall appoint an administrator who: (a) Is at least 18 years of age; (b) Has a high school diploma or its equivalent; (c) Is responsible and mature and exhibits empathy, listening skills and other personal qualities which will enable the administrator to understand the problems of elderly persons and persons with disabilities; (d) Understands the provisions of this chapter and chapter 449 of NRS; and (e) Has demonstrated the ability to read, write, speak and understand the English language. 2. The administrator of an employment agency shall oversee the daily operation of the employment agency and shall appoint another employee to assume the responsibilities of the administrator in the absence of the administrator. The responsibilities of an administrator include, without limitation: (a) Employing qualified personnel and providing for their training; (b) Ensuring that the employment agency refers only properly trained attendants to provide nonmedical services to clients; (c) Ensuring that an initial assessment of the needs of each client is completed and that an attendant referred to provide nonmedical services to a client is capable of providing the services necessary to meet those needs; (d) Ensuring that the clients of the employment agency receive needed nonmedical services; and (e) Developing and implementing policies and procedures for the employment agency, including, without limitation, policies and procedures concerning terminating the nonmedical services provided to a client when they are no longer necessary. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.880 Qualifications of attendant; required training. ( NRS 439.200 , 449.03005 ) Each attendant of an employment agency must: 1. Be at least 18 years of age; 2. Provide to the Division, upon request, documentation that the attendant has taken the tests and obtained the certificates required by NAC 441A.375 ; 3. Be responsible and mature and exhibit empathy, listening skills and other personal qualities which will enable the attendant to understand the problems of elderly persons and persons with disabilities; 4. Understand the provisions of this chapter and chapter 449 of NRS; 5. Demonstrate the ability to read, write, speak and communicate effectively in the English language with the clients of the employment agency; 6. Demonstrate the ability to meet the needs of the clients of the employment agency; and 7. Within the 12 months immediately preceding the date on which the attendant begins providing nonmedical services to a client and annually thereafter, complete not less than 8 hours of training related to providing for the needs of the clients of the employment agency and limitations on the nonmedical services provided by the employment agency. The training must include, without limitation, training concerning: (a) Duties and responsibilities of attendants and the appropriate techniques for providing nonmedical services; (b) Recognizing and responding to emergencies, including, without limitation, fires and medical emergencies; (c) Dealing with the adverse behaviors of clients; (d) Nutrition and hydration, including, without limitation, special diets and meal preparation and service; (e) Bowel and bladder care, including, without limitation, routine care associated with toileting, routine maintenance of an indwelling catheter drainage system such as emptying the bag and positioning of the system, routine care of colostomies such as emptying and changing the colostomy bag, signs and symptoms of urinary tract infections and common bowel problems, including, without limitation, constipation and diarrhea; (f) Methods for preventing skin breakdown, contractures and falls; (g) Handwashing and infection control; (h) Basic body mechanics, mobility and techniques for transferring clients; (i) Proper techniques for bathing clients; (j) The rights of clients and methods to protect the confidentiality of information concerning clients as required by federal and state law and regulations; (k) The special needs of elderly persons and persons with disabilities and sensory, physical and cognitive changes related to the aging process; (l) Maintenance of a clean and safe environment; and (m) First aid and cardiopulmonary resuscitation. A certificate in first aid and cardiopulmonary resuscitation issued to the attendant by the American Red Cross, its successor organization, or an organization determined by the Division to be equivalent shall be deemed adequate proof that the attendant has received the training required by this paragraph. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.882 Duties of employment agency. ( NRS 439.200 , 449.03005 ) An employment agency shall: 1. Provide any records of the employment agency to the Division upon request, including, without limitation, as part of an investigation of a complaint; 2. Evaluate each attendant to determine whether the attendant is competent in the required areas of training set forth in subsection 7 of NAC 449.880 ; 3. Ensure that each attendant does not provide services other than nonmedical services; 4. Before an attendant begins providing nonmedical services to a client, provide information to the client regarding the fees for those nonmedical services; 5. If the employment agency is located outside of this State, pay any necessary expenses, including, without limitation, travel expenses, incurred by the Division to conduct inspections and investigations of complaints; and 6. Inform each client that the employment agency is not an agency to provide nursing in the home and is not authorized to provide services other than nonmedical services. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) CARA PLANS OF CARE NAC 449.939 Definitions. ( NRS 439.200 , 449.0302 ) As used in NAC 449.939 to 449.948 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.941 to 449.945 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R133-18, eff. 12-19-2018) NAC 449.941 “CARA Plan of Care” defined. ( NRS 439.200 , 449.0302 ) “CARA Plan of Care” means a plan that is established pursuant to NAC 449.947 for the care of an infant who has a fetal alcohol spectrum disorder, has been affected by a prenatal substance use disorder or is experiencing symptoms of withdrawal from a substance as a result of exposure to the substance in utero. (Added to NAC by Bd. of Health by R133-18, eff. 12-19-2018) NAC 449.942 “Infant” defined. ( NRS 439.200 , 449.0302 ) “Infant” means a child who is less than 1 year of age. (Added to NAC by Bd. of Health by R133-18, eff. 12-19-2018) NAC 449.944 “Medical facility” defined. ( NRS 439.200 , 449.0302 ) “Medical facility” means a hospital or an obstetric center. (Added to NAC by Bd. of Health by R133-18, eff. 12-19-2018) NAC 449.945 “Provider of health care” defined. ( NRS 439.200 , 449.0302 ) “Provider of health care” has the meaning ascribed to it in NRS 629.031 . (Added to NAC by Bd. of Health by R133-18, eff. 12-19-2018) NAC 449.947 Establishment and contents of plan; use of form; provision of copy to parent or guardian and Division. ( NRS 439.200 , 449.0302 ) 1. A provider of health care who delivers or provides medical services to an infant in a medical facility and who, in his or her professional capacity, knows or has reasonable cause to believe that the infant was born with a fetal alcohol spectrum disorder, is affected by a prenatal substance use disorder or is experiencing symptoms of withdrawal from a substance as a result of exposure to the substance in utero shall ensure that a CARA Plan of Care is established for the infant before the infant is discharged from the medical facility. 2. A CARA Plan of Care must be completed using the form prescribed by the Division and include, without limitation: (a) Measures to ensure the immediate safety of the infant; (b) Measures to address the needs of the infant and his or her family or caregiver for substance use disorder treatment and health care; (c) Measures to ensure that the infant and his or her family or caregiver receive any necessary services, including, without limitation, referrals to appropriate providers of such services; and (d) Any other information necessary to ensure that the needs of the infant are met. 3. When an infant is discharged from a medical facility, the medical facility shall provide a copy of any CARA Plan of Care established pursuant to subsection 1 to: (a) Each parent or legal guardian of the infant to whom the CARA Plan of Care pertains, or both, if applicable; and (b) The Division, within 24 hours after the discharge. (Added to NAC by Bd. of Health by R133-18, eff. 12-19-2018) NAC 449.948 Duties of Division; confidentiality and protection of plans and related information. ( NRS 439.200 , 449.0302 ) 1. The Division shall: (a) Monitor, in accordance with 42 U.S.C. § 5106a(b)(2)(B)(iii)(II), the implementation of each CARA Plan of Care that it receives pursuant to NAC 449.947 to ensure that the infant to whom the CARA Plan of Care pertains and his or her family or caregiver are receiving appropriate services; and (b) Provide a copy of a CARA Plan of Care in the possession of the Division to an agency which provides child welfare services upon request. 2. Except as otherwise provided in this section and NRS 239.0115 , each CARA Plan of Care in the possession of the Division or an agency which provides child welfare services and any information associated with such a CARA Plan of Care is confidential, not subject to subpoena or discovery and not subject to inspection by the general public. 3. The Division and an agency which provides child welfare services shall ensure that each CARA Plan of Care in the possession of the Division or the agency which provides child welfare services, as applicable, and any information associated with such a CARA Plan of Care is: (a) Adequately protected from fire, theft, loss, destruction, other hazards and unauthorized access; and (b) Stored in a manner that protects the security and confidentiality of the information. 4. As used in this section, “agency which provides child welfare services” has the meaning ascribed to it in NRS 432B.030 . (Added to NAC by Bd. of Health by R133-18, eff. 12-19-2018) FINANCIAL REPORTING NAC 449.951 Definitions. ( NRS 449.460 ) As used in NAC 449.951 to 449.969 , inclusive, unless the context otherwise requires, the words and terms defined in NRS 449.450 have the meanings ascribed to them in that section. (Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 1-2-90; 10-20-93) NAC 449.953 Annual fee for insurers: Amount; notice; administrative fine for failure to pay. ( NRS 449.460 , 449.465 ) 1. Each admitted health insurer shall pay an annual fee to cover the costs of carrying out the provisions of NRS 449.450 to 449.530 , inclusive, and for the support of the Joint Interim Standing Committee on Health and Human Services. For each fiscal year, the total amount authorized by the Legislature for this purpose in the biennial budget for that fiscal year must be divided by the number of admitted health insurers on the first day of that fiscal year, pursuant to the records of the Commissioner of Insurance, to determine the amount owed by each insurer for all purposes, including the $50 fee for the support of the Joint Interim Standing Committee on Health and Human Services. 2. The Department will prepare and mail a notice to each insurer subject to the fee specified in subsection 1. The notice must include: (a) The amount of the fee and a statement identifying that portion of the fee which is used for the support of the Joint Interim Standing Committee on Health and Human Services; (b) The day on which payment of the fee is due, which must not be less than 30 days after receipt of the notice; and (c) The penalty for failure to pay the fee as specified in subsection 3. 3. Failure to pay the fee subjects the insurer to an administrative fine not to exceed $500 for each day that the fee remains unpaid after it is due. (Added to NAC by Dep’t of Human Resources, eff. 1-2-90; A 9-16-92; 10-20-93) NAC 449.957 Hospitals to file certain reports; certification; exception; extension. ( NRS 449.460 , 449.490 ) 1. Except as otherwise provided in subsection 3, every hospital shall file with the Department the following reports: (a) A copy of the hospital’s Medicare Cost Report within 150 days after the close of the hospital’s Medicare fiscal year; (b) A copy of the hospital’s proposed operating budget for the fiscal year within 30 days after the beginning of the fiscal year; (c) A copy of any report made by an independent auditor concerning a financial audit of the hospital’s operations within 30 days after the receipt of the report by the hospital; and (d) An annual report including such information as the Department deems necessary. The information in a report filed pursuant to this paragraph must be certified by an independent auditor. 2. Each report filed pursuant to subsection 1 must be certified by a responsible officer of the hospital to be accurate and complete to the best of the officer’s knowledge and belief. 3. Each hospital which has less than 200 beds or which is subject to the provisions of chapter 450 of NRS shall submit to the Department each year a copy of an annual audit conducted by an independent auditor. 4. An extension of the deadline for filing a report pursuant to this section may be granted to a hospital if the hospital certifies before the report is due that the information required for the report is not available on the required reporting date for reasons beyond the control of the hospital. (Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 10-20-93; A by Dep’t of Health & Human Services by R148-17, 8-30-2018) NAC 449.960 Hospitals to submit quarterly financial and utilization report; certification; extension. ( NRS 449.460 , 449.490 ) 1. Each hospital shall submit for each calendar quarter a completed financial and utilization report on a form prepared and distributed by the Department. This report must be submitted no later than 30 days after the last day of the calendar quarter covered by the report. A hospital is not required to include in the report financial and utilization data concerning a patient admitted to the hospital pursuant to an order issued by a court in a criminal proceeding in which the patient is a defendant or potential defendant. 2. The Department will adopt forms and instructions for the quarterly reports required pursuant to subsection 1. 3. Each quarterly report must be certified by a responsible officer of the hospital to be accurate and complete to the best of the officer’s knowledge and belief. 4. An extension of the deadline for filing a quarterly report pursuant to this section may be granted to a hospital if the hospital submits to the Department before the report is due an acceptable reason for granting the extension. The Department will not grant an extension unless the request for an extension includes a proposed date for submission of the report. (Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 10-20-93; A by Dep’t of Health & Human Services by R149-17, 8-30-2018) NAC 449.962 Facility for intermediate care or facility for skilled nursing to submit quarterly financial and utilization report; certification; extension. ( NRS 449.460 ) 1. Each facility for intermediate care or facility for skilled nursing shall submit for each calendar quarter a completed financial and utilization report on a form prepared and distributed by the Department. This report must be submitted no later than 30 days after the last day of the calendar quarter covered by the report. 2. The Department will adopt forms and instructions for the quarterly reports required pursuant to subsection 1. 3. Each quarterly report must be certified by a responsible officer of the facility for intermediate care or facility for skilled nursing to be accurate and complete to the best of the officer’s knowledge and belief. 4. An extension of the deadline for filing a quarterly report pursuant to this section may be granted to a facility for intermediate care or facility for skilled nursing if the facility submits to the Department before the report is due an acceptable reason for granting the extension. The Department will not grant an extension unless the request for an extension includes a proposed date for submission of the report. (Added to NAC by Dep’t of Human Resources, eff. 10-20-93) NAC 449.9625 Institution to submit quarterly financial and utilization report; certification; extension; exception. ( NRS 449.460 ) 1. Except as otherwise provided in subsection 5, each institution shall submit for each calendar quarter a completed financial and utilization report on a form prepared and distributed by the Department. This report must be submitted no later than 30 days after the last day of the calendar quarter covered by the report. 2. The Department will adopt forms and instructions for the quarterly reports required pursuant to subsection 1. 3. Each quarterly report must be certified by a responsible officer of the institution to be accurate and complete to the best of the officer’s knowledge and belief. 4. An extension of the deadline for filing a quarterly report pursuant to this section may be granted to an institution if the institution submits to the Department before the report is due an acceptable reason for granting the extension. The Department will not grant an extension unless the request for an extension includes a proposed date for submission of the report. 5. This section does not apply to a hospital that submits quarterly reports pursuant to NAC 449.960 or to a facility for intermediate care or a facility for skilled nursing that submits quarterly reports pursuant to NAC 449.962 . (Added to NAC by Dep’t of Human Resources, eff. 10-20-93) NAC 449.963 Information concerning treated patients: Submission; limitation on disclosure. ( NRS 449.460 , 449.485 ) 1. Each hospital shall prepare and submit to the Department, for each patient treated by the hospital during each month, the most recent universal billing form specified by the Centers for Medicare and Medicaid Services in an electronic format specified by the Department. The hospital shall submit the required information for each month within 45 days after the last day of the month. 2. The Department and any person with whom the Department may contract for the development and operation of its universal billing data system shall not disclose any information from the data system which reveals the identity of a specific patient of a hospital. 3. As used in this section, “hospital” has the meaning ascribed to it in NRS 449.012 . (Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 1-2-90; 9-16-92; 10-20-93; A by Bd. of Health by R051-02, eff. 7-24-2002; A by Dep’t of Health & Human Services by R151-08, 12-17-2008) NAC 449.966 Notice of insufficiency of submitted information. ( NRS 449.460 ) 1. If the Department determines that the information submitted by an institution is insufficient, the Department will notify the institution of the insufficiency. 2. The institution shall submit the required information to the Department within 30 days after receipt of the notice of insufficiency. (Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A by Dep’t of Health & Human Services by R151-08, 12-17-2008) NAC 449.969 Administrative fine for failing to meet deadlines. ( NRS 449.460 , 449.490 ) Unless an extension is granted, an institution which fails to submit a report or information required pursuant to NAC 449.957 to 449.963 , inclusive, by the deadline for submission is subject to an administrative fine not exceeding $500 for each day the report or information is delinquent. (Added to NAC by Dep’t of Human Resources, eff. 4-29-86; A 10-20-93) MOBILE UNITS NAC 449.970 Definitions. ( NRS 449.0302 ) As used in NAC 449.970 to 449.97042 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.9701 to 449.97018 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.9701 “Independent facility” defined. ( NRS 449.0302 ) “Independent facility” means the owner or operator of a mobile unit who: 1. Is not a parent facility; and 2. Uses the mobile unit to operate a medical facility specified in subsections 1 to 13, inclusive, of NRS 449.0151 . (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97012 “Mobile unit” defined. ( NRS 449.0302 ) “Mobile unit” has the meaning ascribed to it in NRS 449.01515 . (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97014 “Parent facility” defined. ( NRS 449.0302 ) “Parent facility” means a medical facility that is: 1. Specified in subsections 1 to 13, inclusive, of NRS 449.0151 ; and 2. Licensed pursuant to NRS 449.001 to 449.240 , inclusive. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97016 “Service site” defined. ( NRS 449.0302 ) “Service site” means the location where a mobile unit is parked when providing a service to a patient. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97018 “Staging area” defined. ( NRS 449.0302 ) “Staging area” means any location that serves as a base for maintaining a mobile unit. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.9702 Applicability of provisions. ( NRS 449.0302 ) The provisions of NAC 449.970 to 449.97042 , inclusive, do not apply to: 1. A mobile unit that provides services only: (a) Relating to conducting a mammography in accordance with a certificate of authorization to operate a radiation machine for mammography issued pursuant to NRS 457.185 ; (b) Using a radiation machine which is registered in accordance with NAC 459.150 ; or (c) For which a license is not required pursuant to NRS 449.001 to 449.240 , inclusive; or 2. A motor vehicle that is designed and used solely for transportation by a medical facility. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97022 Licensure. ( NRS 449.0302 ) 1. The Division may issue a license to operate a mobile unit only to: (a) A parent facility; or (b) An independent facility. 2. A parent facility or independent facility shall obtain a license for each mobile unit that it operates. 3. In addition to the information required to be included in a license pursuant to NRS 449.085 , each license to operate a mobile unit issued by the Division must set forth: (a) The name of the operator of the mobile unit; (b) The address of the parent facility or independent facility that is issued the license; and (c) Each staging area that the parent facility or independent facility designates for the mobile unit. 4. A parent facility or independent facility that is issued a license to operate a mobile unit shall: (a) Maintain the original of the license in the mobile unit for which the license is issued; and (b) Post a copy of the license in a conspicuous location at the parent facility or independent facility. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97024 Application for licensure. ( NRS 449.0302 ) An application for a license to operate a mobile unit must include: 1. The information required by NRS 449.040 and NAC 449.011 ; 2. A copy of the certificate of registration issued pursuant to chapter 482 of NRS for the mobile unit; and 3. A statement indicating: (a) Whether the applicant is a parent facility or independent facility; (b) If the applicant is an independent facility, the type of medical facility, as specified in subsections 1 to 13, inclusive, of NRS 449.0151 , that the applicant wishes to operate as a mobile unit; (c) Each proposed service and procedure that the mobile unit will provide; (d) Each proposed service site for the mobile unit; and (e) The manufacturer of the mobile unit. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97026 Design, construction, equipment, maintenance and parking. ( NRS 439.200 , 449.0302 ) 1. Except as otherwise provided in subsection 5, a parent facility or independent facility which is issued a license to operate a mobile unit shall ensure that the mobile unit complies with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 . 2. Except as otherwise provided in subsection 4, before any new construction of a mobile unit or any remodeling of an existing mobile unit is begun: (a) The parent facility or independent facility that applies for the license to operate the mobile unit or that has been issued the license to operate the mobile unit must submit a copy of the building plans for the new construction or remodeling to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 ; and (b) The building plans must be approved by the Division. 3. The building plans submitted for review and approval as required pursuant to subsection 2 must be drawn to scale and include a statement indicating: (a) The services and procedures that will be provided at the mobile unit; and (b) Each staging area designated by the parent facility or independent facility for the mobile unit. 4. A parent facility or independent facility is not required to submit plans for remodeling to the entity designated to review such plans by the Division pursuant to the provisions of NAC 449.0115 if the remodeling is limited to refurbishing an area within a mobile unit, including, without limitation, painting the area, replacing the flooring in the area, repairing the windows in the area, and replacing window or wall coverings in the area. 5. A parent facility or independent facility which is issued a license to operate a mobile facility shall ensure that the mobile unit for which the license is issued: (a) Complies with any applicable zoning regulation for each staging area designated for the mobile unit; (b) Is of sufficient size and is arranged in a manner that is appropriate to provide the services for which the mobile unit is licensed; (c) Is furnished with the appropriate equipment to provide for the comfort and safety of each patient who receives services at the mobile unit; (d) Is maintained in good repair and in a clean and sanitary manner; and (e) During any period in which the operator of the mobile unit provides services at the mobile unit: (1) Is located and illuminated in such a manner that each patient who receives services at the mobile unit may safely and comfortably enter and exit the mobile unit; and (2) Complies with any applicable statute, ordinance or regulation relating to the parking of the mobile unit. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002; A by R076-04, 8-5-2004; R122-16, 9-21-2017; R048-22, 12-29-2022) NAC 449.97028 Staging areas; disposal of biohazards and waste. ( NRS 449.0302 ) 1. Each parent facility or independent facility shall designate at least one staging area for each mobile unit for which the parent facility or independent facility is issued a license. A staging area designated by a parent facility or independent facility pursuant to this section must: (a) Provide for the cleaning and sanitizing of the mobile unit and its equipment before and after the mobile unit is used; and (b) Include a clean and sanitary area for the storage of supplies used for the mobile unit. 2. If any biohazard or any solid or liquid waste located at the site of the mobile unit will be disposed of at the staging area, the parent facility or independent facility shall ensure that the staging area is designed and maintained to provide for such disposal. 3. If any biohazard or any solid or liquid waste located at the site of the mobile unit will not be disposed of at the staging area, the parent facility or independent facility shall provide for such disposal in a manner and location approved by the Bureau. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.9703 Compliance with certain statutes and regulations. ( NRS 449.0302 ) A parent facility or independent facility which is issued a license to operate a mobile unit shall ensure that the mobile unit is operated in compliance with: 1. Any applicable statute or regulation relating to the registration of the mobile unit as a motor vehicle and the licensing of each driver of the mobile unit; 2. The applicable provisions of chapter 461 or 489 of NRS; and 3. The applicable provisions of NRS 449.001 to 449.240 , inclusive, and the standards and regulations adopted pursuant to those provisions. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97032 Compliance with regulations relating to evaluation of quality of services. ( NRS 449.0302 ) A parent facility or independent facility which is issued a license to operate a mobile unit shall: 1. Ensure that the mobile unit complies with any regulation which applies to the parent facility or independent facility relating to the evaluation of the quality of services provided by the mobile unit; and 2. Review each service provided by the mobile unit to ensure compliance with subsection 1. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97034 Written policies for operation of unit; agreement with hospital or medical facility for transfer of patients during emergencies. ( NRS 449.0302 ) 1. A parent facility or independent facility which is issued a license to operate a mobile unit must, before operating the mobile unit, establish written policies for the operation of the mobile unit. The written policies must be established in consultation with any other appropriate provider of health care as determined by the parent facility or independent facility and must include, without limitation, provisions relating to: (a) The care of patients; (b) The orientation, training and supervision of employees; (c) The scope of services and the evaluation of the quality of those services; (d) The criteria for selecting patients to receive services at the mobile unit; (e) The procedure for: (1) Performing each service provided at the mobile unit; (2) Storing and handling any medication provided to a patient of the mobile unit; and (3) Collecting, storing and disposing of any biohazard or liquid or solid waste from the mobile unit; (f) The control of any infectious disease or organism in the mobile unit; (g) The preparation and maintenance of any statement, log, document or other record relating to any service provided to a patient of the mobile unit; (h) The transportation of a patient of the mobile unit, including, without limitation: (1) The manner in which the patient must be transported; (2) Any equipment that must be used to transport the patient; and (3) The appropriate protection required for the patient during inclement weather; (i) The manner in which the mobile unit must be evacuated during an emergency and the services that the mobile unit must provide during the emergency, including, without limitation, a plan for coordinating the evacuation and the provision of those services with the parent facility or independent facility of the mobile unit; and (j) The identification of any specific requirements for the mobile unit necessary to provide any service at a service site for the mobile unit. 2. A parent facility or independent facility that establishes written policies for the operation of a mobile unit which include the provisions required by paragraph (i) of subsection 1 shall ensure that each employee and patient of the mobile unit understands those provisions. 3. Each parent facility or independent facility specified in subsection 1 shall maintain a written agreement with at least one hospital or other medical facility for the transfer of the patients of a mobile unit of the parent facility or independent facility during an emergency. The written agreement must include, without limitation, provisions relating to: (a) The manner in which the hospital or medical facility must communicate with the mobile unit during the emergency; (b) The transfer of each patient of the mobile unit to or from the hospital or medical facility; (c) The number of persons required to assist in the transfer of a patient; and (d) Any requirements of the mobile unit or a patient of the mobile unit to conduct the transfer of a patient. 4. A parent facility or independent facility that establishes written policies for the operation of a mobile unit pursuant to this section shall ensure that the written policy is consistent with any other policy or procedure of the parent facility or independent facility relating to the provision of services to a patient of the mobile unit. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97036 Rights of patients. ( NRS 449.0302 ) 1. In addition to complying with the requirements set forth in NRS 449A.100 to 449A.118 , inclusive, a parent facility or independent facility that is issued a license to operate a mobile unit shall ensure that each patient who receives services at the mobile unit is: (a) Treated with respect, consideration and dignity; (b) Provided appropriate privacy; (c) Informed of: (1) His or her rights as a patient in accordance with NRS 449.730 ; (2) Before admission to the mobile unit, each service that is available at the mobile unit and the estimated cost of the service; and (3) Any supplies, medication or equipment that the patient may require after receiving the service; and (d) Allowed to participate in any decision relating to any health care the patient receives at the mobile unit, unless the patient is unable to participate in that decision because of his or her medical condition. 2. If a patient of a mobile unit is unable to understand any information relating to his or her rights as a patient provided to him or her pursuant to subsection 1, the person who is responsible for the provision of services at the mobile unit shall provide that information to an appropriate person who is responsible for the patient. For each patient who is informed of his or her rights as a patient pursuant to this section, the person who is responsible for the provision of services at the mobile unit shall: (a) Prepare a written statement indicating that he or she informed the patient of those rights; and (b) Include the statement in the medical record of the patient that is maintained by the mobile unit. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) REVISER’S NOTE. NRS 449.730 , which is referred to in this section, was recodified as NRS 449A.118 during the 2017-2018 legislative interim. NAC 449.97038 Maintenance of schedule and records; supplies and equipment; diagnostic radiological services; laboratory services. ( NRS 449.0302 ) 1. A parent facility or independent facility which is issued a license to operate a mobile unit shall: (a) On or before the first day of each month, prepare and maintain a schedule setting forth the proposed dates of use for each service site for the mobile unit for that month; (b) Prepare and maintain a record of each service provided to a patient of the mobile unit, including, without limitation: (1) The name, age and sex of the patient; (2) The chart or identification number of the patient; (3) The date, time and service site where the service was provided to the patient; and (4) The duration of any procedure performed for the patient at the mobile unit; (c) In addition to the record of services required by paragraph (b), prepare and maintain a clinical record of each patient who receives any service at the mobile unit in accordance with the requirements of the parent facility or independent facility of the mobile unit; and (d) Ensure that a sufficient amount of supplies and equipment is available at the mobile unit to provide services to each patient of the mobile unit. 2. If a diagnostic radiological service is required to provide services for a patient of a mobile unit, the parent facility or independent facility shall ensure that the diagnostic radiological service is provided: (a) In accordance with the requirements prescribed by the parent facility or independent facility; and (b) Using equipment that is registered pursuant to NAC 459.150 . 3. If a laboratory service is required to provide services for a patient of a mobile unit, the parent facility or independent facility shall ensure that the laboratory service is provided: (a) In accordance with chapters 652 of NRS and 652 of NAC and any applicable federal law; and (b) In the manner prescribed by the parent facility or independent facility for providing the laboratory service. 4. A parent facility or independent facility which is issued a license to operate a mobile unit shall ensure that each record of a patient of the mobile unit which is maintained by the parent facility or independent facility is available for use by the mobile unit. If the patient ceases to receive services at the mobile unit, the parent facility or independent facility shall maintain the records of the patient at the parent facility or independent facility, or at any other location where the records are available for inspection by the Bureau. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.9704 Occupancy; fire safety; exits; use and maintenance of equipment; telecommunications device. ( NRS 449.0302 ) A parent facility or independent facility which is issued a license to operate a mobile unit shall: 1. Limit the occupancy of patients in the mobile unit to not more than five patients at any time; 2. Equip the mobile unit with at least two fire extinguishers having a minimum rating of 2A-20BC, and provide any other equipment for fire safety for the mobile unit that is required by the fire authority having jurisdiction; 3. Ensure that the mobile unit has at least two exits from the mobile unit, at least two of which must be doors if the mobile unit provides a service to a patient at the mobile unit who is unable to exit the mobile unit without assistance; 4. Ensure the existence of a corridor for each exit from the mobile unit that is of sufficient size to provide access to that exit; 5. Ensure that the equipment in the mobile unit is used and maintained in accordance with the instructions of the manufacturer of the equipment; 6. Prepare and maintain a record of any maintenance or procedure for calibration of the equipment that is performed in accordance with the instructions of the manufacturer of the equipment pursuant to subsection 5; and 7. Provide a telecommunications device for the mobile unit. (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) NAC 449.97042 Restrictions on operation; office of independent facility; operation pursuant to contract. ( NRS 449.0302 ) 1. A hospital shall not operate a mobile unit as a primary source for providing a service specified in NRS 449.012 except during an emergency. 2. A parent facility or independent facility that is issued a license to operate a mobile unit shall not use the mobile unit to provide any service for which the mobile unit is not licensed, regardless of whether the mobile unit is operated by a person other than the parent facility or independent facility. 3. An independent facility that is issued a license to operate a mobile unit shall: (a) Maintain an office in this State; (b) Ensure that the office remains open during normal business hours; (c) Ensure that any schedule, record or other information that the independent facility or mobile unit is required to maintain pursuant to NAC 449.970 to 449.97042 , inclusive, is maintained at the office of the independent facility; and (d) Not use the office of the independent facility to provide any service for which the mobile unit is licensed, unless the owner or operator of the independent facility is a physician licensed pursuant to chapter 630 of NRS and uses the office to provide medical services to his or her patients. 4. If a mobile unit is operated pursuant to a contract, the parent facility or independent facility of the mobile unit: (a) Is liable for any failure by the operator of the mobile unit to comply with any provision of NRS 449.001 to 449.240 , inclusive, or the standards and regulations adopted by the State Board of Health concerning the operation and maintenance of the mobile unit; (b) Shall maintain on the premises of the parent facility or independent facility a record satisfactory to the Division setting forth the services provided by the mobile unit pursuant to the contract and the name of each person who is responsible for the provision of services at the mobile unit; (c) Shall ensure that any procedure conducted or service provided by the mobile unit is conducted or provided in accordance with the standard of acceptable practice for the procedure or service; and (d) Shall ensure that the owner or operator of the mobile unit makes the mobile unit available for inspection by the Division pursuant to NRS 449.0307 , 449.131 and 449.132 . (Added to NAC by Bd. of Health by R063-02, eff. 7-24-2002) SURGICAL CENTERS FOR AMBULATORY PATIENTS General Provisions NAC 449.971 Definitions. ( NRS 439.200 , 449.0302 ) As used in NAC 449.971 to 449.997 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.9715 to 449.9743 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R096-08, 8-26-2008, eff. 10-25-2008; R048-22, 12-29-2022) NAC 449.9715 “Allied health profession” defined. ( NRS 449.0302 ) “Allied health profession” has the meaning ascribed to it by NRS 450.006 . (Added to NAC by Bd. of Health, eff. 12-15-88) NAC 449.972 “Ambulatory surgical center” defined. ( NRS 449.0302 ) “Ambulatory surgical center” has the meaning ascribed to “surgical center for ambulatory patients” by NRS 449.019 . (Added to NAC by Bd. of Health, eff. 12-15-88) NAC 449.9721 “Biohazardous waste” defined. ( NRS 441A.120 , 449.0302 ) “Biohazardous waste” means all biological waste or biologically contaminated waste that may cause harm to humans, animals or plants. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.9722 “Biologic indicator test” defined. ( NRS 441A.120 , 449.0302 ) “Biologic indicator test” means a test used in every ethylene oxide cycle and in every sterilization load of implantable medical items to demonstrate through the destruction of highly resistant bacterial spores whether all parameters, including, without limitation, time, temperature, sterilant and humidity, were met to effectively sterilize the medical items. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.9724 “Cleaning” defined. ( NRS 441A.120 , 449.0302 ) “Cleaning” means the physical removal of organic material or soil from objects by using water, with or without detergents, that is designed to remove, rather than kill, microorganisms. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.9725 “Division” defined. ( NRS 449.0302 ) “Division” means the Division of Public and Behavioral Health of the Department of Health and Human Services. (Added to NAC by Bd. of Health, eff. 12-15-88) NAC 449.973 “Governing body” defined. ( NRS 449.0302 ) “Governing body” means the person or persons designated by the licensee as responsible for the total operation of the ambulatory surgical center. (Added to NAC by Bd. of Health, eff. 12-15-88) NAC 449.9731 “High-level disinfection” defined. ( NRS 441A.120 , 449.0302 ) “High-level disinfection” means a type of disinfection which destroys all microorganisms with the exception of high levels of bacterial spores. Such disinfection may be accomplished through the use of processes that include, without limitation, boiling items in water, steaming items in water and soaking items in chemical disinfectants. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.9732 “Implantable device” defined. ( NRS 441A.120 , 449.0302 ) “Implantable device” means a medical device that is implanted in the human body, including, without limitation, a pacemaker, defibrillator, heart valve, hearing device or joint replacement. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.9733 “Invasive procedure” defined. ( NRS 441A.120 , 449.0302 ) “Invasive procedure” means a medical procedure involving entry into the human body by puncture or incision or by insertion of an instrument. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.9735 “Licensee” defined. ( NRS 449.0302 ) “Licensee” means the person or public agency that is licensed by the Division in accordance with the provisions of NRS 449.001 to 449.240 , inclusive, and NAC 449.971 to 449.996 , inclusive. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99) NAC 449.9736 “Low-level disinfection” defined. ( NRS 441A.120 , 449.0302 ) “Low-level disinfection” means a type of disinfection which eliminates most bacteria, some viruses and some fungi, but which may not kill resistant microorganisms. Such disinfection may be accomplished through the use of processes that include, without limitation, soaking items in chemical disinfectants. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.9738 “Multidose vial” defined. ( NRS 441A.120 , 449.0302 ) “Multidose vial” means a vial, including, without limitation, a sealed sterile vial, which may be accessed by insertion of a needle and which, according to the manufacturer’s instructions: 1. Contains more than one dose of a medication; and 2. May be used for one or more patients. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.974 “Patient” defined. ( NRS 449.0302 ) “Patient” means a natural person who is undergoing diagnostic procedures or treatment by surgery in the ambulatory surgical center. (Added to NAC by Bd. of Health, eff. 12-15-88) NAC 449.9741 “Physician” defined. ( NRS 449.0302 ) “Physician” means a person who is licensed to practice medicine pursuant to chapter 630 of NRS or to practice osteopathic medicine pursuant to chapter 633 of NRS. (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99) NAC 449.9742 “Registered nurse” defined. ( NRS 449.0302 ) “Registered nurse” means a person who is licensed to practice professional nursing pursuant to chapter 632 of NRS. (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99) NAC 449.97422 “Reprocess” defined. ( NRS 441A.120 , 449.0302 ) “Reprocess” means the process of subjecting a single-use medical device that has been previously used on a patient to additional cleaning, disinfection or sterilization, manufacturing steps, including, without limitation, repackaging and relabeling, and testing of the technical and functional safety of the device to make the device ready for safe use on another patient. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.97426 “Single-dose vial” defined. ( NRS 441A.120 , 449.0302 ) “Single-dose vial” means a vial, including, without limitation, a sealed sterile vial, which may be accessed by insertion of a needle and which, according to the manufacturer’s instructions: 1. Contains only one dose of a medication; and 2. May be used for only one patient. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.97428 “Sterilization” defined. ( NRS 441A.120 , 449.0302 ) “Sterilization” means a process using medical equipment, including, without limitation, a dry heat sterilizer or an autoclave, to destroy all forms of microbial life. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.9743 “Surgery” defined. ( NRS 449.0302 ) “Surgery” means the treatment of a human being by operative methods. (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99; A by R181-09, 10-4-2013) Licensing NAC 449.9745 Center required to provide proof of national accreditation; submission of reports to Division; application by accrediting organization for recognition by State Board of Health. ( NRS 449.0302 , 449.445 ) 1. The operator of an ambulatory surgical center shall: (a) Not later than 6 months after obtaining a license, submit proof to the Division of accreditation by: (1) The Joint Commission; (2) The Accreditation Association for Ambulatory Health Care; (3) The American Association for Accreditation for Ambulatory Surgery Facilities; or (4) Any other nationally recognized organization approved by the State Board of Health pursuant to subsection 3; and (b) Maintain current accreditation during the term of licensure. 2. The operator of an ambulatory surgical center shall provide to the Division each report provided by the accrediting organization, including, without limitation, the initial report, each report issued upon renewal of an accreditation and any other report issued by the accrediting organization. 3. An organization which accredits ambulatory surgical centers that wishes to be recognized by the State Board of Health as an accrediting organization for purposes of this section must submit to the Division an application on a form prescribed by the Division. The Division shall review each application received pursuant to this subsection and shall forward to the State Board of Health each application, including the recommendation of the Division whether to approve or deny the application. The recommendation of the Division must be based upon whether the applicant requires an ambulatory surgical center to meet the minimum requirements necessary to ensure a high level of quality. The State Board of Health may approve or deny an application submitted pursuant to this subsection. (Added to NAC by Bd. of Health, eff. 12-15-88; A 6-7-90; R049-99, 9-27-99; R203-09, 7-22-2010) NAC 449.9755 Investigation of applicant and inspection of facility. ( NRS 449.0302 ) After it receives a properly completed application, proof of the identity of the applicant that is acceptable to the Division and the appropriate fee, the Division shall conduct an investigation of the applicant and inspect the facility of the proposed ambulatory surgical center. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R078-12, 12-20-2012; R181-09, 10-4-2013) NAC 449.978 Effect of expiration of license. ( NRS 449.0302 ) If a license authorizing an ambulatory surgical center expires, patients must not occupy the center. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R044-97, 10-30-97) NAC 449.9785 Conformance with regulations required. ( NRS 441A.120 , 449.0302 ) During the term of his or her license, the licensee shall continuously maintain the ambulatory surgical center in conformance with the provisions of NAC 449.971 to 449.996 , inclusive. Any violation of these provisions may result in the suspension or revocation of the license. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R096-08, 8-26-2008, eff. 10-25-2008) Administration NAC 449.979 Governing body required. ( NRS 449.0302 ) Except as otherwise provided by NAC 449.9835 , each ambulatory surgical center must have a governing body, chaired by a principal in the organization of the licensee, with legal authority for the operation of the center. (Added to NAC by Bd. of Health, eff. 12-15-88) NAC 449.9795 Duties of governing body. ( NRS 449.0302 ) The governing body shall: 1. Adopt a set of rules which include provisions concerning: (a) The criteria by which the members and officers of the governing body are selected, their terms of office and their duties; (b) The frequency of its meetings; and (c) The annual revision and approval of the rules by the governing body. 2. Arrange for minutes of its meetings to be taken to record the business conducted. These minutes must be available to all members. (Added to NAC by Bd. of Health, eff. 12-15-88) NAC 449.980 Responsibilities of governing body. ( NRS 441A.120 , 449.0302 ) The governing body shall ensure that: 1. Each patient of the center is under the care of a physician. 2. Except as otherwise provided in this subsection, each patient admitted to the center receives a: (a) Physical examination, which must include a medical history of the patient, within the 30 days immediately preceding the date of the patient’s surgery; and (b) Presurgical evaluation conducted by a physician on the day of the patient’s surgery or within the 7 days immediately preceding the date of the patient’s surgery. A podiatric physician licensed pursuant to chapter 635 of NRS may conduct the presurgical evaluation for a podiatric patient. 3. A physician is on the premises of the ambulatory surgical center and immediately available at all times when there are patients in the operating rooms or the recovery room of the center. As used in this subsection, “immediately available” means the physician is able to respond rapidly to an emergency. 4. An annual operating budget and a plan for capital expenditures are established. 5. The center is adequately staffed and equipped. 6. There is documentation in the files of the center of: (a) The qualifications of all persons employed by or under contract with the center; and (b) Whether such persons who work at or are under contract with the center and have exposure to patients have been screened for communicable diseases as described in NAC 441A.375 . 7. The center establishes and maintains a program for the prevention and control of infections and communicable diseases as required pursuant to NAC 449.98452 . 8. The center adopts, enforces and at least annually reviews written policies and procedures required by NAC 449.971 to 449.997 , inclusive, including an organizational chart. These policies and procedures must: (a) Be approved annually by the governing body. (b) Provide that a surgical procedure may be performed on a patient only with the consent of the patient or the patient’s legal representative, except in an emergency. (c) Include procedures for the periodic review and amendment, as deemed appropriate, of the scope of the procedures performed at the center. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R096-08, 8-26-2008, eff. 10-25-2008; R181-09 & R170-12, 10-4-2013) NAC 449.9801 Procedures for granting privileges to members of medical staff. ( NRS 449.0302 ) 1. The governing body shall: (a) Adopt criteria for granting privileges to members of the medical staff based upon the size and complexity of the services provided by the center. (b) Ensure that an application to be accorded privileges or for the renewal of those privileges is processed in an expeditious manner. (c) Adopt procedures for verifying information contained in an application to be accorded privileges or for the renewal of those privileges. The procedures may include a requirement for the applicant to sign a statement granting immunity from liability to the center for actions taken to verify the information and attesting to the accuracy and completeness of the information contained in the application. 2. The procedures for granting privileges to members of the medical staff must be approved by the governing body. 3. An application to be accorded privileges at an ambulatory surgical center must include, without limitation: (a) Information related to the educational and professional training of the applicant; (b) An evaluation conducted by the applicant’s peers concerning the quality of care provided by the applicant; (c) Evidence that the applicant is licensed or certified to provide in this State the professional services for which the privileges are being requested; (d) Evidence of any license required to be obtained by the applicant from the Drug Enforcement Administration; (e) A description or list of the privileges being requested; (f) Information obtained from the National Practitioner Data Bank as may be required by federal law; and (g) Such other information as may be required by the governing body, including, without limitation, information relating to: (1) Any claims filed against the applicant for professional liability; (2) The revocation, suspension or voluntary relinquishment of the applicant’s license or certification to practice in this State, any other disciplinary action that has been taken against the applicant in his or her professional capacity and any limitations or conditions placed on the applicant’s license or certification to practice in this State; (3) Complaints or reports of any adverse action filed against the applicant with a local, state or national professional society or occupational board; (4) Insurance for professional liability maintained by the applicant, including any circumstance under which an insurer has refused to issue such insurance to the applicant or cancelled the applicant’s insurance; (5) The denial, suspension, limitation, termination or refusal to renew privileges accorded to the applicant at another medical facility; (6) The suspension or revocation of a license issued to the applicant by the Drug Enforcement Administration; (7) Any conviction for a criminal offense, other than a minor traffic violation; and (8) Any physical or mental condition of the applicant that would interfere with his or her ability to provide professional services, including an alcohol or other substance use disorder. 4. A member of the medical staff who is applying for the renewal of his or her privileges must provide evidence that the member is in compliance with the provisions of subsection 3 on the date of the application. 5. The ambulatory surgical center shall maintain a record of the privileges accorded to each member of the medical staff of the center. The record must include, without limitation: (a) The application to be accorded privileges at the center; (b) Each application for the renewal of those privileges; (c) Evidence of the verification of the information contained in the applications; (d) The privileges granted; and (e) Such other information as may be required by the governing body. 6. Privileges accorded to a member of the medical staff must be: (a) Consistent with his or her professional experience and authorized scope of practice; (b) For a limited time as specified by the governing body or a person or committee designated by the governing body; and (c) Be reviewed periodically and revised as appropriate. (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99) NAC 449.9805 Establishment of policy for authentication. ( NRS 449.0302 ) The governing body shall establish a policy for authentication that: 1. Authorizes the use of rubber stamps and prohibits the use of any stamp by any person other than the person whose signature the stamp represents; 2. Approves a method for identifying the person making an entry in any record or chart; and 3. Requires that the professional title of the person making such an entry and the date of that entry is included with the entry. (Added to NAC by Bd. of Health, eff. 12-15-88) NAC 449.981 Appointment and responsibilities of administrator. ( NRS 449.0302 ) 1. The governing body shall appoint a qualified administrator for the center who is responsible to the governing board for the performance of his or her duties. 2. The administrator must: (a) Be at least 21 years of age; (b) Possess one of the following qualifications: (1) Be a physician; (2) Be a registered nurse; (3) Have a bachelor’s or postgraduate degree in administration or a field related to health care; or (4) Have at least 1 year of administrative experience in a health care setting; (c) Have experience in the administration and supervision of personnel; and (d) Possess such knowledge of the practice of medicine as to enable him or her to be conversant in surgical protocols. 3. The governing body shall develop and maintain a written job description for the administrator that includes the duties and responsibilities of the administrator. The job description must be made available for review upon the request of the Division. 4. The administrator is responsible for: (a) The daily operation of the center; (b) Serving, along with any committee appointed for the purpose, as a liaison between the governing body, the members of the medical staff and all the departments of the center; (c) Reporting the pertinent activities concerning the center to the governing body at regular intervals; and (d) Appointing a person responsible for the center in his or her absence. The person so appointed must possess the same qualifications as are required of the administrator. 5. The administrator shall: (a) Ensure that the center complies with all applicable federal and state laws and local ordinances and the policies and procedures approved by the governing body; (b) Annually develop, evaluate, revise and carry out policies and procedures for the center; (c) Ensure that there is an adequate number of qualified and competent members of the staff to provide for the needs of the patients at the center; (d) Develop and maintain a clear and complete job description for each member of the staff; (e) Review each incident or accident report filed with the administrator, take appropriate action in response thereto and maintain a record of the action taken; (f) Enter into contracts with such persons as are necessary to obtain any services required by the center; and (g) Establish a program for quality assurance as required by NAC 449.9812 . (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99) NAC 449.9811 Program for review of surgical procedures and patient outcomes. ( NRS 449.0302 ) An ambulatory surgical center shall establish a program for the review of surgical procedures and patient outcomes, including, without limitation, a review of the program for the control and prevention of infections and the rates of infections occurring at the center. The program must require the review to be conducted by a person who does not have a financial interest in the ambulatory surgical center. (Added to NAC by Bd. of Health by R181-09, eff. 10-4-2013) NAC 449.9812 Program for quality assurance. ( NRS 449.0302 ) 1. The administrator of an ambulatory surgical center shall establish a program for quality assurance for the center. 2. The program for quality assurance must include, without limitation: (a) Periodic reviews of the clinical responsibilities and authority of the members of the staff. (b) Periodic evaluations of members of the staff that are conducted by their peers. (c) Procedures for the supervision of the professional and technical activities of the members of the staff. (d) Procedures for identifying and correcting any problems or concerns that provide an opportunity for all members of the staff who are health care practitioners to participate in the program for quality assurance. (e) Techniques for self-assessment that are required to be used by the members of the staff and provide for an examination of the manner in which care has been, is and will be provided and the quality of the care provided. (f) Procedures for identifying and addressing any problems or concerns related to the care provided to patients using the medical records of the center and any other sources of data that may be useful to identify previously unrecognized concerns, and for assessing the frequency, severity and sources of suspected problems and concerns. The procedures must include, without limitation, procedures for assessing: (1) The clinical performances of members of the staff who are health care practitioners; (2) The standards used for the maintenance of medical records; (3) The procedures used to control the quality of radiological, pathological, laboratory and pharmaceutical services provided by the center; (4) The procedures used to control the quality of other professional and technical services provided by the center; (5) The care and services provided by the extended recovery unit, if such a unit is operated by the center; (6) The procedures used to control infection; and (7) The satisfaction of patients who have been treated at the center. (g) The maintenance of a record of all fires and deaths that have occurred at the center and the transfer of all patients from the center to a hospital. (h) Procedures for assessing any actions taken to correct identified problems or concerns and for determining whether the actions taken have achieved or sustained the desired result and, if not, why not. 3. The members of the professional and administrative staffs of the center shall: (a) Understand, support and participate in the program for quality assurance; and (b) Participate in the resolution of any problems and concerns identified pursuant to the procedures required by subsection 2. 4. The members of the staff who are health care practitioners shall participate in the development and application of the criteria used to evaluate the care provided at the center and the evaluation of any problems and concerns identified pursuant to the procedures required by subsection 2. 5. Activities conducted pursuant to the program for quality assurance must be reported to the appropriate members of the staff and to the governing body. The administrator of the center shall establish procedures for carrying out any recommendations of the governing body. 6. As used in this section, “health care practitioner” means a person who is licensed or certified to provide health care services in this State, including, without limitation, a physician, dentist, podiatrist, and registered or licensed practical nurse. (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99; A by R181-09, 10-4-2013) NAC 449.9813 Committee for quality assurance. ( NRS 449.0302 ) 1. The governing body shall establish a committee for quality assurance. 2. The committee must be composed of members of the staff who represent the various clinical and medical services provided by the center. 3. The committee shall: (a) Meet at least once each quarter and maintain minutes of its meetings. (b) Develop and make available a plan of action for carrying out the program for quality assurance established pursuant to NAC 449.9812 . (c) Carry out the program for quality assurance established pursuant to NAC 449.9812 . (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99; A by R181-09, 10-4-2013) NAC 449.9815 Maintenance. ( NRS 449.0302 ) The administrator shall ensure that the person in charge of maintenance at the center: 1. Has a written program of maintenance of all of the equipment used at the center. 2. Has written service contracts with vendors that require the inspection and repair of equipment as needed. 3. Maintains written records of the inspections of the equipment used at the center. 4. Keeps the temperature in the center at a comfortable level. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99) NAC 449.982 Sanitation and housekeeping. ( NRS 449.0302 ) The administrator shall ensure that the sanitation and housekeeping staff of the center: 1. Maintains a clean and sanitary environment in the center with particular regard for: (a) The sanitary disposal of pathological and infectious waste; (b) Methods for handling contaminated linen or substitutes for linen; and (c) An effective program to control pests. 2. Keeps the center free of offensive odors, dirt and hazards. 3. Has suitable equipment and supplies for the routine cleaning of all surfaces in the center and keeps the equipment in a sanitary condition. 4. Uses methods of cleaning that minimize the spread of pathogenic organisms. 5. Cleans all floors in the center on a daily basis. 6. Maintains all toilet facilities and storage areas in a sanitary and orderly manner on a daily basis. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99) NAC 449.983 Protection from fire and other disasters. ( NRS 449.0302 ) 1. The administrator shall ensure that the center, members of the staff and patients are adequately protected from fire or other disasters. He or she shall prepare a written plan describing all actions to be taken by the members of the staff and patients in the case of any such incident. This plan must be approved by the governing body and the local fire department and must include provisions for: (a) Evacuation routes and procedures that are posted in the center. (b) The assignment of personnel to specific tasks and responsibilities. (c) Instruction on the use of alarm stations and the location of signals. (d) Instruction concerning methods of containing a fire. (e) Procedures for the notification of appropriate persons. (f) The location of equipment for fighting fires. (g) The conduct of fire drills not less frequently than once each quarter for each shift of employees and requirements for a dated, written report and an evaluation of each drill. (h) The maintenance of records showing that all employees have been trained in the execution of the plan at the beginning of their employment and annually thereafter. (i) A rehearsal and a review of the plan at least once each year with a separate rehearsal for other disasters at least once each year. A written report and evaluation of each rehearsal must be on file. 2. An ambulatory surgical center must be equipped with an automatic sprinkler system that is in good working condition and is approved by the State Fire Marshal. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99) NAC 449.9832 Establishment of policies for provision of services and care by persons under contract with or who are otherwise not employed by center. ( NRS 449.0302 ) If services and care are provided at an ambulatory surgical center by persons who are under contract with the center or who are otherwise not employees of the center, the governing body shall establish policies for the provision of services and care by those persons, including, without limitation, policies relating to the supervision of such persons and the coordination of services and care. The policies must ensure that services and care are provided at the ambulatory surgical center in a safe and effective manner. (Added to NAC by Bd. of Health by R181-09, eff. 10-4-2013) NAC 449.9835 Exemption from requirements for governing body and administrator. ( NRS 441A.120 , 449.0302 ) 1. If a licensee is a sole physician operator, the ambulatory surgical center operated by the licensee is not required to have a governing body or an administrator. In such a case, in the absence of a governing body or an administrator, the sole physician operator is responsible for complying with all the provisions of NAC 449.971 to 449.996 , inclusive. 2. As used in this section, “sole physician operator” means a physician, a podiatric physician licensed pursuant to chapter 635 of NRS or a dentist licensed pursuant to chapter 631 of NRS who is operating an ambulatory surgical center for the purpose of performing surgery only upon his or her patients. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R096-08, 8-26-2008, eff. 10-25-2008; R170-12, 10-4-2013) NAC 449.9837 Restrictions on operation of ambulatory surgical center; maintenance of records. ( NRS 449.0302 ) 1. An ambulatory surgical center: (a) May be operated only for the purpose of providing surgical services to patients who do not require care for more than 24 hours. (b) Except as otherwise provided in subsection 2, may not be operated in: (1) Conjunction with any other medical facility; or (2) A common area with any other medical facility during its hours of operation. 2. The provisions of subsection 1 do not prohibit an ambulatory surgical center from: (a) Being located in the same building as a physician’s office or clinic if the center is physically separated from the office or clinic by at least one fire wall that is rated to withstand a fire for at least 1 hour. (b) Sharing a lobby with another medical facility. 3. The records of an ambulatory surgical center must be maintained separately from the records of any other medical facility. (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99) NAC 449.9843 Compliance with certain standards, laws, ordinances and codes; submission and approval of building plans; prerequisites to approval of center for licensure. ( NRS 439.200 , 449.0302 ) 1. An ambulatory surgical center shall comply with the provisions of NFPA 99: Health Care Facilities Code concerning medical gases, adopted by reference pursuant to NAC 449.0105 , and the provisions of NFPA 101: Life Safety Code , adopted by reference pursuant to NAC 449.0105 . 2. Any new construction, remodeling or change in the use of an ambulatory surgical center must comply with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 , unless the remodeling is limited to refurbishing an area within the center, including, without limitation, painting the area, replacing flooring in the area, repairing windows in the area and replacing window or wall coverings in the area. 3. An ambulatory surgical center shall be deemed to be in compliance with the provisions of subsection 2 and subsection 2 of NAC 449.983 if: (a) The center is licensed on February 1, 1999, the use of the physical space in the center is not changed and there are no deficiencies in the construction of the center that are likely to cause serious injury, harm or impairment to the public health and welfare; or (b) The center has submitted building plans to the Bureau before February 1, 1999, and: (1) The Bureau determines that the plans comply with standards for construction in effect before December 11, 1998; (2) The center is constructed in accordance with those standards; (3) Construction of the center is begun before August 1, 1999; and (4) There are no deficiencies in the construction of the center that are likely to cause serious injury, harm or impairment to the public health and welfare. 4. An ambulatory surgical center shall comply with all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Life safety, environmental, health, fire and local building codes. Ê If there is a difference between state and local requirements, the more stringent requirements apply. 5. An ambulatory surgical center shall submit building plans for new construction or remodeling to the entity designated to review such plans by the Division pursuant to NAC 449.0115 . The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the center. Before the construction or remodeling may begin, the plans for the construction or remodeling must be approved by the Division. The Bureau shall not approve a center for licensure until all construction is completed and a survey is conducted at the site of the center. (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99; A by R076-01, 10-18-2001; R077-04, 8-5-2004; R122-16, 9-21-2017; R048-22, 12-29-2022) NAC 449.9844 Class designations: Authorized procedures; operating room dimensions. ( NRS 439.200 , 449.0302 ) 1. An ambulatory surgical center must be designated as Class A, Class B, Class C, Class E or Endoscopy Only. 2. An ambulatory surgical center that is designated as Class A may provide minor surgical procedures performed under local or topical anesthesia. An operating room in an ambulatory surgical center that is designated as Class A must have a minimum clear area of 130 square feet (12.077 square meters) and a minimum clear dimension of 10 feet (3.05 meters). 3. An ambulatory surgical center that is designated as Class B may provide any surgical procedure authorized for an ambulatory surgical center that is designated as Class A and any surgical procedure performed under conscious or deep sedation. An operating room in an ambulatory surgical center that is designated as Class B must have a minimum clear area of 250 square feet (23.23 square meters) and a minimum clear dimension of 15 feet (4.57 meters). 4. An ambulatory surgical center that is designated as Class C may provide any surgical procedure authorized for an ambulatory surgical center that is designated as Class A or B and any surgical procedure that requires general anesthesia. An operating room in an ambulatory surgical center that is designated as Class C must have a minimum clear area of 400 square feet (37.16 square meters) and a minimum clear dimension of 18 feet (5.49 meters). 5. An ambulatory surgical center that is designated as Class E must have been licensed before August 5, 2004. 6. An ambulatory surgical center that is designated as Endoscopy Only may only provide endoscopy procedures. An operating room in an ambulatory surgical center that is designated as Endoscopy Only must have a minimum clear area of 180 square feet (16.7225 square meters). 7. As used in this section: (a) “Clear area” means the open area of an operating room, excluding fixed cabinets and built-in shelves. (b) “Clear dimension” means the open space between the operating room and another area of the building. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) Program for the Prevention and Control of Infections and Communicable Diseases NAC 449.98451 Adoption of guidelines by governing body for establishment of program. ( NRS 441A.120 , 449.0302 ) 1. The governing body shall adopt guidelines which must be used by the ambulatory surgical center in establishing the program for the prevention and control of infections and communicable diseases required pursuant to NAC 449.98452 . 2. The guidelines adopted pursuant to subsection 1 may include, without limitation, guidelines, statements or recommendations issued or published by other agencies or organizations, and must: (a) Be based on evidence, theoretical rationale or scientific data; and (b) Include well-designed experimental, clinical or epidemiological studies which document the processes used in the development of the studies and grade the strength of the evidence relied on in the studies. 3. The governing body shall ensure that a copy of the guidelines adopted pursuant to subsection 1 is available at the ambulatory surgical center and accessible to the staff of the ambulatory surgical center and the public. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.98452 General requirements of program. ( NRS 441A.120 , 449.0302 ) 1. Each ambulatory surgical center shall establish and maintain a program for the prevention and control of infections and communicable diseases. 2. In addition to complying with the provisions of NAC 449.98451 to 449.98457 , inclusive, a program for the prevention and control of infections and communicable diseases must be: (a) Appropriate for the services provided at the ambulatory surgical center; (b) Based on the guidelines adopted by the governing body pursuant to NAC 449.98451 ; and (c) Developed in a manner that takes into consideration: (1) All the surgical and other medical services provided at the ambulatory surgical center; (2) The types of patients typically treated at the ambulatory surgical center, including, without limitation, those whose age or medical condition makes them vulnerable to infections and communicable diseases; (3) The types of injuries or illnesses typically treated at the ambulatory surgical center; (4) The number of patients typically treated at the ambulatory surgical center; (5) The level of education and training of the staff of the ambulatory surgical center; (6) The number of nurses available at the ambulatory surgical center, the qualifications of such nurses and the amount of support required of the nurses by the physicians at the ambulatory surgical center; (7) The types of invasive procedures performed at the ambulatory surgical center; (8) The locations within the ambulatory surgical center where invasive procedures are performed; (9) The specific medical instruments and equipment used at the ambulatory surgical center; (10) The physical design of the ambulatory surgical center; and (11) The causes, risks and patterns of infections and transmission of communicable diseases that arise in the setting of each medical procedure performed at the ambulatory surgical center. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.98453 Program required to include policies and procedures for prevention of exposure to blood-borne and other potentially infectious pathogens. ( NRS 441A.120 , 449.0302 ) Each program for the prevention and control of infections and communicable diseases must include policies and procedures to prevent exposure to blood-borne and other potentially infectious pathogens, including, without limitation, policies and procedures relating to: 1. Hand hygiene, including provisions regarding the time and procedure for handwashing with soap and water or use of an alcohol-based hand rub. 2. The proper use of medical gloves. Those policies and procedures must, at a minimum, provide that each person who works at the ambulatory surgical center must wear medical gloves when the person: (a) Anticipates coming in contact with blood or bodily fluids; (b) Handles contaminated instruments, items and equipment; (c) Handles biohazardous waste; (d) Handles linens potentially contaminated with biohazardous waste; and (e) Performs housekeeping activities or cleans contaminated surfaces. 3. Safe injection practices to prevent the contamination of equipment used for injections and medication. Those policies and procedures must provide that a new sterile needle and new sterile syringe must be used for each patient and may not be used for more than one patient. 4. The proper handling of sharp instruments and the disposal of sharp instruments. Those policies and procedures must be consistent with the standards developed by the Occupational Safety and Health Administration for the handling and disposal of such instruments. 5. Techniques for accessing a vial of medication. Those policies and procedures must comply with the requirements set forth in NAC 449.98454 . 6. The infusion of intravenous medications. Those policies and procedures must provide that intravenous tubing and fluid bags or bottles must not be used for more than one patient. 7. The proper sterilization and disinfection of all medical equipment, instruments and devices. Those policies and procedures must, at a minimum, require an ambulatory surgical center to: (a) Sterilize or ascertain the sterility of items that enter sterile tissue or the vascular system, including, without limitation, surgical instruments, endoscopes, endoscopic accessories, catheters, needles and probes used for ultrasounds; (b) Perform high-level disinfection of reusable items that come in contact with nonintact skin or mucus membranes, including, without limitation, respiratory therapy equipment, anesthesia equipment, bronchoscopes and gastrointestinal endoscopes; and (c) Perform low-level disinfection of reusable items that come in contact with only intact skin, including, without limitation, tourniquets, blood pressure cuffs, linens, stands that are used to hold medical instruments and other furnishings. 8. The proper handling of equipment, instruments and devices. Those policies and procedures must, at a minimum, require an ambulatory surgical center to: (a) Sterilize and disinfect reusable items as described in subsection 7; (b) Properly dispose of single-use equipment, instruments and devices after use, if the ambulatory surgical center has decided not to have the equipment, instruments or devices reprocessed; and (c) Ensure that: (1) All equipment, instruments and devices that may be reprocessed are reprocessed only by a third-party processor approved by the United States Food and Drug Administration; and (2) No equipment, instruments or devices that may be reprocessed are reprocessed at the ambulatory surgical center. 9. The proper handling and disposal of medical waste and specimens. 10. The proper cleaning and disinfection of all areas in which patient care is provided. 11. The proper maintenance of a clean and sanitary environment. 12. The identification and reporting of the development and transmission of infections and communicable diseases. Those policies and procedures must include the method by which the ambulatory surgical center must: (a) Track and document the development and transmission of infections and communicable diseases which are related to the medical procedures performed at the ambulatory surgical center; (b) Report the development and transmission of infections and communicable diseases as required by federal, state and local laws; and (c) Identify and address trends in such developments and transmissions of infections and communicable diseases. 13. The care of patients with a communicable disease, including, without limitation, patients who are known to have a communicable disease at the time of arrival at the ambulatory surgical center and patients who are found to have a communicable disease during the course of treatment at the ambulatory surgical center. 14. The screening for communicable diseases as described in NAC 441A.375 of all employees and of all persons under contract with the ambulatory surgical center who work at the center and have exposure to patients at the center. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.98454 Program required to include policies and procedures for single-dose vials and multidose vials. ( NRS 441A.120 , 449.0302 ) 1. Each program for the prevention and control of infections and communicable diseases must include policies and procedures for single-dose vials which provide that a single-dose vial may be accessed only by using an aseptic technique. The policies and procedures must provide that: (a) Each injection of a medication from a single-dose vial must be prepared in a clean, designated area where contamination by blood or bodily fluid is unlikely to occur; (b) The medication in a single-dose vial must not be used for more than one patient; (c) A single-dose vial, including any remaining medication in the vial after its use, must be discarded; and (d) Any remaining medication in a single-dose vial after its use must not be combined with any other medication or otherwise used for any other patients. 2. Each program for the prevention and control of infections and communicable diseases must include policies and procedures for multidose vials which provide that a multidose vial may be accessed only by using an aseptic technique. The policies and procedures must provide that: (a) The cap of a multidose vial must be cleaned with an alcohol-based wipe before the vial is accessed; (b) A new sterile needle and new sterile syringe must be used each time to access a multidose vial; (c) Upon first access of a multidose vial, the person who accessed the vial shall date and initial the vial; (d) Each injection of a medication from a multidose vial must be prepared in a clean, designated area where contamination by blood or bodily fluid is unlikely to occur; (e) A needle must not be left inserted in the cap of a multidose vial after its use; and (f) A multidose vial must be discarded when the medication in the vial has expired or 28 days after the vial was initially accessed. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.98455 Sterilization and disinfection of surgical instruments, items and equipment; training required for employees and contractors responsible for sterilization or disinfection. ( NRS 441A.120 , 449.0302 ) 1. All surgical instruments, items or equipment used in the care of patients at an ambulatory surgical center must be sterilized or disinfected according to the program for the prevention and control of infections and communicable diseases adopted by the ambulatory surgical center pursuant to NAC 449.98452 . 2. If such instruments, items and equipment are sterilized or disinfected by equipment or cleaning agents at the ambulatory surgical center: (a) Before an employee or independent contractor may be assigned the responsibility for sterilizing or disinfecting any instrument, item or equipment, the employee or independent contractor must receive training concerning the instructions of the manufacturer of the device or sterilizer for: (1) Sterilizing and disinfecting the instrument, item or equipment; (2) The use and maintenance of the sterilizer or disinfecting equipment; and (3) The agents used to sterilize and disinfect the instrument, item or equipment. (b) An employee or independent contractor assigned the responsibility for sterilizing or disinfecting the instrument, item or equipment shall: (1) Receive annual training concerning the manufacturer’s instructions described in paragraph (a); and (2) Receive training on any new equipment or procedures if there is any change in the equipment or procedures used to sterilize or disinfect an instrument, item or equipment. (c) The ambulatory surgical center shall ensure that documentation of all training completed pursuant to this subsection is kept in the file of the employee or independent contractor. 3. The manufacturer’s instructions for operating any sterilizer or performing any disinfection procedure must be located or posted near the equipment used for sterilization or disinfection. 4. The ambulatory surgical center shall ensure that each employee or independent contractor follows the manufacturer’s instructions concerning: (a) The instruments, items or equipment that may be sterilized or disinfected; (b) The procedures for cleaning an instrument, item or equipment before the instrument, item or equipment is sterilized or undergoes high-level disinfection; (c) The procedures for sterilizing or disinfecting an instrument, item or equipment; (d) The operation and maintenance of the sterilizer or the equipment used for high-level disinfection; (e) The frequency and type of biologic indicator testing of the sterilizer; (f) The recommended agents for sterilizing and disinfecting the instrument, item or equipment; and (g) The frequency of testing of any solution for disinfecting to ensure maintenance of the minimum level of effectiveness, but not less often than daily testing. 5. The effectiveness of the sterilization procedures must be checked by performing a biologic indicator test: (a) At least weekly, or more frequently if recommended by the manufacturer; and (b) While sterilizing all implantable devices. 6. Sterilization records and logs of the results of the biologic indicator test must be maintained by the ambulatory surgical center for at least 1 year after the test is performed to ensure that the recommended testing and maintenance of the equipment is performed and the manufacturer’s instructions regarding proper sterilization techniques are followed. Each ambulatory surgical center shall establish a method to track and recall instruments, items or equipment previously sterilized or disinfected if there is a failure of the biologic indicator test. 7. To aid in environmental control, each ambulatory surgical center shall provide a physical barrier between the decontamination and sterilization areas of the ambulatory surgical center. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.98456 Center required to designate employee or enter into contract for overseeing and managing program; qualifications and duties of employee or contractor. ( NRS 441A.120 , 449.0302 ) 1. Each ambulatory surgical center shall designate an employee or enter into a contract with a person to oversee and manage all aspects of the program for the prevention and control of infections and communicable diseases. 2. The person described in subsection 1: (a) Shall have completed specialized training in the prevention and control of the development and transmission of infections and communicable diseases; and (b) Shall ensure that the program for the prevention and control of infections and communicable diseases for the ambulatory surgical center: (1) Complies with all applicable federal, state and local laws; (2) Is consistent with the guidelines adopted by the governing body pursuant to NAC 449.98451 ; and (3) Is reviewed with all employees of the ambulatory surgical center and all persons under contract with the ambulatory surgical center who work at the center and have exposure to patients at the center within the first 10 days of employment and every 12 months thereafter, or more often if required pursuant to subsection 2 of NAC 449.98457 . (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.98457 Mandatory training and evaluation of employees and other persons. ( NRS 441A.120 , 449.0302 ) 1. Each employee of an ambulatory surgical center and each person under contract with an ambulatory surgical center who works at the center and has exposure to patients at the center shall receive training and be evaluated by supervising staff on his or her knowledge and skills concerning the program for the prevention and control of infections and communicable diseases within the first 10 days of employment and at least every 12 months thereafter. 2. An employee or person under contract with the ambulatory surgical center may be required to receive the training and evaluation described in subsection 1 more often than every 12 months if his or her supervisor determines that such training and evaluations are necessary to ensure that the employee or person understands and will follow the policies and procedures of the program for the prevention and control of infections and communicable diseases. (Added to NAC by Bd. of Health by R096-08, 8-26-2008, eff. 10-25-2008) Personnel NAC 449.9855 Policies and requirements for personnel. ( NRS 449.0302 ) 1. An ambulatory surgical center shall have written policies for the personnel employed at the center. These policies must be provided to each employee in the form of a manual and must include provisions concerning hours of work, grievances in connection with termination, vacation, sick leave and leaves of absence. 2. Each employee of the center must: (a) Have a skin test for tuberculosis in accordance with NAC 441A.375 . A record of each test must be maintained at the center. (b) Within 10 days after the date of his or her employment, and periodically thereafter, be instructed in the control of infections, the prevention of fires, the safety of the patients, preparation in case of disaster, and the policies and procedures of the center. 3. A current and accurate personnel record for each employee of the center must be maintained at the center. The record must include, without limitation: (a) A job description that: (1) Includes the duties and responsibilities of, and the qualifications required for, the position held by the employee; and (2) Is signed by the employee; (b) Evidence that the employee: (1) Holds in good standing any license, certificate or registration required for the position held by the employee; and (2) Possesses the experience and qualifications required for the position held by the employee; (c) An annual evaluation of the employee that is signed by the employee and his or her supervisor; (d) Such health records as are required by chapter 441A of NAC; and (e) A statement signed by the employee indicating that the employee has read and understands the provisions of NAC 449.971 to 449.997 , inclusive. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R181-09, 10-4-2013) NAC 449.9865 Medical staff. ( NRS 449.0302 ) 1. The medical staff of an ambulatory surgical center is answerable to the governing body for the quality of medical care provided to patients and for the ethical and professional practices of its members. 2. The governing body, or a person or committee designated by the governing body, shall appoint the members of the medical staff and grant, deny and withdraw the privileges to be accorded members of the medical staff as it deems appropriate. Appointments to the medical staff must be made in writing and must be documented in the records of the center. 3. Each member of the medical staff must be qualified for the position to which the member is appointed and the privileges which he or she is accorded. 4. A roster of the surgical privileges of each member of the medical staff must be kept in the files of the operating room, specifying the privileges accorded him or her. 5. A member of the medical staff shall not perform a surgical procedure or provide a treatment for which the member has not been granted privileges. 6. The governing body shall establish procedures for disciplining a member of the medical staff who fails to comply with the policies and procedures of the center, including, without limitation, disciplining a member of the medical staff for performing a surgery for which the member has not been granted privileges. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R181-09, 10-4-2013) NAC 449.988 Nursing staff. ( NRS 449.0302 ) 1. Each ambulatory surgical center must have a department of nursing under the direction of a chief nurse who is a registered nurse. 2. A sufficient number of members of the nursing staff must be on duty at all times to ensure that proper care is provided to each patient. A sufficient number of registered nurses must be on duty at all times to ensure the immediate availability of a registered nurse for the care of any patient. A person who is not a registered nurse may be assigned to care for a patient to the extent consistent with his or her education, experience and authorized scope of practice. 3. A surgical technician or licensed practical nurse may be permitted to serve as a scrub technician only under the direct supervision of a registered nurse. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99) NAC 449.9883 Requirements for employment of certain persons to engage in practice of surgical technology; documentation. ( NRS 439.200 , 449.0302 , 449.24185 ) 1. A person employed to engage in the practice of surgical technology in an ambulatory surgical center pursuant to subsection 3 of NRS 449.24185 must have passed a written competency evaluation demonstrating that he or she is competent to practice surgical technology and have: (a) Not less than 1 year of experience within the immediately preceding 3 years practicing surgical technology in a hospital or surgical center for ambulatory patients that is licensed in a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico or a territory or insular possession subject to the jurisdiction of the United States; or (b) Completed evidence-based training concerning: (1) Proper surgical attire; (2) Identification of patients; (3) Proper positioning of a patient on an operating table; (4) Consent of a patient to surgery; (5) Time-out before surgery; (6) The proper use of instruments and equipment, including, without limitation, identifying dangers associated with equipment; (7) Asepsis and sterile technique, including, without limitation, identifying a break in the sterile field; (8) Washing hands before surgery; (9) Counting surgical instruments, surgical sponges and any other items used during surgery that may be left in the body of a patient; (10) Preparing medications in the sterile field; (11) The use of gowns and gloves; (12) Draping of the patient; (13) Proper care for specimens; (14) Procedures for disinfecting and sterilizing equipment and supplies; (15) Procedures for determining whether equipment and supplies have been properly sterilized and measures to be taken if a break in the sterile field is identified; (16) Storage of sterile equipment and supplies; and (17) Environmental cleaning and disinfecting the operating room. 2. An ambulatory surgical center shall be deemed to have conducted a thorough and diligent search for the purposes of subsection 3 of NRS 449.24185 if the ambulatory surgical center advertises for a surgical technologist who meets the requirements of subsection 1 or 2 of NRS 449.24185 for not less than 30 days: (a) In a newspaper of general circulation within 50 miles of the ambulatory surgical center; or (b) On an Internet website on which jobs in health care are regularly posted. 3. The administrator of an ambulatory surgical center that employs a person to engage in the practice of surgical technology in the ambulatory surgical center pursuant to subsection 3 of NRS 449.24185 shall maintain in the personnel file of the person documentation demonstrating: (a) Compliance with subsection 1 of this section; (b) Evidence of the advertising conducted pursuant to subsection 2 of this section; and (c) The reasons the ambulatory surgical center was unable to employ a sufficient number of surgical technologists who meet the requirements prescribed by subsection 1 or 2 of NRS 449.24185 . 4. As used in this section, “time-out” means pausing immediately before surgery to confirm the identity of the patient, the surgical procedure that will be performed and the site of the surgery. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) Medical Records, Services and Facilities NAC 449.9885 Medical records: Maintenance. ( NRS 449.0302 ) 1. An employee shall oversee the completion, filing and retention of each medical record. 2. Records must be maintained for each patient admitted for care in the center in accordance with accepted professional principles. 3. Only authorized personnel may have access to medical records. Information contained in a medical record must not be released without the written consent of the patient or his or her guardian except: (a) As required by law; (b) Under a contract involving a third-party payor; or (c) As otherwise provided by the agreement on admission. 4. A medical record may be microfilmed if the record can be legibly reproduced. 5. A licensee who ceases operations shall notify the Division of the arrangements made for access to and the safe preservation of medical records. 6. Medical records must not be removed from the center except upon the issuance of an order by a court of competent jurisdiction. 7. The records of each patient discharged from the center must be completed within 30 days after the date of his or her discharge. 8. An index of medical records must be maintained. The medical records of each patient must be indexed, within 6 months after discharge, according to the surgery performed and the physician attending the patient. 9. Each record must be protected against loss, destruction or unauthorized use. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99) NAC 449.989 Medical records: Contents. ( NRS 449.0302 ) The medical record of each patient must be complete, authenticated, accurate and current, and must include the following information: 1. A complete identification of the patient, including information on his or her next of kin and on the person or agency legally or financially responsible for him or her. 2. A statement concerning the admission and diagnosis of the patient. 3. The medical history of the patient. 4. Documentation that the patient has been given a: (a) Physical examination, which must include a medical history of the patient, conducted by a physician within the 30 days immediately preceding the date of the patient’s surgery; and (b) Presurgical evaluation conducted by a physician or a podiatric physician licensed pursuant to chapter 635 of NRS, as applicable, on the day of the patient’s surgery or within the 7 days immediately preceding the date of the patient’s surgery. 5. Evidence of any informed consent given for the care of the patient. 6. Any clinical observations of the patient, such as the notes of a physician, a nurse or any other professional person in attendance. Such an entry must be signed by the person making the entry and include the title of that person. 7. Reports of all studies ordered, including laboratory and radiological examinations. 8. Confirmation of the original diagnosis, or the diagnosis at the time of discharge. 9. A report of any surgery performed on the patient, prepared by the surgeon. 10. A description of the procedure followed in any administration of anesthesia to the patient. 11. A recovery report for the patient. 12. A summary of discharge, including, without limitation, the disposition of the patient and any recommendations and instructions given to the patient. 13. Documentation that a member of the nursing staff interviewed the patient within 72 hours after the patient was discharged from the center to determine the condition of the patient and whether the patient was satisfied with the services provided, and to receive any complaints or problems the patient may have. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R181-09 & R170-12, 10-4-2013) NAC 449.990 Medication and treatment. ( NRS 441A.120 , 449.0302 ) 1. Any medication or treatment may be given only upon the written or oral order of a person lawfully authorized to prescribe that medication or treatment. This order must be authenticated by the prescriber and the person administering the medication. An oral order must be recorded and authenticated within 24 hours after it is given. 2. Medications prepared by one nurse may not be administered by another nurse. 3. At the time the medication is administered, the patient must be identified and the medication must be identified as being ordered for that patient and recorded in the medical record of the patient. 4. Intravenous medications or fluids may be administered only by persons who have been specially trained and are authorized for that duty. 5. Any suspected adverse reaction to a medication must be reported by members of the nursing staff to the physician attending the patient. The nursing staff shall document the reaction in the medical record of the patient. 6. All medications must be prepared and administered in a safe and effective manner in accordance with the program for the prevention and control of infections and communicable diseases adopted pursuant to NAC 449.98452 and in accordance with the manufacturer’s instructions. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.9902 Emergency equipment and supplies. ( NRS 449.0302 ) 1. An ambulatory surgical center must be equipped with: (a) A cardiac defibrillator; (b) A tracheostomy or cricothyroidotomy set; (c) A mobile cart which contains the equipment and supplies specified by the medical staff pursuant to subsection 3; (d) If the ambulatory surgical center provides services to pediatric patients who are less than 9 years of age, the equipment and supplies specified by the medical staff pursuant to subsection 3 needed to treat a pediatric patient during an emergency; (e) If general anesthesia is provided at the ambulatory surgical center or if the center offers to patients a triggering agent for malignant hyperthermia, a mobile cart which contains the equipment and supplies specified by the medical staff pursuant to subsection 3 needed to treat a patient with malignant hyperthermia; (f) In addition to the mobile cart required by paragraph (e), if general anesthesia is provided at the ambulatory surgical center, the equipment and supplies specified by the medical staff pursuant to subsection 3 needed to manage a difficult airway of a patient; and (g) Such other emergency medical equipment and supplies as are specified by the members of the medical staff pursuant to subsection 3. 2. A person trained: (a) In the use of emergency equipment; (b) In advanced cardiac life support; and (c) If the ambulatory surgical center provides services to pediatric patients less than 9 years of age, in pediatric advanced life support, Ê must be on the premises of the ambulatory surgical center and immediately available at all times when there is a patient in the center. As used in this subsection, “immediately available” means that the person is able to respond rapidly to an emergency. 3. The medical staff of the ambulatory surgical center shall annually review and prescribe the equipment and supplies which must be available pursuant to subsection 1, including, without limitation, equipment and supplies frequently used in hospitals at the sites of medical and surgical emergencies for life support protocols to potentially save the life of a patient. (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99; A by R181-09 & R170-12, 10-4-2013) NAC 449.9905 Pharmacist employed by or contracted with center; records, storage and administration of drugs; center required to obtain license to operate pharmacy. ( NRS 441A.120 , 449.0302 ) 1. A pharmacist employed by or contracted with an ambulatory surgical center pursuant to NAC 639.4996 is responsible for all matters pertaining to the use of drugs in the ambulatory surgical center. 2. Records of all transactions must be in writing and maintained in accordance with the provisions of state and federal law so the receipt and disposition of any drug may be readily traced. 3. Drugs requiring refrigeration must be stored in a locked refrigerator or a refrigerator in a locked room. 4. In the absence of a full-time pharmacist, the director of nursing must be designated in writing as responsible for the control of dangerous drugs and controlled substances. Controlled substances as described in chapter 453 of NRS must be stored in a storage area with two locks. If a box is used, it must be securely fastened and immovable. The keys or combinations to the locks must be accessible only to licensed health care professionals. 5. All drugs must be logged into and checked out of stock only by a licensed health care professional. 6. The ambulatory surgical center shall obtain a license to operate a pharmacy pursuant to chapter 639 of NRS. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R096-08, 8-26-2008, eff. 10-25-2008; R181-09, 10-4-2013) NAC 449.991 Laboratory services. ( NRS 449.0302 ) 1. Laboratory services must be provided to meet the needs of patients and must be available to each center at all times. 2. If the ambulatory surgical center has its own laboratory, it must be a licensed clinical laboratory under the provisions of chapter 652 of NRS. 3. If the ambulatory surgical center contracts with a laboratory for its services, that laboratory must be certified in accordance with the Clinical Laboratory Improvement Amendments of 1988, Public Law No. 100-578. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99) NAC 449.992 Pathological services. ( NRS 449.0302 ) 1. Pathology services must be provided by a staff pathologist or by a pathologist used as a consultant by the ambulatory surgical center. The pathologist must be licensed to practice in this State. 2. All material removed from a patient during surgery must be clearly labeled and examined microscopically as required by a pathologist. In the absence of a staff pathologist, written arrangements must be made to send tissues to a pathologist outside the center. 3. A list of tissues that do not routinely require microscopic examination must be approved by a pathologist and made available to the laboratory and the members of the medical staff. 4. Reports of examinations of tissues must be signed, which may include an electronic signature, by the examining pathologist. The original report must be filed in the medical record of the patient. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R181-09, 10-4-2013) NAC 449.9925 Blood and derivatives of blood: Procurement, storage, transfusion and administration; policies and procedures; reporting of adverse reaction. ( NRS 441A.120 , 449.0302 ) 1. If the ambulatory surgical center provides its own service for blood transfusions through its medical laboratory as defined in NRS 652.060 : (a) Any arrangement for the procurement, safekeeping or transfusion of blood or derivatives of blood must be under the supervision of a pathologist; (b) Any reaction to a transfusion of blood must be investigated; (c) The storage equipment for blood and derivatives of blood must be protected by an alarm system which must be tested each month and the temperature continuously monitored to verify its operation; (d) Samples of the blood of any patient receiving a transfusion and of each unit of blood used in the center must be retained in accordance with the written policy of the laboratory for at least 7 days for further testing in the event of a reaction to the transfusion; and (e) Blood and derivatives of blood that have exceeded their expiration date must not be used and must be disposed of as biohazardous waste. 2. If the ambulatory surgical center depends on an outside source for blood, there must be in force a written agreement governing the procurement of blood and derivatives of blood that is reviewed annually by the governing body and the staff pathologist or the pathologist used as a consultant by the center. 3. Blood and derivatives of blood used in the ambulatory surgical center must be administered only by a physician or a registered nurse. 4. The ambulatory surgical center shall establish policies and procedures for the administration of blood and derivatives of blood that are in accordance with the program for the prevention and control of infections and communicable diseases adopted pursuant to NAC 449.98452 . 5. Any suspected adverse reaction to a blood transfusion must immediately be reported by members of the nursing staff to the physician attending the patient and to the service that furnished the blood. The nursing staff shall document the reaction in the medical history of the patient. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R096-08, 8-26-2008, eff. 10-25-2008) NAC 449.993 Diagnostic radiological services. ( NRS 449.0302 ) 1. Each ambulatory surgical center shall maintain diagnostic radiological services or have such services immediately available. Whether these services are provided directly or by contract, personnel capable of supervising the performance of the services must be available. 2. If a center provides diagnostic radiological services directly, the center must have a full-time radiologist or a radiologist who works as a part-time consultant available to supervise the department of radiology and to interpret films. 3. Only a person designated as qualified by the radiologist may operate the equipment for X-rays. 4. Only the following persons may operate a fluoroscopy machine: (a) A physician or a podiatric physician licensed pursuant to chapter 635 of NRS; (b) A physician assistant, advanced practice registered nurse or certified registered nurse anesthetist if that person has at least 16 hours of documented training in radiation safety; (c) A radiologic technologist registered by the American Registry of Radiologic Technologists if the person is acting under the personal direction or written protocol of a physician and registrant of the fluoroscopy machine; and (d) A registered nurse or operating room technician if the person is acting under the direct supervision of a physician or surgeon who is present in the room at the time the fluoroscopy machine is used and the person has documented training in radiation safety as follows: (1) The applicable provisions of chapter 459 of NAC; (2) Orientation to field size; (3) Orientation to the energy used and the setting (kVp) to use on patients of varying sizes and pathology; (4) Orientation to the concept of “as low as is reasonably achievable,” as defined in NAC 459.0205 ; (5) The use of protective gloves, aprons, thyroid shields and glasses; (6) The use of particular machines and the operation of each type of machine; (7) Orientation to the concept of source to image distance; (8) Safety protocol for staff in the operating room and adjacent areas, including, without limitation, physicians, patients and operators; (9) The requirements for dosimetry and postings and the certificate and output measurements necessary to allow use of the fluoroscopy machine; (10) The appropriate use of high-level versus regular settings; (11) The relevance of pregnancy in the use of machines that produce radiation; and (12) An annual review of radiation safety. 5. Examinations by X-ray must be ordered by the physician or podiatrist responsible for the care of the patient, and the order must contain a concise statement of the reason for the examination. Reports of these examinations must be signed by the reporting physician. The original report must be filed in the medical records of the patient, and a copy of the report must be kept in the radiology department. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R181-09, 10-4-2013) NAC 449.9935 Operating and recovery rooms; endoscopy suite; revision of certain standards adopted by reference. ( NRS 439.200 , 449.0302 ) 1. The operating and recovery rooms of an ambulatory surgical center must be used exclusively for surgical procedures. 2. Except as otherwise provided in subsection 3, surgical procedures must be conducted in an ambulatory surgical center designated as Class A, B or C pursuant to NAC 449.9844 in accordance with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 . 3. If an ambulatory surgical center is designated as Endoscopy Only pursuant to NAC 449.9844 , such procedures may be conducted in an endoscopy suite in accordance with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 . 4. A registered nurse experienced in surgical procedures shall supervise the operating room. 5. Only a registered nurse may function as the circulating nurse in the operating room. 6. Each employee of an ambulatory surgical center who provides medical services and care to a patient must be trained to carry out the medical services and care that the employee will provide. 7. The operating room must be equipped with: (a) A system for making emergency calls; (b) Oxygen; (c) Mechanical ventilatory assistance equipment, including, without limitation, a manual breathing bag and a ventilator; (d) Cardiac monitoring equipment; (e) Laryngoscopes and endotracheal and airway tubes in sizes sufficient to meet the needs of the patients of the ambulatory surgical center; and (f) Suction equipment. 8. The recovery room must: (a) Meet nationally recognized standards of practice for postanesthesia care, as approved by the governing body, and maintain a copy of those standards at the ambulatory surgical center during all hours of operation and in a location which is accessible to the medical staff; (b) Comply with the guidelines for postanesthesia patient classification and staffing recommendations as published in the 2021-2022 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements , which is adopted by reference in subsection 10; (c) Be equipped with or have easily accessible a mobile cart which contains the equipment and supplies specified by the medical staff pursuant to subsection 3 of NAC 449.9902 needed to treat a patient with malignant hyperthermia; and (d) Be equipped with all other equipment and supplies needed to safely care for patients. 9. If the operating team consists of persons who are not physicians, a physician must be on the premises and immediately available in case of an emergency. As used in this subsection, “immediately available” means the physician is able to respond rapidly to the emergency. 10. The 2021-2022 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements , published by the American Society of PeriAnesthesia Nurses is hereby adopted by reference. A copy of the standards may be obtained at a cost of $75 for members and $180 for nonmembers from the American Society of PeriAnesthesia Nurses by mail at 90 Frontage Road, Cherry Hill, New Jersey 08034-1424, by telephone at (877) 737-9696 or at the Internet address http://www.aspan.org . 11. The Division shall review each revision of the publication adopted by reference in subsection 10 to ensure its suitability for this State. If the Division determines that a revision is not suitable for this State, the Division shall hold a public hearing to review its determination within 12 months after the date of the publication of the revision and give notice of that hearing. If, after the hearing, the Division does not revise its determination, the Division shall give notice within 30 days after the hearing that the revision is not suitable for this State. If the Division does not give such notice, the revision becomes part of the publication adopted by reference in subsection 10. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R077-04, 8-5-2004; R181-09 & R170-12, 10-4-2013; R122-16, 9-21-2017; R048-22, 12-29-2022) NAC 449.9937 Extended recovery units. ( NRS 449.0302 ) 1. An ambulatory surgical center may operate an extended recovery unit. 2. An extended recovery unit must: (a) Be located in an area of the center that is separate from the other operations of the center; (b) Provide audio and visual privacy for each patient in the unit; (c) Be supervised by at least one physician who is recommended for the position by the members of the medical staff and approved by the governing body; (d) Have at least one physician on the premises or immediately available by telephone at all times when there is a patient in the unit; (e) Except as otherwise provided in paragraph (f), have at least one nurse who is trained in advanced cardiac life support on duty for every two patients in the unit; (f) Have at least two nurses who are trained in advanced cardiac life support on duty at all times when there is a patient in the unit; and (g) Be equipped with: (1) A system for making emergency calls; (2) Oxygen; (3) A cardiac defibrillator; (4) Cardiac monitoring equipment; (5) A mobile cart which contains the equipment and supplies specified by the medical staff pursuant to subsection 3 of NAC 449.9902 ; (6) A manual breathing bag; (7) Suction equipment; and (8) Such other emergency equipment as is needed to provide care to patients in the unit. 3. A patient must be admitted and discharged from an extended recovery unit only upon the order of the physician of record. If a patient is admitted to the unit, the time he or she remains in the unit for treatment, when added to the time he or she remains in any other area of the ambulatory surgical center for treatment, may not exceed 23 hours and 59 minutes. 4. The center shall adopt policies and procedures for the extended recovery unit that include, without limitation: (a) Clinical criteria for determining a patient’s eligibility for admission into the unit; (b) Clinical criteria for determining a patient’s eligibility for being discharged from the unit; (c) Procedures for providing emergency services; and (d) Procedures for transferring a patient in need of other health care services. 5. An ambulatory surgical center shall provide food to meet the needs of patients in an extended recovery unit. A patient on a special diet must be served food that conforms to the patient’s prescribed diet. If the food is prepared by the center, the center shall: (a) Comply with the applicable provisions of chapter 446 of NRS and the regulations adopted pursuant thereto; and (b) Obtain such permits as are necessary from the Division of Public and Behavioral Health to prepare the food. (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99; A by R155-10, 12-16-2010; R181-09, 10-4-2013) NAC 449.994 Records required before surgery; report of surgery. ( NRS 449.0302 ) 1. A physical examination, which must include a medical history of the patient, within the 30 days immediately preceding the date of the patient’s surgery and a presurgical evaluation conducted by a physician or a podiatric physician licensed pursuant to chapter 635 of NRS, as applicable, on the day of the patient’s surgery or within the 7 days immediately preceding the date of the patient’s surgery must be recorded in the chart of the patient before surgery. 2. A properly executed form of consent to surgery as set forth in NRS 449A.106 must be placed in the medical record of the patient before surgery. 3. A report must be prepared within 24 hours after surgery describing the techniques and findings of the surgery and the tissues removed or altered during the surgery. If a report is dictated, a written report must be signed by the surgeon within 7 days after the surgery. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R181-09 & R170-12, 10-4-2013) NAC 449.9945 Administration and record of anesthesia. ( NRS 449.0302 ) 1. Anesthetics must be administered in the operating room of an ambulatory surgical center by an anesthesiologist, a qualified physician, a dentist or, under the direction of the operating physician and in accordance with the provisions of chapter 632 of NRS and the regulations adopted pursuant thereto, a certified registered nurse anesthetist. 2. Persons designated to administer anesthetics must be qualified to administer anesthetics based on their credentials and must be approved by the governing body. 3. General anesthesia must not be administered to a patient unless a physician has evaluated the patient immediately before surgery to assess and document the risks of administering the anesthesia relative to the surgical procedure to be performed. A patient who receives general anesthesia must be evaluated by a physician after the patient has recovered from the general anesthesia and before he or she is discharged from the recovery room. 4. A person who administers anesthetics shall continuously monitor a patient who has received anesthesia and shall not have any other responsibility while the patient is under anesthesia. A person who administers anesthetics shall not leave a patient who is under anesthesia unless relieved by a person authorized to administer anesthetics pursuant to this section who agrees to assume responsibility for the care of the patient. 5. A record of anesthesia must be completed after surgery, and there must be a follow-up on each patient who has received anesthesia with the findings recorded by the person who administered the anesthesia. 6. As used in this section, “certified registered nurse anesthetist” has the meaning ascribed to it in NRS 632.014 . (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99; R181-09, 10-4-2013) NAC 449.9947 Register of surgeries performed in operating rooms. ( NRS 449.0302 ) An ambulatory surgical center shall keep a complete and current register of all surgeries performed in an operating room at the center. The register must include, without limitation, for each patient who underwent surgery in an operating room: 1. The name of the patient; 2. The identification number of the patient; 3. The date of the surgery; 4. The name of the surgeon who performed the surgery and each person who was present for the surgery; 5. The total time for performing the surgery; 6. The type of anesthesia provided to the patient; 7. The name of the person administering the anesthesia; 8. The type of surgery that was performed; and 9. The preoperative and postoperative diagnoses of the patient. (Added to NAC by Bd. of Health by R181-09, eff. 10-4-2013) NAC 449.9955 Informing patient of rights, services and cost. ( NRS 449.0302 ) The administrator of an ambulatory surgical center shall ensure that: 1. Each patient admitted to the center is treated with respect, consideration and dignity. 2. Each patient admitted to the center is provided appropriate privacy. 3. Each patient admitted to the center is informed of his or her rights as a patient in accordance with the provisions of NRS 449A.118 . The patient must be informed, at the time of his or her admission, of the services available and the estimated cost of those services. If a patient is unable to understand his or her rights, they must be explained to the patient’s guardian, next of kin or the agency financially responsible for his or her care. 4. The records of a patient admitted to the center are kept confidential, except as otherwise provided by law. 5. Each patient admitted to the center is given the opportunity to participate in decisions relating to his or her health care, unless the patient is unable to do so because of his or her medical condition. 6. Information is available to patients and members of the staff concerning: (a) The policies of the center relating to the conduct and responsibilities of patients; (b) The care that is available at the center during emergencies and after normal business hours; (c) The policies of the center related to the payment of fees; (d) A patient’s right to refuse to participate in experimental research; and (e) The procedures for filing complaints or grievances at the center. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R049-99, 9-27-99) NAC 449.996 Transfer of patients. ( NRS 439.200 , 449.0302 ) 1. An ambulatory surgical center shall establish written guidelines for transferring patients to a licensed hospital that has medical and surgical capabilities using an ambulance or air ambulance for emergencies that require medical care which is not provided at the center. The guidelines must be approved by the governing body of the ambulatory surgical center. 2. If a patient is transferred, all medical and administrative information relating to the patient must be transferred with him or her or promptly made available to the licensed center or agency responsible for the patient’s continuing care. (Added to NAC by Bd. of Health, eff. 12-15-88; A by R181-09, 10-4-2013; R048-22, 12-29-2022) NAC 449.9965 Prohibited locations for construction of center. ( NRS 449.0302 ) A new ambulatory surgical center must not be constructed over any underground liquid butane, propane or transmission line for gas, or over any underground high pressure lines, under high voltage electrical lines or near hazardous or hazard-producing plants. (Added to NAC by Bd. of Health, eff. 12-15-88) NAC 449.997 Conversion of hazardous building into center prohibited. ( NRS 449.0302 ) No building may be converted for use as an ambulatory surgical center if, because of its location, physical condition, state of repair or arrangement of facilities, the building would be hazardous to the health and safety of patients. (Added to NAC by Bd. of Health, eff. 12-15-88) RECOVERY CENTERS General Provisions NAC 449.99702 “Recovery center” defined. ( NRS 439.200 , 449.0302 , 449.0303 ) As used in NAC 449.99702 to 449.99762 , inclusive, “recovery center” or “center” means any public or private facility that provides only short-term care, not to exceed 72 hours, to a person recovering from surgery. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) Licensing and Inspection NAC 449.99704 License required to operate. ( NRS 439.200 , 449.0302 , 449.0303 ) A person or a public or private facility shall not operate or provide the services of a recovery center or represent that the person or the public or private facility operates or provides the services of a recovery center, unless the person or the public or private facility is licensed by the Division pursuant to NAC 449.99702 to 449.99762 , inclusive, to operate the recovery center. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99706 Requirements to operate. ( NRS 439.200 , 449.0302 , 449.0303 ) If a person or a public or private facility wants to operate a recovery center, the person or the public or private facility must: 1. File with the Division an application for a license pursuant to NAC 449.011 ; and 2. Demonstrate that the proposed recovery center is able to comply with the requirements set forth in NAC 449.99702 to 449.99762 , inclusive. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99708 Prelicensure investigation and inspection. ( NRS 439.200 , 449.0302 , 449.0303 ) After the Division receives a properly completed application, accompanied by the appropriate fee, the Division shall conduct an investigation of the applicant and inspect the proposed recovery center. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.9971 Issuance and expiration of license. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. The Division shall issue a license to operate a recovery center to the applicant if, after investigation, the Division finds that the applicant is in substantial compliance with the provisions of NAC 449.99702 to 449.99762 , inclusive. 2. A license issued pursuant to NAC 449.99702 to 449.99762 , inclusive, expires on the date specified in NRS 449.089 and may be renewed in accordance with that section and NAC 449.0116 . (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99712 Suspension, revocation or cancellation of license; provisional license. ( NRS 439.200 , 449.0302 , 449.0303 ) The Division may suspend or revoke a license issued pursuant to NAC 449.99702 to 449.99762 , inclusive, or cancel such a license and issue a provisional license based upon any grounds for such action set forth in chapter 449 of NRS or NAC 449.002 to 449.99939 , inclusive. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) Administration NAC 449.99714 Governing body; quality improvement and risk management programs; review of programs. ( NRS 439.200 , 449.0302 , 449.0303 ) A recovery center must have a governing body that is legally responsible for establishing and carrying out policies regarding the management and operation of the center. The governing body shall develop both a quality improvement program and a risk management program for the recovery center and conduct a review of each program at least every 3 months. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99716 Appointment, qualifications and responsibilities of administrator. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. The governing body of a recovery center shall appoint a qualified administrator for the center who is responsible to the governing body for the performance of his or her duties. 2. The administrator must: (a) Be at least 21 years of age; and (b) Possess one of the following qualifications: (1) Be a physician; (2) Be a registered nurse; (3) Have a bachelor’s or postgraduate degree in administration or a field related to health care; or (4) Have at least 1 year of administrative experience in a health care setting. 3. The administrator is responsible for the daily operation of the recovery center. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) Construction and Operation NAC 449.99718 Design, construction, equipment and maintenance. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center must be designed, constructed, equipped and maintained in a manner that protects the health and safety of the patients and personnel of the recovery center and members of the general public. 2. A recovery center shall comply with all applicable: (a) Federal and state laws; (b) Local ordinances, including, without limitation, zoning ordinances; and (c) Life safety, environmental, health, fire and local building codes, Ê related to the construction and maintenance of the recovery center. If there is a difference between state and local requirements, the more stringent requirements apply. 3. Except as otherwise provided in this section: (a) Each recovery center shall comply with the provisions of NFPA 101: Life Safety Code , as adopted by reference pursuant to NAC 449.0105 . (b) Any new construction, remodeling or change in use of a recovery center must comply with the applicable provisions of the guidelines adopted by reference in paragraphs (c), (d) and (e) of subsection 1 of NAC 449.0105 , unless the remodeling is limited to refurbishing an area within the recovery center, including, without limitation, painting the area, replacing the flooring, repairing windows or replacing window and wall coverings. 4. A recovery center shall be deemed to be in compliance with the provisions of subsection 3 if: (a) The recovery center: (1) Was licensed as a facility for intermediate care pursuant to NRS 449.040 to 449.094 , inclusive, before September 21, 2017; (2) Is seeking to change its operation as an intermediate care facility to a recovery center; (3) Does not change the use of the physical space in the recovery center; and (4) Does not have any deficiencies in the construction of the recovery center that are likely to cause serious injury, harm or impairment to the health and welfare of the public; or (b) Before September 21, 2017, the recovery center initially applied for licensure as an intermediate care facility pursuant to NRS 449.040 to 449.094 , inclusive, and: (1) The recovery center submitted building plans to the Division in the manner set forth in NAC 449.0115 ; (2) The Division determines that the plans comply with the standards for construction of intermediate care facilities, which are set forth in NAC 449.685 to 449.728 , inclusive; (3) Construction of the recovery center has commenced; (4) The center is constructed in accordance with such standards; and (5) There are no deficiencies in the construction of the recovery center that are likely to cause serious injury, harm or impairment to the health and welfare of the public. 5. A recovery center shall submit building plans for new construction or remodeling to the entity designated to review such plans by the Division pursuant to NAC 449.0115 . The entity’s review of those plans is advisory only and does not constitute approval for the licensing of the recovery center. Before the construction or remodeling may begin, the plans for the construction or remodeling must be approved by the Division. The Division shall not approve a recovery center for licensure until all construction or remodeling has been completed and a survey is conducted at the site of the recovery center. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017; A by R016-20, 11-2-2020; R048-22, 12-29-2022) NAC 449.9972 General requirements. ( NRS 439.200 , 449.0302 , 449.0303 ) A recovery center shall: 1. Provide a safe, functional, sanitary and comfortable environment for the patients in the center, the members of its staff and members of the general public; 2. Care for each patient in the center in a manner that promotes the dignity of the patient and his or her quality of life; 3. Ensure that the environment of the center is free of hazards that would cause accidents; 4. Ensure that each patient in the center receives adequate supervision and devices to prevent accidents; 5. Provide such housekeeping and maintenance services as are necessary to maintain a sanitary, orderly and comfortable environment; 6. Provide adequate and comfortable levels of lighting in all areas of the center; 7. Maintain an effective program to control pests in order to ensure that the center is free from pests and rodents; 8. Have adequate outside ventilation by means of windows or mechanical ventilation, or both; and 9. Provide safe and comfortable levels of temperature in the center. The temperature of the center must be maintained at a level that is not less than 71 degrees Fahrenheit and not more than 81 degrees Fahrenheit. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99722 Patients’ rooms. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A patient’s room within a recovery center must be designed and equipped in a manner that allows adequate nursing care to be provided and provides comfort and privacy for the patient. 2. A recovery center shall provide to each patient in the center: (a) A separate bed of proper size and height for the convenience of the patient; (b) A clean, comfortable mattress; (c) Bedding that is appropriate for the weather and climate; (d) Clean linens for his or her bed and bath that are in good condition; and (e) Furniture that is appropriate for the patient’s needs. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99724 Limitation on number of patients; insurance. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall: (a) Not admit more patients to the facility than the number of beds for which it is licensed at any one time. (b) Maintain a contract of insurance to ensure adequate coverage against liabilities resulting from claims incurred in the course of its operation. 2. A certificate of insurance must be furnished to the Division as evidence that the contract of insurance required pursuant to subsection 1 is in force, and a license must not be issued until that certificate is furnished. Each certificate of insurance must contain an endorsement providing for 30 days’ notice to the Bureau before the effective date of a cancellation or nonrenewal of the policy. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99726 Preparations for emergencies; reporting of fire or disaster. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center must have a written disaster preparedness plan for members of the staff and patients to follow in case of fire, explosion or other emergency. 2. The plan must include, without limitation, written procedures for personnel to follow in an emergency, including: (a) The care of the patients in the recovery center and emergency evacuation; (b) The notification of persons responsible for the patients in the recovery center; and (c) Arrangements for transportation for medical care or other appropriate services. 3. A recovery center shall notify the Bureau of the occurrence of any fire or disaster in the center within 24 hours after the center becomes aware of the fire or disaster. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99728 Administration of prescription medications. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. Prescription medications for a patient admitted to a recovery center shall only be administered by the patient, a registered nurse or another licensed health care professional. 2. A recovery center shall ensure that all patients are not subjected to errors in the administration of their medication. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.9973 Control of infections. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall establish and maintain a program for the control of infections within the center. 2. The program required pursuant to subsection 1 must: (a) Be designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of disease and infection. (b) Create infection prevention and control procedures, which must include: (1) Policies and procedures for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers and any other person contracting with the recovery center; and (2) A surveillance system designed to identify possible infections and communicable diseases before they can spread to other persons in the facility. (c) Establish the procedures that will be followed if a patient becomes infectious, including, without limitation, the circumstances under which a patient may be isolated. A recovery center shall isolate any patient if required to prevent the spread of infection. The type and duration of such isolation should depend on the infectious agent or organism involved and always be the least restrictive as possible. (d) Provide for the maintenance of records of infections and the corrective actions taken when infections occur. 3. A recovery center shall ensure that: (a) An employee with a communicable disease or an infected skin lesion does not come into direct contact with persons admitted to the center or their food if such contact may result in the transmission of the disease. (b) Employees wash their hands after any direct contact with a patient admitted to the center. (c) Linens are handled, stored, processed and transported in a manner which prevents the spread of infection. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99732 Meals; hydration; sanitation. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall ensure that each patient admitted to the center receives: (a) Meals at regular intervals; and (b) A therapeutic diet if such a diet is prescribed by the attending physician, physician assistant, dentist, advanced practice registered nurse or podiatric physician of the patient or ordered by a licensed dietitian. 2. A recovery center shall provide to each patient admitted to the center: (a) Food that is prepared to conserve the nutritional value and flavor of the food. (b) Food that is nourishing, palatable, attractive and served at the proper temperature. (c) A well-balanced diet that meets the daily nutritional and special dietary needs of the patient. 3. A recovery center shall provide each patient in the center with sufficient fluids to maintain proper hydration and health. 4. A recovery center shall: (a) Comply with the applicable provisions of chapter 446 of NRS and chapter 446 of NAC and obtain such permits as are necessary from the Division for the preparation and service of food; (b) Maintain a report of each inspection concerning the sanitation of the center for at least 1 year after the date of the inspection; (c) Maintain a report of each corrective action taken to address a deficiency noted in a report described in paragraph (b) for at least 1 year after the date of the corrective action; (d) Procure food from sources that are approved or considered satisfactory by federal, state and local authorities; (e) Store, prepare and serve food under sanitary conditions; and (f) Dispose of refuse and garbage properly. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017; A by R048-22, 12-29-2022) Admission, Care, Transfer and Discharge of Patients NAC 449.99734 Responsibilities for admission and care of patient. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A patient may be admitted to a recovery center only upon the written approval of a physician. Upon a patient’s admission to the recovery center, the center shall ensure that orders for the care of the patient have been received from the patient’s attending physician. 2. A recovery center shall ensure that the medical care of each patient is supervised by a physician. 3. After the initial visit with a patient by a physician at the recovery center, every other visit with the patient at the center may be made by a physician assistant, nurse practitioner or clinical nurse specialist on behalf of the physician if the physician assistant, nurse practitioner or clinical nurse specialist is acting: (a) Within the authorized scope of his or her practice and under the supervision of the physician; and (b) In accordance with state law and the policies of the recovery center. 4. Any orders for the treatment of the patient must be signed and dated by the health care professional ordering the treatment. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99736 Assessment of needs of patient. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall conduct an initial and ongoing assessment of the needs of each patient admitted to the center. 2. The initial assessment of each patient must be conducted at the time of his or her admission to the recovery center and must include, without limitation: (a) Demographic and other pertinent information required to identify the patient; (b) The customary routine of the patient; (c) The physical condition of the patient; (d) Any problems related to the functional or structural physical condition of the patient; (e) Medications required to be taken by the patient; (f) Any special treatments and procedures required by the patient; and (g) The probability of discharging the patient from the center within 72 hours after admission and any other information related to the discharge of the patient from the center. 3. Any assessment of a patient must be conducted through direct observation and communication with the patient. 4. An assessment conducted pursuant to subsection 1 must be conducted by a registered nurse or coordinated by a registered nurse with the participation of other appropriate health care professionals. Each person who completes a portion of the assessment shall certify the accuracy of that portion. The registered nurse shall certify that the assessment is completed. 5. An assessment conducted pursuant to subsection 1 must be: (a) Included in the patient’s medical record maintained pursuant to NAC 449.99746 ; and (b) Used to develop, review and revise the patient’s plan of care developed pursuant to NAC 449.99738 . (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99738 Plan of care; compliance with professional standards. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall develop for each patient admitted to the center a plan of care, which must include, without limitation: (a) Measureable objectives and timetables to meet the needs of the patient that are identified in an assessment conducted pursuant to NAC 449.99736 ; and (b) A description of the services that will be provided to the patient. 2. A plan of care must be: (a) Developed on the same day as the completion of the initial assessment required by NAC 449.99736 and revised as necessary after each subsequent assessment; and (b) Prepared by a registered nurse. 3. Services provided to a patient admitted to a recovery center must: (a) Comply with the professional standards of quality applicable to those services; and (b) Be provided by qualified persons in accordance with the patient’s plan of care. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.9974 Provision of service or treatment. ( NRS 439.200 , 449.0302 , 449.0303 ) A recovery center shall provide to each patient admitted to the center any service or treatment that is: 1. Identified in the plan of care developed pursuant to NAC 449.99738 ; and 2. Necessary to ensure proper care while the person is admitted to the center. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99742 Summary of discharge. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall prepare a summary of discharge for each patient discharged from the center. 2. Each summary of discharge must include, without limitation: (a) A summary of the pertinent information relating to the patient’s stay at the recovery center; (b) A final summary of the patient’s physical health at the time of discharge; and (c) A plan of care for the patient after his or her discharge, including, without limitation, any recommended or necessary follow-up care. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99744 Agreement with hospital for transfer of patients. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. Except as otherwise provided in subsection 2, a recovery center shall enter into an agreement with at least one licensed hospital that provides for the transfer of patients from the center to the licensed hospital. The agreement must provide for the timely admittance of a patient transferred from the center to the licensed hospital if the transfer is medically appropriate as determined by the patient’s attending physician. 2. A recovery center that attempts in good faith to enter into an agreement pursuant to subsection 1 with every licensed hospital reasonably close to the center but is unable to enter into such an agreement is not required to comply with subsection 1. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) Records of Patients NAC 449.99746 Contents, maintenance and confidentiality of medical records. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall maintain a medical record for each patient admitted to the center in accordance with accepted professional principles. 2. A medical record must be: (a) Complete; (b) Accurate; (c) Organized; and (d) Readily accessible to those persons who are authorized to review the records. 3. A medical record must include, without limitation: (a) Sufficient information to identify the patient; (b) A record of any assessment of the patient conducted pursuant to NAC 449.99736 ; and (c) The patient’s plan of care developed pursuant to NAC 449.99738 and the services and treatments provided to the patient during the patient’s stay at the recovery center. 4. A recovery center shall maintain the medical records of each patient admitted to the center for at least: (a) Five years after the discharge of the patient; and (b) If the patient is a minor, 3 years after the patient reaches 18 years of age. 5. A recovery center shall ensure that: (a) Information contained in a medical record is not lost, destroyed or used in an unauthorized manner; and (b) No person willfully and knowingly falsifies or causes another person to falsify information contained in a medical record. 6. Information contained in a medical record is confidential and must not be released without the written consent of the patient except: (a) As required by law; (b) Under a contract involving a third-party payor; or (c) As required upon transfer of the patient to another facility. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99748 Inspection of records relating to patient. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A person who is or was previously admitted to a recovery center or his or her legal representative may submit an oral or written request to the center to inspect all records relating to the patient maintained by the center. The recovery center shall, within 24 hours after the receipt of such a request, excluding weekends and holidays, allow the patient or his or her legal representative to inspect the patient’s records. 2. Upon request, a recovery center shall furnish to a patient who is or was previously admitted to the center or his or her legal representative a copy of the records or any portion thereof at the cost of obtaining records from a custodian of health care records as set forth in NRS 629.061 . The copy must be furnished within 48 hours after receipt of the request, excluding weekends and holidays. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) Personnel and Staffing NAC 449.99749 Personnel policies and records. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall adopt written policies for the personnel employed by the center. 2. The written policies required pursuant to subsection 1 must: (a) Include the duties and responsibilities of, and the qualifications required for, each position at the recovery center; (b) Include the conditions of employment for each position at the recovery center; (c) Include the policies and objectives of the recovery center related to training while on the job and the requirements for continuing education; and (d) Be periodically reviewed and made available to each person employed by the recovery center. 3. A current and accurate personnel record for each person employed by the recovery center must be maintained at the center. The record must include, without limitation: (a) Evidence that the employee has obtained any license, certificate or registration, and possesses the experience and qualifications, required for the position held by the employee; (b) Such health records as are required by chapter 441A of NAC which include evidence that the employee has had a skin test for tuberculosis in accordance with NAC 441A.375 ; and (c) Documentation that the recovery center has not received any information that the employee has been convicted of a crime listed in paragraph (a) of subsection 1 of NRS 449.174 . 4. A recovery center shall make its personnel records available to the Bureau for inspection upon request. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99752 Staffing. ( NRS 439.200 , 449.0302 , 449.0303 ) A recovery center shall ensure that there is a sufficient number of members of the staff on duty at all times to provide care to and attain and maintain the highest practicable physical, mental and psychosocial well-being of each patient in the center in accordance with his or her plan of care developed pursuant to NAC 449.99738 . (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99754 Employment of health care professionals. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall employ full-time, part-time or as consultants such health care professionals as are necessary to provide adequate care for each patient admitted to the center and to carry out the provisions of NAC 449.99702 to 449.99762 , inclusive. 2. A health care professional employed by a recovery center shall comply with accepted professional standards applicable to the services provided by the health care professional. 3. If a recovery center does not employ a person to furnish a service required by the center, the center shall obtain that service from a qualified outside source. An agreement for obtaining such services must specify, in writing, that the center assumes responsibility for: (a) Obtaining services that comply with accepted professional standards applicable to the services being obtained; and (b) The timely delivery of such services. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) Medical Services NAC 449.99756 Specialized rehabilitative services. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall provide to a patient in the center, according to his or her plan of care developed pursuant to NAC 449.99738 , specialized rehabilitative services, including, without limitation, physical therapy and occupational therapy. Such services must be provided by the recovery center or obtained from a qualified outside source pursuant to NAC 449.99754 . 2. Specialized rehabilitative services may be provided to a patient admitted to a recovery center only upon the written order of a physician. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99758 Pharmaceutical services; labeling and storage of drugs and biologicals; licensure of pharmacy; chart order signed by prescribing practitioner. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall provide such pharmaceutical services, including, without limitation, acquiring, receiving, dispensing and administering drugs and biologicals, as are required to meet the needs of the patients admitted to the center. The recovery center shall provide such drugs and biologicals as are needed or obtain them from a qualified outside source pursuant to NAC 449.99754 . 2. A recovery center shall employ or otherwise obtain the services of a registered pharmacist who shall: (a) Provide consultations on all matters relating to the pharmaceutical services provided by the center; (b) Establish a system of records for the receipt and disposition of all controlled substances in the center in sufficient detail to ensure an accurate reconciliation; and (c) Ensure that those records are in order and that an account of all controlled substances in the center is maintained and periodically reconciled. 3. The regimen of drugs for each patient admitted to the recovery center must be reviewed at least once each month by a registered pharmacist. The pharmacist shall report any irregularities he or she discovers to the patient’s attending physician and the chief administrative nurse of the recovery center. The physician and chief administrative nurse shall take such actions as they deem necessary in the response to the report. 4. Drugs and biologicals provided by a recovery center must be: (a) Labeled in accordance with state and federal law and accepted professional standards. Each label must include the appropriate accessory and cautionary instructions and the expiration date, if applicable. (b) Stored in accordance with state and federal law in locked compartments with proper controls for the temperature. Only authorized personnel may have access to the keys to unlock such compartments. Substances listed as schedule II controlled substances pursuant to chapter 453 of NRS and other drugs that have the potential for misuse must be stored separately in a locked compartment that is immovable, unless the recovery center uses a system to distribute the substances or drugs in single-unit packages, the quantity stored is minimal and any dosage that is missing can be readily detected. 5. A recovery center that operates a pharmacy shall obtain a license from the State Board of Pharmacy pursuant to NRS 639.2177 and comply with the regulations adopted by the State Board of Pharmacy pursuant to that section. 6. A chart order for a patient at a recovery center must be signed by the prescribing practitioner within the time period set forth in NRS 639.23275 . 7. As used in this section, “practitioner” has the meaning ascribed to it in NRS 639.0125 . (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017; A by R048-22, 12-29-2022) NAC 449.9976 Laboratory services. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall provide laboratory services to meet the needs of the patients admitted to the center or contract with a laboratory to obtain such services. 2. If a recovery center has its own laboratory, it must be a licensed laboratory under the provisions of chapter 652 of NRS and comply with the provisions of 42 C.F.R. Part 493. The provisions of this subsection do not prohibit a licensed nurse from performing laboratory tests pursuant to NRS 652.217 . 3. If a recovery center contracts with a laboratory for its services, that laboratory must be: (a) A laboratory licensed pursuant to the provisions of chapter 652 of NRS; and (b) Certified in the specialties and subspecialties required by the center in accordance with the provisions of 42 C.F.R. Part 493. 4. A recovery center shall: (a) Provide or obtain only such laboratory tests as are ordered by the attending physician of a patient admitted to the center; (b) Promptly notify the attending physician of the results of any laboratory tests ordered for a patient; (c) Arrange transportation for a patient to obtain laboratory tests ordered by the patient’s attending physician, if the patient requires such assistance; and (d) Include in the medical records of a patient all reports of the results of laboratory tests ordered for the patient. The reports must include, without limitation: (1) The date on which the tests were performed; and (2) The name and address of the laboratory performing the tests. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) NAC 449.99762 Radiological and other diagnostic services. ( NRS 439.200 , 449.0302 , 449.0303 ) 1. A recovery center shall provide radiological and other diagnostic services to meet the needs of the patients admitted to the center or contract with qualified outside sources to obtain such services. 2. If a recovery center provides radiological and other diagnostic services pursuant to this section, it shall comply with all applicable state law related to the provision of such services. 3. A recovery center shall: (a) Provide or obtain only such radiological and other diagnostic tests as are ordered by the attending physician of a patient in the center; (b) Promptly notify the attending physician of the results of any radiological and other diagnostic tests ordered for the patient; (c) Arrange transportation for a patient to obtain radiological and other diagnostic tests ordered by the patient’s attending physician, if the patient requires such assistance; and (d) Include in the medical records of a patient all reports of the results of radiological and other diagnostic tests ordered for the patient. The reports must: (1) Include the date on which the tests were performed; and (2) Be signed by the person performing the tests. (Added to NAC by Bd. of Health by R121-16, eff. 9-21-2017) RECEIVERS NAC 449.9981 List of interested and qualified persons. ( NRS 449.0302 ) The Division may solicit applications from persons interested in being nominated by the Division as receivers whenever receivership proceedings are brought. The Division shall develop and maintain a list of persons who are interested and qualified to act as receivers for facilities. Persons or organizations appearing on the list must have experience in the delivery of health care services or other relevant experience. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99811 Experience. ( NRS 449.0302 ) 1. In recommending a person or organization to serve as a receiver in a case, the Division shall, if feasible, nominate a receiver who has experience in the delivery of the type of care, treatment or services provided by the facility for which a receiver is requested. 2. If the primary deficiencies leading to the request for appointment of a receiver are related to the financial stability of the facility, the person or organization recommended must have experience in financial management and, if feasible, in the financial management of health care facilities. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99812 Authority. ( NRS 449.0302 ) A receiver appointed pursuant to NAC 449.9981 to 449.99814 , inclusive, may exercise such authority as is granted by the court appointing the receiver and as is consistent with the laws governing the authority of a receiver in this State. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99813 Compensation and payment of bond. ( NRS 449.0302 ) The compensation of the receiver and the expense of any bond he or she is required to furnish must be paid from the revenues of the facility for which the receiver is appointed. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99814 Operation of facility. ( NRS 449.0302 ) 1. The Bureau shall provide a receiver appointed by the court with a provisional license to operate the facility during the pendency of the receivership. 2. The receiver is responsible to the court for the operation of the facility during the receivership. Any deficiencies concerning the operation during the receivership, if not corrected, must be reported by the Division to the court. (Added to NAC by Bd. of Health, eff. 8-1-91) ADMINISTRATIVE SANCTIONS General Provisions NAC 449.9982 Definitions. ( NRS 439.200 , 449.0302 ) As used in NAC 449.9982 to 449.99939 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.99821 to 449.99841 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R131-99, 11-29-99; R051-02, 7-24-2002; R048-22, 12-29-2022) NAC 449.99821 “Ban on admissions” defined. ( NRS 449.0302 ) “Ban on admissions” means a prohibition on the provision of care, treatment or services to recipients who are newly admitted. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99822 “Cluster” defined. ( NRS 449.0302 ) “Cluster” means a deficiency that involves the same or similar kinds of care, treatment or services as one or more other deficiencies. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99823 “Compliance” and “substantially correct the deficiency” defined. ( NRS 449.0302 ) “Compliance” or “substantially correct the deficiency” means that no major deficiency is present and that effective steps have been taken to resolve all deficiencies. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99824 “Costs” defined. ( NRS 449.0302 ) 1. “Costs” means the expenses of implementing and enforcing administrative sanctions and of bringing an action in a court of competent jurisdiction. 2. The term includes, without limitation, filing fees, fees for service of notices or process and all expenses of litigation recoverable as costs pursuant to chapter 18 of NRS. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99825 “De minimis deficiency” defined. ( NRS 449.0302 ) “De minimis deficiency” means a deficiency rated at a severity level of one or two and at a scope level of one or two. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.998253 “Division of Health Care Financing and Policy” defined. ( NRS 449.0302 ) “Division of Health Care Financing and Policy” means the Division of Health Care Financing and Policy of the Department of Health and Human Services. (Added to NAC by Bd. of Health by R051-02, eff. 7-24-2002) NAC 449.998255 “Facility” defined. ( NRS 449.0302 ) “Facility” means a medical facility or facility for the dependent. (Added to NAC by Bd. of Health by R131-99, eff. 11-29-99) NAC 449.99826 “Immediate family” defined. ( NRS 449.0302 ) “Immediate family” means the spouse, parent, child or sibling of a recipient. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99827 “Initial deficiency” defined. ( NRS 449.0302 ) 1. “Initial deficiency” means the first occurrence of a deficiency recorded by the Bureau. 2. The term includes any deficiency found during a standard survey, during an extended survey or in response to a complaint. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99828 “Major deficiency” defined. ( NRS 449.0302 ) “Major deficiency” means a deficiency with a combined severity and scope rating of five or more. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99829 “Medicaid facility” defined. ( NRS 449.0302 ) “Medicaid facility” means a facility that has entered into an agreement to provide care, services or treatment paid under the joint federal-state Medicaid program described in 42 U.S.C. §§ 1396 et seq. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.9983 “Medicare facility” defined. ( NRS 449.0302 ) “Medicare facility” means a facility that has entered into an agreement to provide care, services or treatment paid by Medicare pursuant to 42 U.S.C. §§ 1395 et seq. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99832 “Monitor” defined. ( NRS 449.0302 ) “Monitor” means to observe, advise or supervise a facility on an as-needed basis to ensure compliance with the plan of correction for the facility (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99833 “New admission” defined. ( NRS 449.0302 ) “New admission” means a person who is admitted to the facility on or after the effective date of a ban on admissions and who has not been admitted before or, if previously admitted, has been discharged or left the facility voluntarily more than 30 days before the effective date of the ban. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99834 “Particular kinds of care, treatment or services” defined. ( NRS 449.0302 ) “Particular kinds of care, treatment or services” includes discrete areas such as bowel and bladder training, catheter care, restraints, injections, parenteral fluid administration, tube feedings, gastrostomy care, colostomy care, ileostomy care, respiratory therapy, tracheostomy care, suctioning, physical therapy and occupational therapy. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99835 “Plan of correction” defined. ( NRS 449.0302 ) “Plan of correction” means a plan developed by the facility and approved by the Bureau that: 1. Describes the actions to be taken by the facility to correct one or more deficiencies; and 2. Specifies the date by which those deficiencies will be corrected. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99836 “Provider agreement” defined. ( NRS 449.0302 ) “Provider agreement” means an agreement between a facility and: 1. The Centers for Medicare and Medicaid Services, if the facility is a Medicare facility; or 2. The Division of Health Care Financing and Policy, if the facility is a Medicaid facility. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99837 “Repeated deficiency” defined. ( NRS 449.0302 ) “Repeated deficiency” means a deficiency found by the Bureau again within 18 months, including one found at a follow-up survey, an investigation of a complaint or the next annual survey. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99838 “Resurvey” defined. ( NRS 449.0302 ) “Resurvey” means a subsequent survey conducted to evaluate compliance with a plan of correction. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99839 “Severity and scope score” defined. ( NRS 449.0302 ) “Severity and scope score” means the sum of the numerical levels of severity and scope assigned to a deficiency. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.9984 “Subsequent deficiency” defined. ( NRS 449.0302 ) “Subsequent deficiency” means a deficiency found on a resurvey. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99841 “Temporary management” defined. ( NRS 449.0302 ) “Temporary management” means the temporary appointment by the Bureau or by a court of competent jurisdiction of a manager or administrator with authority to operate the facility and to hire, terminate or reassign staff, obligate money of the facility, alter procedures and manage the facility to correct the deficiencies found during a survey or visit identifying the deficiencies. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99843 Purposes of administrative sanctions. ( NRS 449.0302 ) The purposes of administrative sanctions are to: 1. Safeguard the rights, interests and well-being of recipients, including the protection of recipients from actual or potential harm resulting from deficiencies; 2. Encourage and assist facilities to comply with the requirements of the Division, including those imposed by federal law; 3. Promote the efficient use of resources to ensure appropriate care, treatment and services for recipients; and 4. Protect Medicare beneficiaries and Medicaid recipients against health care of substandard quality. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99844 Interpretation of provisions in accordance with federal standards. ( NRS 449.0302 ) With respect to facilities governed by the federal Medicare or Medicaid criteria, the provisions of NAC 449.9982 to 449.99939 , inclusive, must be interpreted in accordance with applicable federal standards. (Added to NAC by Bd. of Health, eff. 8-1-91) Imposition: Generally NAC 449.9985 Authority of Division and Bureau. ( NRS 449.0302 ) Administrative sanctions authorized by NRS 449.163 must be imposed by the Division through the Bureau. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99851 Requirement for imposition; optional imposition. ( NRS 449.0302 , 449.165 ) At least one administrative sanction must be imposed for each deficiency in any facility with a severity level of four and for each deficiency in any facility with a combined severity and scope score of six or more. The Bureau may impose sanctions if deficiencies of a severity level three or less or a combined severity and scope score of less than six are identified. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99852 Requirement for imposition; multiple sanctions. ( NRS 449.0302 , 449.165 ) The Bureau must impose at least one of the sanctions listed in NAC 449.99863 upon any facility that has a deficiency with a severity level of four or a combined severity and scope score of six or more. More than one of these sanctions may be imposed in the discretion of the Bureau. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99853 Imposition of one or more sanctions; criteria for imposition of particular sanction. ( NRS 449.0302 , 449.165 ) The Bureau may apply one or more sanctions as provided in NAC 449.99863 and 449.99935 . If the Bureau chooses to impose a particular sanction, it must be applied according to the severity and scope factors established in NAC 449.99858 to 449.99861 , inclusive. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99854 Imposition in lieu of or in addition to recommendation to terminate provider agreement; duration of sanctions. ( NRS 449.0302 , 449.165 ) 1. The Bureau may apply one or more of the sanctions specified in NAC 449.99863 in lieu of or in addition to a recommendation to the Division of Health Care Financing and Policy or the Centers for Medicare and Medicaid Services to terminate a provider agreement. 2. Sanctions applied pursuant to NAC 449.9982 to 449.99939 , inclusive, may be imposed until substantial compliance is achieved or, if compliance is not achieved, until the day before termination of the license or provider agreement becomes effective. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99855 Imposition in emergencies: Authority; notice. ( NRS 449.0302 , 449.165 ) 1. If necessary to protect the public health and safety, the Bureau may impose such sanctions as are necessary without notice to the facility or by oral notice to the facility. 2. If there is an immediate and serious threat to the health and safety of recipients served by a facility, the Bureau may appoint a temporary manager to remove the threat. A temporary manager may also be appointed without prior written notice on an emergency basis if a facility violates any ban on admissions. If there is an immediate and serious threat to the health and safety of recipients, the times provided for notice contained in this subsection govern. In all other respects, the provisions governing temporary management found in NAC 449.99915 to 449.99921 , inclusive, apply. 3. The Bureau may, in an emergency, impose a ban on admissions, a limitation on occupancy of a residential facility or may suspend the license of a facility without notice or upon oral notice as provided in this section. 4. In any case where sanctions are imposed without written notice, the Bureau shall provide written notice that complies with the requirements of NAC 439.345 within 48 hours after the imposition of the sanctions. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R044-97, 10-30-97) NAC 449.99856 Deficiencies: Basis for imposition of sanctions; reporting; presumption of de minimis deficiency; confidentiality. ( NRS 439.200 , 449.0302 , 449.165 ) 1. Except as otherwise provided in NAC 449.0108 , the Bureau may apply one or more sanctions on the basis of deficiencies found during surveys or investigations of complaints conducted by the Bureau. 2. Deficiencies must be reported to the facility and, if applicable, to the Centers for Medicare and Medicaid Services. The notice to the facility must specify the deficiencies found and the severity and scope score for each deficiency determined by the Bureau. 3. Any deficiency for which a severity and scope score is not specified is presumed to be a de minimis deficiency. 4. A notice of deficiencies is confidential until 14 days after the date on which the notice is sent to the facility. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002; R048-22, 12-29-2022) NAC 449.99857 Classifications of severity and scope of deficiencies: Use. ( NRS 449.0302 , 449.165 ) In determining the sanctions to be imposed, the Bureau shall consider the severity and scope of the deficiencies according to the classifications of severity and scope described in NAC 449.99858 to 449.99861 , inclusive. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99858 Scope of violations: Evaluation of representative sample of recipients; size of sample. ( NRS 449.0302 , 449.165 ) 1. In determining the scope of a violation, a survey of a facility must evaluate a representative sample of recipients as described in the protocol for the survey of such a facility. Unless a sample of a different size is required for the survey by federal law, the sample must consist of at least the following size: Number of recipients Minimum number of recipients in sample 1 - 9 All recipients 10 - 40 10 41 - 75 15 76 - 100 20 101 - 175 25 176 - 250 30 251 - 350 35 351 - 450 40 451 or more 50 2. The sample size used in identifying the scope of a deficiency in a resurvey must not be less than 60 percent of the sample size used in the initial survey. 3. In determining the scope of a violation involving particular kinds of care, treatment or services, the survey must evaluate a representative sample of recipients receiving or requiring the particular kinds of care, treatment or services. Unless a sample of a different size is required for the survey by federal law, the sample must consist of at least the following size: Number of recipients needing or receiving a particular kind of care, treatment or services Minimum number of recipients in sample 1 - 9 All recipients 10 - 40 10 41 - 75 15 76 - 100 20 101 - 175 25 176 - 250 30 251 - 350 35 351 - 450 40 451 or more 50 4. The Bureau may review more than the minimum number of recipients. If it does so, the determination of scope must be based on the number of recipients actually reviewed. 5. If the Bureau investigates a complaint relating to a recipient, the Bureau may sample only that recipient. The scope of any deficiency cited pursuant to this subsection must be scope level one. 6. As used in this section, “recipient” means a person who: (a) Is admitted to a licensed bed maintained by the facility at the time the Bureau surveys the facility; or (b) Received services at the facility within the 30 days immediately preceding the date the Bureau surveys the facility, if the facility is not licensed to maintain beds. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99859 Scope of deficiencies: Use of scope scale; basis for assessment. ( NRS 449.0302 , 449.165 ) 1. The scope scale must be used to assess the scope of a particular deficiency in or by the facility. 2. The basis for the assessment is the actual or potential harm to recipients as shown by: (a) The frequency of the deficiency; (b) The number or percentage of recipients affected; (c) The number or percentage of staff involved; and (d) The pattern or lack of pattern of the deficiencies. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.9986 Scope of deficiencies: Criteria for evaluation. ( NRS 449.0302 , 449.165 ) 1. The scope of the deficiencies must be evaluated using the criteria prescribed in this section. 2. A deficiency of scope level one consists of one or an isolated number of unrelated incidents in the sample surveyed. A deficiency is of this scope if it involves 20 percent or less of the recipients sampled in a facility. 3. A deficiency is scope level two if the Bureau identifies a pattern of incidents at the facility, including any deficiencies involving recipients who require particular kinds of care, treatment or service. The number or percentage of recipients or staff involved in the incidents or the repeated occurrences of incidents in short succession may also establish a pattern by indicating a reasonable degree of predictability of similar incidents. A deficiency is also of this scope if it involves more than 20 percent but not more than 50 percent of the recipients sampled in a facility. 4. A deficiency is of scope level three if it occurs in a sufficient number or percentage of recipients or staff or with sufficient regularity over time that it may be considered systemic or pervasive in or by the facility. A deficiency is also of this scope if it involves more than 50 percent of the recipients sampled in a facility. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99861 Severity of deficiencies: Use of severity scale; basis for assessment; criteria for evaluation. ( NRS 449.0302 , 449.165 ) 1. The severity scale must be used to assess the severity of a particular deficiency pertaining to the facility. The basis for the assessment must be the actual or potential harm to recipients. 2. Deficiencies of severity level one concern requirements promulgated primarily for administrative purposes. No harm is likely to occur to a recipient. No negative recipient impact has occurred or is likely to occur. The ability of a recipient to achieve the highest practicable physical, mental or psychosocial well-being has not been and is not likely to be compromised. 3. Deficiencies of severity level two indirectly threaten the health, safety, rights, security, welfare or well-being of a recipient. A potential for harm, as yet unrealized, exists. If continued over time, a negative impact on one or more recipients or a violation of one or more recipients’ rights would occur or would be likely to occur or the ability of one or more recipients to achieve the highest practicable physical, mental or psychosocial well-being would be, or would likely be, compromised. 4. Deficiencies of severity level three create a condition or incident in the operation or maintenance of a facility that directly or indirectly threatens the health, safety, rights, security, welfare or well-being of one or more recipients. A negative impact on the health, safety, rights, security, welfare or well-being of one or more recipients has occurred or can be predicted with substantial probability to occur or the ability of recipients to achieve the highest practicable physical, mental or psychosocial well-being has been or is about to be compromised and requires intervention and correction of the deficiency. Violation of a partial or complete ban on admissions imposed on a facility, violation of a limitation on occupancy of a residential facility or failure to implement a directed plan of correction is presumed to be a deficiency of this level of severity. 5. Deficiencies of severity level four create a condition or incident that has resulted in or can be predicted with substantial probability to result in death or serious harm to a recipient. As used in this subsection, “serious harm” includes serious mental harm, serious impairment of bodily functions, serious dysfunction of any bodily organ or part, life-threatening harm or death. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99862 Presumption when same deficiency found on resurvey; imposition of sanction for subsequent deficiency. ( NRS 449.0302 , 449.165 ) If the same deficiency is found on a resurvey, there is a rebuttable presumption that the deficiency continued through the period between the survey and resurvey. A sanction may be imposed for a subsequent deficiency only if the resurvey is made and the deficiency is again actually found to be present. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99863 Available sanctions. ( NRS 449.0302 , 449.165 ) The sanctions available for all facilities include: 1. The imposition of a plan of correction as directed by the Bureau; 2. The issuance of a provisional license as provided by NRS 449.091 ; 3. The imposition of a limitation on the occupancy of a residential facility; 4. The imposition of a ban on admissions; 5. Monitoring of the facility by the Bureau; 6. The assessment of monetary penalties; 7. The requirement that the facility be managed temporarily by a person appointed by the Bureau; and 8. The denial, suspension or revocation of the license of the facility or an endorsement on a license, if applicable. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R119-10, 1-13-2011) NAC 449.99864 Determination of appropriate sanction: Procedure. ( NRS 449.0302 , 449.165 ) To determine the appropriate sanction, the Bureau shall follow the procedure set forth in NAC 449.99864 to 449.99867 , inclusive. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99865 Determination of appropriate sanction: Initial assessment. ( NRS 449.0302 , 449.165 ) The Bureau shall initially assess individual deficiencies or clusters of deficiencies according to the following initial factors: 1. The presence or absence of an immediate and serious threat to the health and safety of residents; 2. The severity of the deficiency; and 3. The scope of the deficiency. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99866 Determination of appropriate sanction: Consideration of secondary factors. ( NRS 449.0302 , 449.165 ) After the initial assessment, the Bureau shall consider the following secondary factors in determining the sanction to impose: 1. The relationship of one deficiency or cluster or pattern of deficiencies to other deficiencies; 2. The history of previous compliance by the facility generally and specifically with reference to the deficiencies in issue; 3. Whether the deficiencies are directly related to the care, services or treatment received by persons from the facility; and 4. The corrective and long-term compliance outcomes desired. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99867 Determination of appropriate sanction: Basis for selection; presumption. ( NRS 449.0302 , 449.165 ) The selection of a sanction must be based upon the nature of the deficiencies or cluster of deficiencies and the sanction most likely to correct those deficiencies. Absent evidence to the contrary, restrictions upon service and monetary penalties are presumed to be the most effective sanctions for deficiencies that do not cause an immediate and serious threat to recipients. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) Plan of Abatement NAC 449.99868 Notification of immediate and serious threat to health and safety; submission and contents of plan. ( NRS 439.200 , 449.0302 ) 1. If the Bureau determines that there is an immediate and serious threat to the health and safety of recipients served by a facility, the Bureau: (a) Shall notify the facility as soon as possible; and (b) May require the facility to submit a plan of abatement. 2. If the Bureau requires a facility to submit a plan of abatement, the facility shall submit the plan within the time specified by the Bureau, which must not exceed 48 hours after the Bureau notifies the facility of the requirement to submit the plan. 3. A plan of abatement: (a) Must include, without limitation, a description of the immediate action that the facility has taken or will take to end the immediate and serious threat and the date by which the immediate and serious threat will cease to exist. (b) Must ensure that serious harm does not occur or recur but is not required to include measures to correct all items of noncompliance associated with the immediate and serious threat. (Added to NAC by Bd. of Health by R048-22, eff. 12-29-2022) Plan of Correction NAC 449.9987 Development and submission of plan; authority of Bureau when plan is not acceptable; effect of failure to submit plan; confidentiality. ( NRS 439.200 , 449.0302 , 449.165 ) 1. The facility shall develop a plan of correction for each deficiency and submit the plan to the Bureau for approval within 10 days after receipt of the statement of deficiencies. The plan of correction must include specific requirements for corrective action, which must include times within which the deficiencies are to be corrected. 2. If the plan is not acceptable to the Bureau, the Bureau may direct the facility to resubmit a plan of correction or the Bureau may develop a directed plan of correction with which the facility must comply. 3. Failure to submit the plan of correction to the Bureau within 10 days constitutes a separate deficiency subject to monetary penalties with severity and scope rated at the same levels as the highest deficiency identified on the notice of deficiencies. 4. Except as otherwise provided in this subsection, a plan of correction that has not been approved by the Bureau is confidential. The Bureau may provide such a plan of correction to any entity within the Department of Health and Human Services or the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. If the Bureau develops a directed plan of correction pursuant to subsection 2, the unapproved plan of correction submitted by the facility pursuant to subsection 1 and the directed plan of correction cease to be confidential 14 days after the date on which the Bureau sends the directed plan of correction to the facility. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R048-22, 12-29-2022) Limitation on Occupancy of Residential Facility NAC 449.99875 Purpose and scope of limitation; imposition in addition to partial ban on admissions. ( NRS 449.0302 , 449.165 ) 1. A limitation on the occupancy of a residential unit must be imposed by the Bureau to safeguard the health, safety and well-being of residents currently receiving care, treatment or services and to prevent the admission of persons who cannot adequately be served by the facility. If a limitation on occupancy is imposed, the limitation applies regardless of the source of payment. The Bureau may limit the occupancy of a facility to the number of beds occupied at the time the deficiency occurred. If such a limitation is imposed, priority in new admissions must be given to immediate relatives of persons presently occupying the facility. 2. If the facility contains separately identifiable units and the deficiencies are confined to one or more discrete units, the limitation on occupancy may be limited to those units. 3. A limitation on occupancy may be imposed in addition to a partial ban on admissions if the facility is unable to provide adequate care, treatment or services for persons needing a discrete kind or type of care. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99876 Criteria for imposition. ( NRS 449.0302 , 449.165 ) 1. If the Bureau imposes a limitation on the occupancy of a residential facility, the limitation must be imposed as provided in this section. 2. For deficiencies with a combined severity and scope score of six or more, a limitation on occupancy must be imposed. 3. For deficiencies with a severity and scope score of less than six, a limitation on occupancy may be imposed if the deficiencies involve direct recipient care, services or treatment or the ability of residents to exit the facility safely in case of a fire or other emergency. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99877 Duration and termination of limitation. ( NRS 449.0302 , 449.165 ) A limitation on occupancy: 1. Must be imposed for not less than 72 hours. 2. Must be terminated if the facility demonstrates that substantial improvements have been made to correct the deficiencies and that the health, safety and well-being of recipients are adequately safeguarded. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99878 Notice of limitation: General requirements; effect of noncompliance. ( NRS 449.0302 , 449.165 ) 1. If a limitation on occupancy is imposed, a notice of the limitation must be posted at all public entrances to the facility within 48 hours after the facility receives notice of the limitation. Each notice must be not less than 15 inches by 20 inches in size and include: (a) The words “NOTICE OF LIMITATION ON OCCUPANCY” printed in boldface type not less than 1 1/2 inches in size; (b) A statement specifying the number of residents the facility is authorized to serve; (c) A statement identifying a member of the staff of the facility who will provide additional information relating to the limitation on occupancy; and (d) The telephone number of the Bureau. 2. Any person contacting the facility in writing or by telephone or any other means of telecommunication relating to a recipient seeking admission to the facility must be: (a) Notified of the limitation on occupancy; and (b) Provided with the information required by subsection 1. 3. The failure to post notice of a limitation on occupancy as required by this section, or the removal of such a notice, is a deficiency of severity level three and a scope level of three. The failure to inform an inquirer as to the existence of a limitation on occupancy is a deficiency of severity level two and a scope level of three. 4. In addition to the information required by subsection 1, the content of any notice required to be posted or published pursuant to this section must conform to the requirements set forth by the Bureau in the notice of sanction. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) Ban on Admissions NAC 449.9988 Purpose and scope of ban. ( NRS 449.0302 , 449.165 ) 1. A ban on admissions may be imposed by the Bureau on a residential or nonresidential facility to safeguard the health, safety and well-being of recipients receiving care, treatment or services and to prevent the admission of persons who cannot adequately be served by the facility. If a ban is imposed, it applies to all new admissions, regardless of the source of payment. 2. An immediate family member of a resident of a residential facility is not a new admission for the purposes of a ban on admissions unless the deficiencies are such that the health, safety or well-being of the immediate family member will be directly jeopardized. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99881 Criteria for imposition. ( NRS 449.0302 , 449.165 ) 1. If the Bureau imposes a ban on admissions, the ban must be imposed as provided in this section. 2. For deficiencies of severity level four and scope level two or more, a ban on all new admissions must be imposed. 3. For deficiencies of severity level three and scope level three, a ban on all new admissions must be imposed. 4. For deficiencies of severity level three and scope level two, a complete or partial ban on admissions may be imposed. If the deficiency is related to a discrete type of care, treatment or services, the ban may be limited to new admissions requiring the care, treatment or services for which the deficiency is found. 5. For deficiencies with a severity level of three or four and a scope level of one, the Bureau may impose a partial ban on admissions, limited to persons needing the care, treatment or services affected by the deficiency. 6. For deficiencies with a severity level of two and a scope level of three, a ban on admissions may be imposed if the deficiencies directly affect the care, treatment or services furnished to recipients. The ban may be limited to those persons requiring the kind or type of services affected by the deficiencies. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99882 Duration and termination of ban. ( NRS 449.0302 , 449.165 ) A ban on admissions: 1. Must be imposed for not less than 72 hours. 2. Must be terminated if the facility demonstrates that substantial improvements have been made to correct the deficiencies and that the health, safety and well-being of recipients are adequately safeguarded. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99883 Notice of ban: General requirements; effect of noncompliance. ( NRS 449.0302 , 449.165 ) 1. If a ban on admissions is imposed, a notice of the ban must be posted at all public entrances to the facility within 48 hours after the facility receives notice of the ban. Each notice must be not less than 15 inches by 20 inches in size and include: (a) The words “NOTICE OF BAN ON ADMISSIONS” printed in boldface type not less than 1 1/2 inches in size; (b) A statement identifying a member of the staff of the facility who will provide additional information relating to the ban on admissions; and (c) The telephone number of the Bureau. 2. If the facility provides care, treatment or services at a site other than the location of the office of the facility, notice must be provided by publishing an announcement, identified as a “LEGAL NOTICE” and not less than 25 percent of a newspaper page in size, in a newspaper of general circulation in the geographic area served by the facility on two separate occasions. The first publication must occur within 7 days after the facility receives notice of the ban, and the second publication must occur within 14 days after that date. At least one publication must be in a Sunday edition of the publication. Each publication must include the information required by subsection 1. 3. Any person contacting the facility in writing or by telephone or any other means of telecommunication relating to a recipient seeking admission must be: (a) Notified of the ban; and (b) Provided with the information required by subsection 1. 4. The failure to post or publish notice of a ban on admissions as required by this section, or the removal of such a notice, is a deficiency of severity level three and a scope of level three. A failure to inform an inquirer as to the existence of the ban is a deficiency of severity level two and a scope of level three. 5. In addition to the information required by subsection 1, the content of any notice required to be posted or published pursuant to this section must conform to the requirements set forth by the Bureau in the notice of sanction. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) Monitoring of Facility NAC 449.99885 Authority of Bureau. ( NRS 449.0302 , 449.165 ) 1. The Bureau may monitor the implementation of the plan of correction of the facility to determine whether the facility carries out the plan of correction. 2. The Bureau may also monitor the facility if the scope of the deficiencies identified is difficult to evaluate on a single visit. Such deficiencies include, without limitation, violations of recipients’ rights, inappropriate use of restraints and cases in which the Bureau has reason to question the ongoing compliance of the facility with the requirements of federal or state law. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) Monetary Penalties NAC 449.99895 Imposition by Bureau; purpose; applicable criteria. ( NRS 449.0302 , 449.165 ) The Bureau may impose a monetary penalty alone or in addition to other penalties. The purpose of a monetary penalty is to provide a fund for protecting the health, safety, rights, welfare and well-being of recipients and the property of residents in facilities and to deter future deficiencies. If a monetary penalty is imposed, the criteria in NAC 449.99896 must be applied. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99896 Criteria for imposition; imposition of initial and daily penalties. ( NRS 449.0302 , 449.165 ) 1. Except as otherwise provided in subsection 4 of this section, the Bureau may impose a monetary penalty including interest thereon on any facility that is not in compliance with any participation requirement, regardless of whether the deficiency constitutes an immediate and serious threat. 2. If a monetary penalty is imposed, the initial amount of the penalty must be based on the severity and scope score of the deficiency and must be imposed as provided in NAC 449.99899 . 3. In addition to the initial monetary penalty, the Bureau may impose a monetary penalty for each day of noncompliance from the date the noncompliance occurs or is identified until compliance is verified. 4. A facility is not subject to a monetary penalty for a de minimis deficiency. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99897 Imposition of initial penalty pending hearing or appeal; stay of payment of penalties pending appeal. ( NRS 449.0302 , 449.165 ) 1. The Bureau shall impose an initial monetary penalty pending a hearing or appeal. The payment of the initial penalty must not be stayed during the pendency of any administrative appeal. 2. The payment of any daily monetary penalties or interest that accrue while the facility has a hearing pending on the initial determination of deficiencies leading to the imposition of sanctions must be stayed pending the appeal. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99898 Procedure for imposition; interest on total penalty assessed. ( NRS 439.200 , 449.0302 , 449.165 ) If the Bureau imposes a monetary penalty, the penalty must be imposed as provided in NAC 449.99899 to 449.99908 , inclusive. In imposing the monetary penalty, the total penalty assessed against any facility bears interest at the rate of 10 percent per annum. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R109-18, 1-30-2019) NAC 449.99899 Determination of amount of penalties. ( NRS 439.200 , 449.0302 , 449.165 ) 1. In determining the amount of an initial monetary penalty, the Bureau shall consider the severity alone if the severity level is four. In determining the amount of the monetary penalty where the severity level is less than four, both severity and scope must be considered. In determining whether to impose a daily monetary penalty, the Bureau shall consider the severity and scope and the factors indicated for increased and decreased penalties provided in NAC 449.99902 and 449.99904 . 2. For initial deficiencies with a severity level of four: (a) If the violation creates harm or a risk of harm to one person, an initial monetary penalty of $2,500 per deficiency must be imposed. (b) If the violation creates harm or a risk of harm to more than one person, an initial monetary penalty of $5,000 per deficiency must be imposed. 3. For initial deficiencies rated with a severity level of three and a scope level of three: (a) If the violation creates harm or a risk of harm to one person, a monetary penalty of $2,000 per deficiency must be imposed. (b) If the violation creates harm or a risk of harm to more than one person, an initial monetary penalty of $4,000 per deficiency must be imposed. 4. For initial deficiencies with a severity level of three and a scope level of two or less: (a) If the violation creates harm or a risk of harm to one person, an initial monetary penalty of $1,500 per deficiency must be imposed. (b) If the violation creates harm or a risk of harm to more than one person, an initial monetary penalty of $3,000 per deficiency must be imposed. 5. For initial deficiencies with a severity level of two and a scope level of three, an initial monetary penalty of $1,000 per deficiency may be imposed. The payment of this monetary penalty must be suspended if the facility has corrected the deficiencies within the time specified in the plan of correction approved by the Bureau. 6. In addition to any monetary penalty imposed pursuant to this section, the Bureau may impose a monetary penalty of not more than $10 per recipient per day for each day the deficiency continues. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002; R109-18, 1-30-2019) NAC 449.998995 Use of initial monetary penalty to correct deficiency. ( NRS 439.200 , 449.165 ) 1. A facility may submit to the Bureau a request to use all or a portion of an initial monetary penalty imposed upon the facility pursuant to NAC 449.99899 to correct the deficiency for which the penalty was imposed in lieu of paying the penalty to the Bureau. The Bureau may approve such a request if the deficiency results from the facility’s first violation of a particular provision of law or regulation. 2. If the Bureau approves a request pursuant to subsection 1, the facility must: (a) Adhere to any requirements prescribed in a plan of correction approved pursuant to NAC 449.9987 concerning the use of the monetary penalty; (b) Complete all corrections for which the monetary penalty is used not later than 1 year after the date on which the request was approved; (c) Submit to the Bureau proof satisfactory to the Bureau that the monetary penalty was used to make corrections for which the use of the monetary penalty was approved by the Bureau pursuant to subsection 1; and (d) Remit to the Bureau any portion of the monetary penalty that is not used to correct the deficiency. (Added to NAC by Bd. of Health by R109-18, eff. 1-30-2019) NAC 449.999 Limitation on principal amount of total daily penalty. ( NRS 439.200 , 449.0302 , 449.165 ) In no event may the principal amount of the total daily monetary penalty assessed against any facility exceed $5,000 per deficiency per day. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R109-18, 1-30-2019) NAC 449.99901 Daily penalty: Computation according to number of recipients. ( NRS 449.0302 , 449.165 ) If a monetary penalty is assessed on a daily basis according to the number of recipients and the number of recipients fluctuates, the penalty must be computed on the basis of the average daily number of recipients during the 3 months preceding the imposition of the penalty. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99902 Increase in penalty for repeated deficiencies or false compliance. ( NRS 449.0302 , 449.165 ) 1. Penalties must be increased if deficiencies are repeated or compliance is falsely alleged. 2. For each repeat deficiency present within 18 months after an initial deficiency, the monetary penalty must be computed at the rate of one and one-half times the rate that was or could have been assessed initially for a deficiency of that severity and scope. 3. The Bureau may double the daily monetary penalty that was or could have been assessed if the facility alleges compliance and the Bureau finds on a survey that at the time compliance was alleged the deficiencies continued to exist. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99903 Presumption regarding deficiencies identified on resurvey. ( NRS 449.0302 , 449.165 ) There is a rebuttable presumption that deficiencies identified on a resurvey were present on each day between the date of the initial deficiency and the date of the resurveyed deficiency. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99904 Reduction of penalty. ( NRS 449.0302 , 449.165 ) If a facility against which a monetary penalty is imposed: 1. Waives the right to a hearing; 2. Corrects the deficiencies that were the basis for the sanction; and 3. Pays the monetary penalty within 15 days after receipt of the notice of the penalty, Ê the penalty must be reduced by 25 percent and no interest may be charged. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99905 Daily penalty: Effective beginning date. ( NRS 449.0302 , 449.165 ) The effective beginning date of a daily monetary penalty is: 1. In the case of an immediate and serious threat, the date the deficiency occurred; or 2. In any other case, the day the deficiency is identified. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99906 Daily penalty: Date and period of computation; notice to facility. ( NRS 449.0302 , 449.165 ) 1. Daily penalties and interest must be computed after compliance has been verified or the provider has been sent notice of termination of a license or provisional license. A daily monetary penalty must end on the effective date of compliance or termination of the license of the facility. 2. If a provider achieves compliance, the Bureau shall send a separate notice to the facility containing: (a) The amount of the penalty per day; (b) The number of days involved; (c) The due date of the penalty; and (d) The total amount due. 3. If the license of a facility is to be terminated, the Bureau shall send the information required by subsection 2 in the notice of termination. 4. If the Bureau’s decision of noncompliance is upheld on appeal or the facility waives its right to a hearing, the monetary penalty must be imposed for the number of days between the effective date of the penalty and the date of correction of the deficiencies or, if applicable, the date the license of the facility is terminated. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99907 Termination of daily penalties; failure of Medicaid facility to remove immediate and serious threat after appointment of temporary management. ( NRS 449.0302 , 449.165 ) 1. The daily accrual of a monetary penalty must end if the facility demonstrates that substantial improvements have been made to correct the deficiencies and that the health, safety and well-being of recipients are adequately protected and safeguarded. 2. A monetary penalty may be imposed on a daily basis for not longer than 6 months, after which the Bureau shall deny, suspend or revoke the license of the facility and, if the facility is a Medicaid facility and major deficiencies remain, request the Division of Health Care Financing and Policy to terminate the Medicaid provider agreement of the facility. 3. If a deficiency in a Medicaid facility presents an immediate and serious threat and continues to exist on the 23rd day after the appointment of temporary management, the Bureau shall request the Division of Health Care Financing and Policy to terminate the Medicaid provider agreement of the facility. 4. If the provider can supply credible evidence that substantial compliance with participation requirements was attained on a date preceding that of the survey, monetary penalties accrue only until that date of correction for which there is credible evidence. As used in this subsection, “credible evidence” means actual documentation that compliance has been achieved. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99908 Time for payment of penalties. ( NRS 449.0302 , 449.165 ) 1. Initial monetary penalty assessment payments are due within 15 days after the notice of the penalty and must be paid irrespective of any administrative appeal. 2. The daily monetary penalty is due and must be paid within 15 days after compliance is verified or termination of a license is effective and the facility is notified of the amount of the total daily monetary penalty and interest due. 3. If the facility has appealed a decision imposing a monetary penalty, the daily penalty is due and must be paid after the final administrative decision is rendered and 15 days after the facility has been notified of the amount of the total daily penalty and interest due. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99909 Assessment of interest on unpaid balance of penalty. ( NRS 449.0302 , 449.165 ) Unless it is waived as provided in NAC 449.002 to 449.99939 , inclusive, interest at the rate prescribed in NRS 449.163 will be assessed on the unpaid balance of the penalty, beginning on the due date. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.9991 Recovery of costs for collection of penalty. ( NRS 449.0302 , 449.165 ) Any costs, including attorney’s fees, incurred by the Bureau or the Division in the collection of any monetary penalty may be recovered from the facility. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99911 Failure to pay penalty: Suspension of license of facility. ( NRS 439.200 , 449.0302 , 449.165 ) 1. If the facility fails to pay a monetary penalty and the Bureau has not approved the use of the penalty for corrections pursuant to NAC 449.998995 , the Division may suspend the license of the facility. 2. The Division shall, in accordance with the requirements of NAC 439.345 , provide notice of its intention to suspend the license of the facility. 3. If the facility fails to pay the monetary penalty, including any additional costs incurred in collection of the penalty, within 10 days after receipt of the notice and the Bureau has not approved the use of the penalty for corrections pursuant to NAC 449.998995 , the Division shall suspend the license of the facility. The suspension must not be stayed during the pendency of any administrative appeal. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R044-97, 10-30-97; R109-18, 1-30-2019) NAC 449.99912 Disposition of money collected. ( NRS 449.0302 ) 1. Unless otherwise required by federal law, money collected by the Division as administrative sanctions must be deposited into a separate fund and applied to the protection of the health, safety, well-being and property of recipients, including residents of facilities that the Division finds deficient. 2. Any of the following applications of money collected, without limitation, are permissible: (a) Reimbursement of costs related to the operation of a facility pending correction of deficiencies or closure; (b) Reimbursement of residents for personal money lost; and (c) Payment of the cost of relocating residents to other facilities. (Added to NAC by Bd. of Health, eff. 8-1-91) Temporary Management NAC 449.99915 Appointment of temporary manager when there is immediate and serious threat: Notice; effect of failure to accept manager and to remove threat. ( NRS 449.0302 , 449.165 , 449.170 ) 1. If a temporary manager is to be appointed, the Bureau shall orally notify the facility of the appointment. Written notice that complies with the requirements of NAC 439.345 must be mailed within 48 hours after the oral notice. 2. If the facility does not accept the temporary manager or a temporary manager is not available within 10 days after the date of the deficiency, and the immediate and serious threat is not removed, the Bureau shall deny, suspend or revoke the license of the facility and, if applicable, shall recommend to the Division of Health Care Financing and Policy termination or suspension of the Medicaid provider agreement of the facility. 3. If the facility accepts the temporary manager, the Bureau shall: (a) Notify the facility that, unless it removes the immediate and serious threat, its license will be denied, suspended or revoked pursuant to NRS 449.160 ; and (b) If applicable, recommend to the Division of Health Care Financing and Policy that the Medicaid provider agreement of the facility be terminated, effective on the 23rd day after the date of appointment of the temporary manager. 4. If the immediate and serious threat is not removed on or before the 23rd day after the appointment of the temporary manager, the Bureau shall deny, suspend or revoke the license of the facility and, if applicable, recommend to the Division of Health Care Financing and Policy that the Medicaid provider agreement be terminated. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R044-97, 10-30-97; R051-02, 7-24-2002) NAC 449.99916 Appointment of temporary manager when there is no immediate and serious threat: Notice. ( NRS 449.0302 , 449.170 ) Appointment of a temporary manager where there is not an immediate and serious threat must be made in conformity with the provisions for notice contained in NAC 439.345 . (Added to NAC by Bd. of Health, eff. 8-1-91; A by R044-97, 10-30-97) NAC 449.99917 Temporary manager: Qualifications. ( NRS 449.0302 ) 1. The temporary manager must: (a) Be a person qualified to operate the facility pursuant to the provisions of chapter 449 of NRS relating to the licensing of the facility; (b) Demonstrate prior competency as an administrator of a medical facility or a facility for the dependent or have other relevant experience pertinent to the deficiencies identified; and (c) Have had no disciplinary action taken against him or her by any licensing board or professional society in any state. 2. The temporary manager may be an employee of the Division or a private person or agency that contracts with the Division to serve in that capacity. 3. The temporary manager must not be: (a) An employee of the facility or an affiliated facility; or (b) A person or agency that has served as a consultant to the facility or an affiliated facility within the 2 years preceding the appointment of the temporary manager. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99918 Temporary manager: Authority. ( NRS 449.0302 , 449.165 ) The temporary manager may take such action as is required to mitigate the immediate danger at the facility, including, without limitation, providing for the safe transfer of residents or prohibiting the transfer of residents. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99919 Effect of failure to agree to appointment of or to relinquish authority to temporary manager. ( NRS 449.0302 , 449.165 ) If a facility fails to agree to the appointment of a temporary manager or fails to relinquish authority to the temporary manager, the Division of Public and Behavioral Health shall: 1. Request the Attorney General to bring an action pursuant to NRS 439.565 ; 2. Deny, suspend or revoke the license of the facility; and 3. If applicable, request the Division of Health Care Financing and Policy to terminate the provider agreement of the facility in accordance with the requirements of the Medicaid program. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.9992 Events requiring termination of management; initiation of judicial proceedings. ( NRS 449.0302 , 449.165 ) 1. Temporary management of a facility must be terminated if the Bureau determines that: (a) The facility has substantially corrected the deficiency and has secured management capable of ensuring continued compliance with applicable state and federal statutes, regulations, conditions and standards; or (b) The license of the facility has been denied, revoked or suspended. 2. If temporary management will be needed for more than 24 days, the Bureau shall request the Attorney General to initiate judicial proceedings as authorized by NRS 439.565 . (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99921 Payment of costs and expenses. ( NRS 449.0302 , 449.165 ) The costs and expenses of temporary management, including the compensation of the manager, must be paid by the facility through the Bureau while the temporary manager is assigned to the facility. (Added to NAC by Bd. of Health, eff. 8-1-91) Closure of Facility and Transfer of Residents NAC 449.99925 Authority of Bureau. ( NRS 449.0302 ) The Bureau shall in an emergency deny, suspend or revoke the license of a facility and, in the case of a residential facility that is no longer licensed to operate, arrange for the appointment of a temporary manager to oversee the timely and orderly transfer of any residents. This sanction may be used only if other less drastic measures are inadequate to prevent or remove a serious threat to the health, safety and well-being of recipients and, in the case of a residential facility, the action is deemed necessary to safeguard and protect the health of residents of the facility. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99926 Requirements for notification. ( NRS 449.0302 ) 1. Except as otherwise provided in subsection 2, if the Bureau proposes to close a facility, the Division shall, at least 5 days before the transfer, notify or cause to be notified personally or by written or telephonic means: (a) Each recipient; and (b) Any person indicated on the record of the recipient as a person to be notified in case of an emergency, Ê of the nature of the emergency and the proposed transfer. 2. In an acute emergency, residents may be transferred without prior notice. As used in this subsection, “acute emergency” means that action must be taken without prior notice as a result of an immediate and serious threat. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99927 Appointment of temporary manager. ( NRS 449.0302 ) If the Bureau denies, revokes or suspends the license of a facility, the Bureau shall appoint a temporary manager to assist in the orderly closure of the facility and, in the case of a residential facility, the transfer of residents. (Added to NAC by Bd. of Health, eff. 8-1-91) NAC 449.99928 Bureau to supervise or appoint temporary manager to supervise transfer; imposition of other appropriate sanctions. ( NRS 449.0302 ) If a residential facility is to be closed, the Bureau shall supervise, or appoint a temporary manager to supervise, the orderly transfer of residents. The Bureau may also impose other appropriate sanctions as authorized by the regulations of the Division. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99929 Determination of appropriate placement of residents. ( NRS 449.0302 ) If the residents of a residential facility are to be transferred, the following criteria must be applied by the Bureau or temporary manager responsible for supervising the orderly transfer of residents in the following order to determine the most appropriate placement of each resident: 1. The medical and psychological health of the resident and the suitability of the proposed facility to meet the resident’s medical and psychosocial needs; 2. The facility, if any, where the spouse or immediate family member of the resident is a resident; and 3. The geographical proximity of the proposed facility to the immediate family or regular visitors of the resident. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.9993 Rights of appeal for transferred residents. ( NRS 449.0302 ) Except in cases of emergency or termination of the license of a facility, the rights of appeal provided by federal and state statutes or regulations governing the transfer of residents apply to residents who are transferred. (Added to NAC by Bd. of Health, eff. 8-1-91) Facilities Participating in Medicaid NAC 449.99935 Authorized recommendations in addition to available sanctions. ( NRS 449.0302 ) For a facility that participates in Medicaid, in addition to imposing any sanction authorized by NAC 449.99863 , the Bureau may recommend to the Division of Health Care Financing and Policy: 1. That the provider agreement of the facility be terminated. 2. That Medicaid payment for new admissions be denied. 3. That Medicaid payment for certain diagnostic categories or certain types of specialized care be denied. 4. That all or part of the Medicaid payments to the facility be suspended. 5. That the facility be allowed to continue to participate as a Medicaid facility for 6 months after the date of the survey if: (a) The Bureau finds that it is more appropriate to impose alternative sanctions than to recommend termination of the facility from the Medicaid program; (b) The facility has submitted an acceptable plan of correction; (c) The Bureau approves the plan of correction; and (d) The facility agrees to repay the Federal Government for any payments received under the Medicare or Medicaid program if timely corrective action is not taken in accordance with the approved plan of correction. Ê If the facility does not substantially correct the cited deficiencies within 6 months after the last day of the survey, the Bureau shall recommend that the Division of Health Care Financing and Policy terminate the Medicaid agreement of any facility whose participation was continued under these conditions. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99936 Withholding of monetary penalties from payments owed to facility. ( NRS 449.0302 ) 1. The amount of any monetary penalty owed by a Medicaid facility, if it has been determined, may be deducted from any money otherwise owed to the facility by the Division of Health Care Financing and Policy. 2. If the facility does not pay a monetary penalty by the date it is due and no extension of time to pay is granted, the Administrator of the Division of Public and Behavioral Health shall notify the Administrator of the Division of Health Care Financing and Policy of the amount of the penalty due and owing and shall request withholding of the amount owed. 3. The Administrator of the Division of Health Care Financing and Policy shall take the appropriate steps to withhold the amount of the monetary penalty owed, including any interest and costs of collection, from the Medicaid payment otherwise due the facility. Money so withheld must be remitted to the Division of Public and Behavioral Health for deposit in the special fund established pursuant to NAC 449.99912 . Money withheld for costs of collection must be applied by the Administrator of the Division of Public and Behavioral Health to the account incurring the costs. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99937 Denial of payments for new admissions generally. ( NRS 449.0302 ) 1. The Bureau may request the Division of Health Care Financing and Policy to deny Medicaid payment to a facility for new admissions if: (a) The facility does not substantially correct the deficiencies within 90 days or within the time required by federal Medicaid law after the facility is notified by the Bureau of the deficiencies; or (b) The Bureau has cited a facility with substandard quality of care (severity score of level three or more and scope of level three) on two of the last three consecutive standard surveys. 2. If the facility achieves and maintains compliance with the requirements, the Bureau shall request the Division of Health Care Financing and Policy to resume payments to the facility prospectively, effective on the date compliance was achieved. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99938 Denial of payments for new admissions who have certain specified diagnoses or special care needs. ( NRS 449.0302 ) 1. The Bureau may request the Division of Health Care Financing and Policy to deny payment to a facility for new admissions who have certain specified diagnoses or special care needs if: (a) The facility is not currently able to provide appropriate care, services or treatment for those persons; or (b) Caring for those persons will adversely affect care provided to other recipients. 2. If the facility achieves and maintains compliance with the requirements, the Bureau must request the Division of Health Care Financing and Policy to resume payment to the facility prospectively, effective on the date compliance was achieved. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) NAC 449.99939 Suspension of payments for services furnished to Medicaid recipient on or after date of deficiency. ( NRS 449.0302 ) 1. The Bureau may request the Division of Health Care Financing and Policy to suspend all or part of the Medicaid payments to a facility for services furnished to a Medicaid recipient on or after the date of the deficiency, regardless of whether the recipient was admitted before, on or after the date of the deficiency. 2. If the facility achieves compliance with the requirements, the Bureau shall request the Division of Health Care Financing and Policy to resume payments retroactively. (Added to NAC by Bd. of Health, eff. 8-1-91; A by R051-02, 7-24-2002) OUTPATIENT FACILITIES: PERMIT FOR SERVICES OF GENERAL ANESTHESIA, CONSCIOUS SEDATION AND DEEP SEDATION General Provisions NAC 449.9994 Definitions. ( NRS 449.448 ) As used in NAC 449.9994 to 449.999489 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.99941 to 449.999419 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.99941 “Bureau” defined. ( NRS 449.448 ) “Bureau” means the Bureau of Health Care Quality and Compliance of the Division. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999413 “Division” defined. ( NRS 449.448 ) “Division” means the Division of Public and Behavioral Health of the Department of Health and Human Services. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999415 “Inspection” defined. ( NRS 449.448 ) “Inspection” means the inspection of an outpatient facility conducted by employees of the Bureau pursuant to NRS 449.443 or 449.446 . The term includes a follow-up inspection to renew the permit of an outpatient facility or evaluate compliance with a plan of correction or an inspection made in response to a complaint. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999417 “Outpatient facility” defined. ( NRS 449.448 ) “Outpatient facility” means an office of a physician or a facility that provides health care, other than a medical facility, which offers to a patient a service of general anesthesia, conscious sedation or deep sedation. The term does not include an office of a physician or a facility to which the provisions of NRS 449.435 to 449.448 , inclusive, do not apply. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999419 “Treatment” defined. ( NRS 449.448 ) “Treatment” means any medication, drug, test or procedure conducted or administered to diagnose or remedy a physical or mental illness or condition. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) Permitting NAC 449.99942 Application; general requirements; proof of national accreditation; fee; period for validity; application required for each location. ( NRS 449.442 , 449.443 , 449.448 ) 1. Before offering to a patient a service of general anesthesia, conscious sedation or deep sedation, an outpatient facility shall submit to the Division an application for a permit to offer those services at the outpatient facility on a form prescribed by the Division. 2. An application for a permit must: (a) Be complete and, if the applicant is a natural person, include proof of the identity of the applicant that is acceptable to the Division. (b) Be accompanied by the appropriate application fee as prescribed in subsection 3. (c) Include: (1) The name of the applicant and, if a natural person, evidence that the applicant has attained the age of 21 years. (2) The location of the outpatient facility. (3) In specific terms, the nature of services and type of care to be offered. (4) The name of the person in charge of the outpatient facility. (5) Such other information as may be required by the Division for the proper administration and enforcement of NRS 449.435 to 449.448 , inclusive, and NAC 449.9994 to 449.999489 , inclusive. (6) Evidence satisfactory to the Division that the applicant is of reputable and responsible character. If the applicant is a firm, association, organization, partnership, business trust, corporation or company, similar evidence must be submitted as to the members thereof, and the person in charge of the outpatient facility for which application is made. If the applicant is a political subdivision of the State or other governmental agency, similar evidence must be submitted as to the person in charge of the outpatient facility for which application is made. (7) Evidence satisfactory to the Division of the ability of the applicant to comply with the standards and regulations adopted by the Board. (8) Evidence satisfactory to the Division that the outpatient facility: (I) Conforms to the zoning regulations of the local government within which the outpatient facility will be operated; or (II) Has applied for an appropriate reclassification, variance, permit for special use or other exception for the outpatient facility. (d) Be accompanied by: (1) Except as otherwise provided in subparagraph (2), proof of accreditation by a nationally recognized organization approved by the Board pursuant to NAC 449.999424 ; or (2) If the application is for an initial permit, evidence that the outpatient facility has applied for accreditation by a nationally recognized organization approved by the Board pursuant to NAC 449.999424 . 3. An applicant for a permit must pay to the Division a nonrefundable fee of $3,570. 4. An application for a permit is valid for 1 year after the date on which the application is submitted. If an applicant does not meet the requirements for a permit within 1 year after the date on which the application was submitted, the applicant must submit a new application and pay the required fee to be considered for a permit. 5. An application for a permit must be submitted for each location of the outpatient facility where a service of general anesthesia, conscious sedation or deep sedation will be offered. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010; A by R078-12, 12-20-2012) NAC 449.999421 Inspection by Division of applicant and outpatient facility; prerequisite of satisfactory fire inspection. ( NRS 449.443 , 449.446 , 449.448 ) 1. Upon receipt of a properly completed application for a permit, proof of the identity of the applicant, if applicable, that is acceptable to the Division and the appropriate fee, the Division shall conduct an investigation of the applicant and the outpatient facility pursuant to the provisions of NRS 449.446 . During the investigation, the Division shall determine whether the outpatient facility is in compliance with the provisions of NRS 449.435 to 449.448 , inclusive, and NAC 449.9994 to 449.999489 , inclusive. 2. Before issuing a permit, the Division must receive a satisfactory report of inspection of the outpatient facility from the State Fire Marshal or the local fire department. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010; A by R078-12, 12-20-2012) NAC 449.999422 Term of permit; circumstances under which permit deemed invalid. ( NRS 449.442 , 449.444 , 449.448 ) 1. Except as otherwise provided in subsection 2, a permit is valid for 1 year after the date of issuance, and the holder of the permit may apply for renewal of the permit pursuant to NAC 449.999423 . 2. A permit is invalid on the date on which the holder of the permit fails to: (a) Obtain accreditation as required by NRS 449.442 and NAC 449.999424 within 6 months after the date of issuance of the permit; (b) Maintain current accreditation; or (c) Provide a report from a nationally recognized organization for accreditation as required by NAC 449.999424 . (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999423 Renewal of permit: Application; additional inspection by Division authorized; fees; untimely filing or failure to file application. ( NRS 449.444 , 449.448 ) 1. Except as otherwise provided in subsection 3, a holder of a permit to operate an outpatient facility who wishes to renew the permit must submit a completed application for renewal to the Division, on a form prescribed by the Division, not later than 45 days before the date on which the permit expires. In addition to the annual inspection required by NRS 449.446 , the Division may require an inspection of the outpatient facility to ensure that it meets the requirements of NRS 449.435 to 449.448 , inclusive, and NAC 449.9994 to 449.999489 , inclusive, before deciding whether to renew a permit. 2. An applicant for the renewal of a permit to operate an outpatient facility must pay to the Division a nonrefundable fee of $1,785. 3. A holder of a permit who, without good cause, files an application for the renewal of a permit after the date set forth in subsection 1 but before the expiration of the permit must pay, in addition to the renewal fee for the permit prescribed in subsection 2, a fee equal to one-half the amount of the fee required for the renewal of the permit pursuant to that subsection. 4. A holder of a permit who fails to file an application for the renewal of the permit before the permit expires is not eligible to renew the permit and, if he or she wishes to be permitted, must submit an application for a new permit pursuant to NAC 449.99942 . (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999424 Outpatient facility required to provide proof of national accreditation; submission of reports to Division; application by accrediting organization for recognition by State Board of Health; maintenance of list by Division of approved accrediting organizations. ( NRS 449.442 , 449.448 ) 1. An outpatient facility shall: (a) Not later than 6 months after obtaining a permit, submit proof to the Division of accreditation by a nationally recognized organization approved by the Board pursuant to subsection 3; and (b) Maintain current accreditation during the term of the permit. 2. An outpatient facility shall provide to the Division each report provided by the accrediting organization, including, without limitation, the initial report, each report issued upon renewal of an accreditation and any other report issued by the accrediting organization. 3. An organization that accredits outpatient facilities and which wishes to be recognized by the Board as an accrediting organization for the purposes of this section must submit to the Division an application on a form prescribed by the Division. The Division shall review each application received pursuant to this subsection and shall forward to the Board each application and the recommendation of the Division that the Board approve or not approve the organization as an accrediting organization for purposes of this section. The recommendation of the Division must be based upon whether the applicant requires an outpatient facility to meet the minimum requirements necessary to ensure a high level of quality. The Board may approve or deny an application for recognition as an accrediting organization submitted pursuant to this subsection. 4. The Division shall maintain on its Internet website a list of all accrediting organizations approved by the Board pursuant to this section. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999425 Display of permit; maintenance of outpatient facility in compliance with law; notification of transfer of real property; notification of change of ownership, location or services provided. ( NRS 449.448 ) 1. Upon receipt of a permit, the holder shall display the permit at a conspicuous location within the outpatient facility. 2. During the term of the permit, the outpatient facility shall continuously maintain the facility in conformance with the provisions of NRS 449.435 to 449.448 , inclusive, and NAC 449.9994 to 449.999489 , inclusive. 3. If there is a transfer of the real property on which the outpatient facility is located, but no change in the operator of the outpatient facility, the holder of a permit shall, within 10 days after the transfer, notify the Division of the transfer in writing and provide the Division with a copy of any lease agreement relating to the transfer. 4. The holder of a permit shall notify the Division immediately of any change in the ownership of, location of or services provided by the outpatient facility. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999426 Additional grounds for denial, suspension or revocation of permit. ( NRS 449.447 , 449.448 ) In addition to the grounds set forth in NRS 449.447 and NAC 449.999459 , the Division may deny an application for a permit or may suspend or revoke a permit upon any of the following grounds: 1. Misappropriation of the property of a patient of the outpatient facility. 2. Abuse, neglect or exploitation of a person who is infirm, a person with an intellectual disability, a person with a disability or a person who is 60 years of age or older. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) Program for the Prevention and Control of Infections and Communicable Diseases NAC 449.99943 Definitions. ( NRS 441A.120 , 449.448 ) As used in NAC 449.99943 to 449.999448 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.999431 to 449.99944 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999431 “Biologic indicator test” defined. ( NRS 441A.120 , 449.448 ) “Biologic indicator test” means a test used in every ethylene oxide cycle and in every sterilization load of implantable devices to demonstrate through the destruction of highly resistant bacterial spores whether all parameters, including, without limitation, time, temperature, sterilant and humidity, were met to effectively sterilize the medical items. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999432 “Cleaning” defined. ( NRS 441A.120 , 449.448 ) “Cleaning” means the physical removal of organic material or soil from objects by using water, with or without detergents, that is designed to remove, rather than kill, microorganisms. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999433 “High-level disinfection” defined. ( NRS 441A.120 , 449.448 ) “High-level disinfection” means a type of disinfection which destroys all microorganisms with the exception of high levels of bacterial spores. Such disinfection may be accomplished through the use of processes that include, without limitation, boiling items in water, steaming items in water and soaking items in chemical disinfectants. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999434 “Implantable device” defined. ( NRS 441A.120 , 449.448 ) “Implantable device” means a medical device that is implanted in the human body, including, without limitation, a pacemaker, defibrillator, heart valve, hearing device or joint replacement. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999435 “Invasive procedure” defined. ( NRS 441A.120 , 449.448 ) “Invasive procedure” means a medical procedure involving entry into the human body by puncture or incision or by insertion of an instrument. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999436 “Low-level disinfection” defined. ( NRS 441A.120 , 449.448 ) “Low-level disinfection” means a type of disinfection which eliminates most bacteria, some viruses and some fungi, but which may not kill resistant microorganisms. Such disinfection may be accomplished through the use of processes that include, without limitation, soaking items in chemical disinfectants. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999437 “Multidose vial” defined. ( NRS 441A.120 , 449.448 ) “Multidose vial” means a vial, including, without limitation, a sealed sterile vial, which may be accessed by insertion of a needle and which, according to the manufacturer’s instructions: 1. Contains more than one dose of a medication; and 2. May be used for one or more patients. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999438 “Reprocess” defined. ( NRS 441A.120 , 449.448 ) “Reprocess” means the process of subjecting a single-use medical device that has been previously used on a patient to additional cleaning, disinfection or sterilization, manufacturing steps, including, without limitation, repackaging and relabeling, and testing of the technical and functional safety of the device to make the device ready for safe use on another patient. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999439 “Single-dose vial” defined. ( NRS 441A.120 , 449.448 ) “Single-dose vial” means a vial, including, without limitation, a sealed sterile vial, which may be accessed by insertion of a needle and which, according to the manufacturer’s instructions: 1. Contains only one dose of a medication; and 2. May be used for only one patient. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.99944 “Sterilization” defined. ( NRS 441A.120 , 449.448 ) “Sterilization” means a process using medical equipment, including, without limitation, a dry heat sterilizer or an autoclave, to destroy all forms of microbial life. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999441 Adoption of guidelines by holder of permit for establishment of program. ( NRS 441A.120 , 449.448 ) 1. The holder of a permit issued pursuant to NAC 449.99942 shall adopt guidelines which must be used by the outpatient facility in establishing the program for the prevention and control of infections and communicable diseases required by NAC 449.999442 . 2. The guidelines adopted pursuant to subsection 1 may include, without limitation, guidelines, statements or recommendations issued or published by other agencies or organizations, and must: (a) Be based on evidence, theoretical rationale or scientific data; and (b) Include well-designed experimental, clinical or epidemiological studies which document the processes used in the development of the studies and which grade the strength of the evidence relied on in the studies. 3. The holder of the permit shall ensure that a copy of the guidelines adopted pursuant to subsection 1 is available at the outpatient facility and accessible to the staff of the outpatient facility and the public. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999442 General requirements of program. ( NRS 441A.120 , 449.448 ) 1. Each outpatient facility shall establish and maintain a program for the prevention and control of infections and communicable diseases. 2. In addition to complying with the provisions of NAC 449.999441 to 449.999447 , inclusive, a program for the prevention and control of infections and communicable diseases must be: (a) Appropriate for the services provided at the outpatient facility; (b) Based on the guidelines adopted by the holder of the permit pursuant to NAC 449.999441 ; and (c) Developed in a manner that takes into consideration: (1) All surgical and other medical services provided at the outpatient facility; (2) The types of patients typically treated at the outpatient facility, including, without limitation, those whose age or medical condition makes them vulnerable to infections and communicable diseases; (3) The types of injuries or illnesses typically treated at the outpatient facility; (4) The number of patients typically treated at the outpatient facility; (5) The level of education and training of the staff of the outpatient facility; (6) The number of nurses available at the outpatient facility, the qualifications of such nurses and the amount of support required of the nurses by the physicians at the outpatient facility, if applicable; (7) The types of invasive procedures performed at the outpatient facility; (8) The locations within the outpatient facility where invasive procedures are performed; (9) The specific medical instruments and equipment used at the outpatient facility; (10) The physical design of the outpatient facility; and (11) The causes, risks and patterns of infections and transmission of communicable diseases that arise in the setting of each medical procedure performed at the outpatient facility. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999443 Program required to include policies and procedures for prevention of exposure to blood-borne and other potentially infectious pathogens. ( NRS 441A.120 , 449.448 ) Each program for the prevention and control of infections and communicable diseases must include policies and procedures to prevent exposure to blood-borne and other potentially infectious pathogens, including, without limitation, policies and procedures relating to: 1. Hand hygiene, including provisions regarding the time and procedure for hand washing with soap and water or the use of an alcohol-based hand rub. 2. The proper use of medical gloves, including, without limitation, a requirement that each person who works at the outpatient facility must wear medical gloves when the person: (a) Anticipates coming in contact with blood or bodily fluids; (b) Handles contaminated instruments, items and equipment; (c) Handles biological waste or biologically contaminated waste that may cause harm to humans, animals or plants; (d) Handles linens potentially contaminated with biological waste or biologically contaminated waste that may cause harm to humans, animals or plants; and (e) Performs housekeeping activities or cleans contaminated surfaces. 3. Safe injection practices to prevent the contamination of equipment used for injections and medication, including, without limitation, a requirement that a new sterile needle and new sterile syringe be used for each patient and not used for more than one patient. 4. The proper handling of sharp instruments and the disposal of sharp instruments, which must be consistent with the standards developed by the Occupational Safety and Health Administration of the United States Department of Labor for the handling and disposal of such instruments. 5. Techniques for accessing a vial of medication, which must comply with the requirements set forth in NAC 449.999444 . 6. The infusion of intravenous medications, which must provide, without limitation, that intravenous tubing and fluid bags or bottles are not to be used for more than one patient. 7. The proper sterilization and disinfection of all medical equipment, instruments and devices. Those policies and procedures must, at a minimum, require the outpatient facility to: (a) Sterilize or ascertain the sterility of items that enter sterile tissue or the vascular system, including, without limitation, surgical instruments, endoscopes, endoscopic accessories, catheters, needles and probes used for ultrasounds; (b) Perform high-level disinfection of reusable items that come in contact with nonintact skin or mucous membranes, including, without limitation, respiratory therapy equipment, anesthesia equipment, bronchoscopes and gastrointestinal endoscopes; and (c) Perform low-level disinfection of reusable items that come in contact with only intact skin, including, without limitation, tourniquets, blood pressure cuffs, linens, stands that are used to hold medical instruments and other furnishings. 8. The proper handling of equipment, instruments and devices. Those policies and procedures must, at a minimum, require the outpatient facility to: (a) Sterilize and disinfect reusable items as described in subsection 7; (b) Properly dispose of single-use equipment, instruments and devices after use, if the outpatient facility has decided not to have the equipment, instruments or devices reprocessed; and (c) Ensure that: (1) All equipment, instruments and devices that may be reprocessed are reprocessed only by a third-party processor approved by the United States Food and Drug Administration; and (2) No equipment, instruments or devices that may be reprocessed are reprocessed at the outpatient facility. 9. The proper handling and disposal of medical waste and specimens. 10. The proper cleaning and disinfection of all areas in which patient care is provided. 11. The proper maintenance of a clean and sanitary environment. 12. The identification and reporting of the development and transmission of infections and communicable diseases, including, without limitation, the method by which the outpatient facility must: (a) Track and document the development and transmission of infections and communicable diseases which are related to the medical procedures performed at the outpatient facility; (b) Report the development and transmission of infections and communicable diseases as required by federal, state and local laws; and (c) Identify and address trends in such developments and transmissions of infections and communicable diseases. 13. The care of patients with a communicable disease, including, without limitation, patients who are known to have a communicable disease at the time of arrival at the outpatient facility and patients who are found to have a communicable disease during the course of treatment at the outpatient facility. 14. The screening for communicable diseases as described in NAC 441A.375 of all employees and of all persons under contract with the outpatient facility who work at the outpatient facility and have exposure to patients at the outpatient facility. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999444 Program required to include policies and procedures for single-dose vials and multidose vials. ( NRS 441A.120 , 449.448 ) 1. Each program for the prevention and control of infections and communicable diseases must include policies and procedures for single-dose vials which provide that a single-dose vial may be accessed only by using an aseptic technique. The policies and procedures must provide that: (a) Each injection of a medication from a single-dose vial must be prepared in a clean, designated area where contamination by blood or bodily fluid is unlikely to occur; (b) The medication in a single-dose vial must not be used for more than one patient; (c) A single-dose vial, including any remaining medication in the vial after its use, must be discarded; and (d) Any remaining medication in a single-dose vial after its use must not be combined with any other medication or otherwise used for any other patients. 2. Each program for the prevention and control of infections and communicable diseases must include policies and procedures for multidose vials which provide that a multidose vial may be accessed only by using an aseptic technique. The policies and procedures must provide that: (a) The cap of a multidose vial must be cleaned with an alcohol-based wipe before the vial is accessed; (b) A new sterile needle and new sterile syringe must be used each time to access a multidose vial; (c) Upon first access of a multidose vial, the person who accessed the vial shall date and initial the vial; (d) Each injection of a medication from a multidose vial must be prepared in a clean, designated area where contamination by blood or bodily fluid is unlikely to occur; (e) A needle must not be left inserted in the cap of a multidose vial after its use; and (f) A multidose vial must be discarded when the medication in the vial has expired or 28 days after the vial was initially accessed. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999445 Sterilization and disinfection of surgical instruments, items and equipment; training required for employees and contractors responsible for sterilization or disinfection. ( NRS 441A.120 , 449.448 ) 1. All surgical instruments, items or equipment used in the care of patients at an outpatient facility must be sterilized or disinfected according to the program for the prevention and control of infections and communicable diseases adopted by the outpatient facility pursuant to NAC 449.999442 . 2. If such instruments, items and equipment are sterilized or disinfected by equipment or cleaning agents at the outpatient facility: (a) Before an employee or independent contractor may be assigned the responsibility for sterilizing or disinfecting any instrument, item or equipment, the employee or independent contractor must receive training concerning the instructions of the manufacturer of the device or sterilizer for: (1) Sterilizing and disinfecting the instrument, item or equipment; (2) The use and maintenance of the sterilizer or disinfecting equipment; and (3) The agents used to sterilize and disinfect the instrument, item or equipment. (b) An employee or independent contractor assigned the responsibility for sterilizing or disinfecting the instrument, item or equipment shall: (1) Receive annual training concerning the manufacturer’s instructions described in paragraph (a); and (2) Receive training on any new equipment or procedures if there is any change in the equipment or procedures used to sterilize or disinfect an instrument, item or equipment. (c) The outpatient facility shall ensure that documentation of all training completed pursuant to this subsection is kept in the file of the employee or independent contractor. 3. The manufacturer’s instructions for operating any sterilizer or performing any disinfection procedure must be located or posted near the equipment used for sterilization or disinfection. 4. The outpatient facility shall ensure that each employee or independent contractor follows the manufacturer’s instructions concerning: (a) The instruments, items or equipment that may be sterilized or disinfected; (b) The procedures for cleaning an instrument, item or equipment before the instrument, item or equipment is sterilized or undergoes high-level disinfection; (c) The procedures for sterilizing or disinfecting an instrument, item or equipment; (d) The operation and maintenance of the sterilizer or the equipment used for high-level disinfection; (e) The frequency and type of biologic indicator testing of the sterilizer; (f) The recommended agents for sterilizing and disinfecting the instrument, item or equipment; and (g) The frequency of testing of any solution for disinfecting to ensure maintenance of the minimum level of effectiveness, but the solution must be tested not less often than daily. 5. The effectiveness of the sterilization procedures must be checked by performing a biologic indicator test: (a) At least weekly, or more frequently if recommended by the manufacturer; and (b) While sterilizing all implantable devices. 6. Sterilization records and logs of the results of the biologic indicator test must be maintained by the outpatient facility for at least 1 year after the test is performed to ensure that the recommended testing and maintenance of the equipment is performed and the manufacturer’s instructions regarding proper sterilization techniques are followed. Each outpatient facility shall establish a method to track and recall instruments, items or equipment previously sterilized or disinfected if there is a failure of the biologic indicator test. 7. To aid in environmental control, each outpatient facility shall provide a physical barrier between the decontamination and sterilization areas of the outpatient facility. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999446 Outpatient facility required to designate employee or enter into contract for overseeing and managing program; qualifications and duties of employee or contractor. ( NRS 441A.120 , 449.448 ) 1. Each outpatient facility shall designate an employee or enter into a contract with a person to oversee and manage all aspects of the program for the prevention and control of infections and communicable diseases. 2. The person described in subsection 1: (a) Must have completed specialized training in the prevention and control of the development and transmission of infections and communicable diseases; and (b) Shall ensure that the program for the prevention and control of infections and communicable diseases for the outpatient facility: (1) Complies with all applicable federal, state and local laws; (2) Is consistent with the guidelines adopted by the holder of the permit pursuant to NAC 449.999441 ; and (3) Is reviewed with all employees of the outpatient facility and all persons under contract with the outpatient facility who work at the facility and have exposure to patients at the facility within the first 10 days of employment and every 12 months thereafter, or more often if required pursuant to subsection 2 of NAC 449.999447 . (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999447 Mandatory training and evaluation of employees and other persons. ( NRS 441A.120 , 449.448 ) 1. Each employee of an outpatient facility and each person under contract with an outpatient facility who works at the facility and has exposure to patients at the facility shall receive training and must be evaluated by supervising staff on the employee’s or contractor’s knowledge and skills concerning the program for the prevention and control of infections and communicable diseases within the first 10 days of employment and at least every 12 months thereafter. 2. An employee or person under contract with the outpatient facility may be required to receive the training and evaluation described in subsection 1 more often than every 12 months if a supervisor determines that such training and evaluations are necessary to ensure that the employee or contractor understands and will follow the policies and procedures of the program for the prevention and control of infections and communicable diseases. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999448 Establishment of additional policies and guidelines by holder of permit to ensure health and safety of patients; professional standards of practice; requirement of tuberculosis test for employees and persons under contract with outpatient facility. ( NRS 441A.120 , 449.448 ) In addition to the guidelines established pursuant to NAC 449.999441 , the holder of a permit to operate an outpatient facility shall establish guidelines and maintain policies for the outpatient facility which: 1. Ensure the health, safety and well-being of patients of the outpatient facility; 2. Provide the professional standards of practice for services provided by the outpatient facility and ensure that all persons employed by the outpatient facility or under contract with the outpatient facility comply with such professional standards; and 3. Require each person employed by the outpatient facility or under contract with the outpatient facility to have a skin test for tuberculosis in accordance with NAC 441A.375 . (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) Administrative Sanctions NAC 449.99945 Definitions. ( NRS 449.447 , 449.448 ) As used in NAC 449.99945 to 449.999489 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.999451 to 449.999457 , inclusive, have the meanings ascribed to them in those sections. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999451 “Cluster” defined. ( NRS 449.447 , 449.448 ) “Cluster” means a deficiency that involves the same or similar kinds of care, treatment or services as one or more other deficiencies. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999452 “De minimis deficiency” defined. ( NRS 449.447 , 449.448 ) “De minimis deficiency” means a deficiency rated at a severity level of one or two and at a scope level of one or two. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999453 “Deficiency” defined. ( NRS 449.447 , 449.448 ) 1. “Deficiency” means noncompliance with any state statute or regulation of the Board. The term includes an incident concerning an outpatient facility where there are no extenuating circumstances or where the facility has made an inappropriate response to a complaint, including the failure to: (a) Prevent an incident from occurring, if the incident could have been avoided; (b) Identify an incident; (c) Take action to correct an incident before the identification of the incident by the Bureau; or (d) Implement a contingency plan if permanent action to correct an incident has not been undertaken. 2. In determining whether an incident is a deficiency, the right of the patient to refuse treatment, when applicable, shall be deemed an extenuating circumstance. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999454 “Immediate and serious threat” and “immediate jeopardy” defined. ( NRS 449.447 , 449.448 ) “Immediate and serious threat” or “immediate jeopardy” means a situation in which corrective action within 48 hours is necessary because the failure by an outpatient facility to comply with a requirement of statute or regulation has caused, or if uncorrected is likely to cause, serious injury or harm, or even death, to a patient. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999455 “Incident” defined. ( NRS 449.447 , 449.448 ) “Incident” means an action, practice or situation that appears to be inconsistent with a state statute or regulation of the Board. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999456 “Initial deficiency” defined. ( NRS 449.447 , 449.448 ) “Initial deficiency” means the first occurrence of a deficiency recorded by the Bureau, including, without limitation, any deficiency found during a standard inspection, during an extended inspection or in response to a complaint. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999457 “Severity and scope score” defined. ( NRS 449.447 , 449.448 ) “Severity and scope score” means the sum of the numerical levels of severity and scope assigned to a deficiency. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999458 Purpose of sanctions. ( NRS 449.447 , 449.448 ) The purposes of administrative sanctions are to: 1. Safeguard the rights, interests and well-being of patients, including the protection of patients from actual or potential harm resulting from deficiencies; and 2. Encourage and assist outpatient facilities to comply with the requirements of the Division. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999459 Grounds for denial, suspension or revocation of permit. ( NRS 449.447 , 449.448 ) In accordance with NRS 449.447 , the Division may deny an application for a permit or may suspend or revoke a permit upon any of the following grounds: 1. Offering to a patient a service of general anesthesia, conscious sedation or deep sedation without a permit, if a permit is required pursuant to NRS 449.435 to NRS 449.448 , inclusive, and NAC 449.99942 . 2. The failure or refusal of the holder of a permit to return an adequate plan of correction to the Division within 10 days after the receipt of a statement of deficiencies compiled pursuant to NRS 449.446 . 3. The failure or refusal of the entity to whom a permit has been issued to comply with a directed plan of correction issued by the Bureau. 4. The failure or refusal to cooperate fully with an investigation or inspection by the Bureau. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.99946 Appeal of denial, suspension or revocation of permit or other sanction. ( NRS 449.447 , 449.448 ) An applicant or holder of a permit who is aggrieved by an action of the Division relating to the denial, suspension or revocation of a permit or any other sanction assessed pursuant to NAC 449.99945 to 449.999489 , inclusive, may appeal pursuant to the procedures set forth in NAC 439.300 to 439.395 , inclusive. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999461 Imposition of sanctions: Authority of Division and Bureau. ( NRS 449.447 , 449.448 ) Administrative sanctions authorized by NRS 449.447 may be imposed by the Division through the Bureau. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999462 Imposition of sanctions: Requirement for imposition; optional imposition; multiple sanctions; use of severity and scope factors for particular sanction. ( NRS 449.447 , 449.448 ) 1. The Bureau shall impose at least one sanction listed in NRS 449.447 upon an outpatient facility that has a deficiency with a severity level of four or a combined severity and scope score of six or more. 2. More than one sanction may be imposed at the discretion of the Bureau. 3. The Bureau may impose sanctions if deficiencies of a severity level of three or less or a combined severity and scope score of less than six are identified. 4. If the Bureau chooses to impose a particular sanction, it must be applied according to the severity and scope factors established in NAC 449.999465 to 449.999468 , inclusive. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999463 Imposition of sanctions in emergencies: Notice; authority; exception to notice requirement. ( NRS 449.447 , 449.448 ) 1. Except as otherwise provided in this section, the Bureau shall give notice pursuant to the provisions of NAC 439.300 to 439.395 , inclusive, before taking disciplinary action against an outpatient facility. 2. If necessary to protect the public health and safety, the Bureau may impose such sanctions as are necessary without notice to the outpatient facility or by oral notice to the outpatient facility. 3. If there is an immediate and serious threat to the health and safety of patients served by an outpatient facility, the provisions concerning notice contained in this section govern. 4. The Bureau may suspend the permit of an outpatient facility without notice or upon oral notice if the Bureau finds that an emergency has caused a deficiency with a severity and scope score of five or more which places one or more patients in immediate jeopardy. For purposes of this subsection, “emergency” means any situation in which an outpatient facility is unable to operate in a safe manner, including, without limitation, due to a fire, flood, contagious infection, loss of utilities or inappropriate transfer of patients. 5. In any case where sanctions are imposed without written notice, the Bureau shall provide written notice that complies with the requirements of NAC 439.345 within 48 hours after the imposition of the sanctions. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999464 Deficiencies: Basis for imposition of sanctions; reporting; presumption of de minimis deficiency. ( NRS 449.447 , 449.448 ) 1. The Bureau may apply one or more sanctions on the basis of deficiencies found during inspections or investigations of complaints conducted by the Bureau. 2. Deficiencies must be reported to the outpatient facility by the Bureau. The notice to the outpatient facility must specify the deficiencies found and the severity and scope score for each deficiency determined by the Bureau. 3. Any deficiency for which a severity and scope score is not specified is presumed to be a de minimis deficiency. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999465 Scope of violations: Evaluation of representative sample of recipients; sample size. ( NRS 449.447 , 449.448 ) 1. In determining the scope of a violation, an inspection of an outpatient facility must evaluate a representative sample of patients as provided in this section. Unless a sample of a different size is required for the inspection by federal law, the sample must consist of at least the following size: Number of patients offered a service of general anesthesia, conscious sedation or deep sedation Minimum number of such patients in sample 1 - 9.......................................................................................... All patients 10 - 40...................................................................................... 10 41 - 75...................................................................................... 15 76 - 100.................................................................................... 20 101 - 175.................................................................................. 25 176 - 250.................................................................................. 30 251 - 350.................................................................................. 35 351 - 450.................................................................................. 40 451 or more............................................................................. 50 2. The sample size used in identifying the scope of a deficiency in a subsequent inspection conducted to evaluate compliance with a plan of correction must not be less than 60 percent of the sample size used in the initial inspection. 3. In determining the scope of a violation involving particular kinds of care, treatment or services, the inspection must evaluate a representative sample of patients receiving or requiring the particular kinds of care, treatment or services. Unless a sample of a different size is required for the inspection by federal law, the sample must consist of at least the following size: Number of patients needing or receiving a particular kind of care, treatment or services Minimum number of such patients in sample 1 - 9....................................................................................... All patients 10 - 40................................................................................... 10 41 - 75................................................................................... 15 76 - 100................................................................................. 20 101 - 175............................................................................... 25 176 - 250............................................................................... 30 251 - 350............................................................................... 35 351 - 450............................................................................... 40 451 or more........................................................................... 50 4. The Bureau may review more than the minimum number of patients. If it does so, the determination of scope must be based on the number of patients actually reviewed. 5. If the Bureau investigates a complaint relating to a patient, the Bureau may sample only that patient. The scope of any deficiency cited pursuant to this subsection must be scope level one. 6. As used in this section, “patient” means a person who was offered a service of general anesthesia, conscious sedation or deep sedation at the outpatient facility within the 30 days immediately preceding the date the Bureau inspects the outpatient facility. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999466 Scope of deficiencies: Use of scope scale; basis for assessment. ( NRS 449.447 , 449.448 ) 1. The scope scale must be used to assess the scope of a particular deficiency in or by the outpatient facility. 2. The basis for the assessment is the actual or potential harm to patients as shown by: (a) The frequency of the deficiency; (b) The number or percentage of patients affected; (c) The number or percentage of staff involved; and (d) The pattern or lack of pattern of the deficiencies. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999467 Scope of deficiencies: Criteria for evaluation. ( NRS 449.447 , 449.448 ) 1. The scope of the deficiencies must be evaluated using the criteria prescribed in this section. 2. A deficiency of scope level one consists of one or an isolated number of unrelated incidents. A deficiency is of this scope if it involves 20 percent or less of the patients sampled in an outpatient facility. 3. A deficiency is scope level two if the Bureau identifies a pattern of incidents at the outpatient facility, including any deficiencies involving patients who require particular kinds of care, treatment or service. The number or percentage of patients or staff involved in the incidents or the repeated occurrences of incidents in short succession may also establish a pattern by indicating a reasonable degree of predictability of similar incidents. A deficiency is also of this scope if it involves more than 20 percent but not more than 50 percent of the patients sampled in an outpatient facility. 4. A deficiency is of scope level three if it occurs in a sufficient number or percentage of patients or staff or with sufficient regularity over time that it may be considered systemic or pervasive in or by the outpatient facility. A deficiency is also of this scope if it involves more than 50 percent of the patients sampled in an outpatient facility. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999468 Severity of deficiencies: Use of severity scale; basis for assessment; criteria for evaluation. ( NRS 449.447 , 449.448 ) 1. The severity scale must be used to assess the severity of a particular deficiency pertaining to the outpatient facility. The basis for the assessment must be the actual or potential harm to patients. 2. Deficiencies of severity level one concern requirements promulgated primarily for administrative purposes. No harm is likely to occur to a patient. No negative patient impact has occurred or is likely to occur. The ability of a patient to achieve the highest practicable physical, mental or psychosocial well-being has not been and is not likely to be compromised. 3. Deficiencies of severity level two indirectly threaten the health, safety, rights, security, welfare or well-being of a patient. A potential for harm, as yet unrealized, exists. If continued over time, a negative impact on one or more patients or a violation of one or more patients’ rights would occur or would be likely to occur or the ability of one or more patients to achieve the highest practicable physical, mental or psychosocial well-being would be, or would likely be, compromised. 4. Deficiencies of severity level three create a condition or incident in the operation or maintenance of an outpatient facility that directly or indirectly threatens the health, safety, rights, security, welfare or well-being of one or more patients. A negative impact on the health, safety, rights, security, welfare or well-being of one or more patients has occurred or can be predicted with substantial probability to occur, or the ability of patients to achieve the highest practicable physical, mental or psychosocial well-being has been or is about to be compromised and requires intervention and correction of the deficiency. Failure to implement a directed plan of correction is presumed to be a deficiency of this level of severity. 5. Deficiencies of severity level four create a condition or incident that has resulted in or can be predicted with substantial probability to result in death or serious harm to a patient. As used in this subsection, “serious harm” includes serious mental harm, serious impairment of bodily functions, serious dysfunction of any bodily organ or part, life-threatening harm or death. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999469 Presumption when same deficiency found on subsequent inspection; imposition of sanction for subsequent deficiency. ( NRS 449.447 , 449.448 ) If the same deficiency is found during a subsequent inspection conducted to evaluate compliance with a plan of correction, there is a rebuttable presumption that the deficiency continued through the period between the inspection and the subsequent inspection. A sanction may be imposed for a subsequent deficiency only if the subsequent inspection is made and the deficiency is again actually found to be present. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.99947 Available sanctions. ( NRS 449.447 , 449.448 ) The sanctions available for all outpatient facilities include: 1. The assessment of monetary penalties; and 2. The denial, suspension or revocation of the permit for the outpatient facility. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999471 Determination of appropriate sanction: Procedure. ( NRS 449.447 , 449.448 ) To determine the appropriate sanction, the Bureau shall follow the procedures set forth in NAC 449.99945 to 449.999489 , inclusive. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999472 Determination of appropriate sanction: Initial assessment. ( NRS 449.447 , 449.448 ) The Bureau shall initially assess individual deficiencies or clusters of deficiencies according to the following initial factors: 1. The presence or absence of an immediate and serious threat to the health and safety of patients; 2. The severity of the deficiency; and 3. The scope of the deficiency. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999473 Determination of appropriate sanction: Consideration of secondary factors. ( NRS 449.447 , 449.448 ) After the initial assessment, the Bureau shall consider the following secondary factors in determining the sanction to impose: 1. The relationship of one deficiency or cluster or pattern of deficiencies to other deficiencies; 2. The history of previous compliance by the outpatient facility generally and specifically with reference to the deficiencies in issue; 3. Whether the deficiencies are directly related to the care, services or treatment received by patients who were offered a service of general anesthesia, conscious sedation or deep sedation by the outpatient facility; and 4. The corrective and long-term compliance outcomes desired. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999474 Determination of appropriate sanction: Basis for selection; presumption for monetary penalties. ( NRS 449.447 , 449.448 ) 1. The selection of a sanction must be based upon the nature of the deficiencies or cluster of deficiencies and the sanction most likely to correct those deficiencies. 2. Absent evidence to the contrary, monetary penalties are presumed to be the most effective sanctions for deficiencies that do not cause an immediate and serious threat to patients. 3. The Bureau may impose a monetary penalty alone or in addition to other penalties. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999475 Plan of correction: Development and submission of plan; authority of Bureau when plan is not acceptable; effect of failure to submit plan. ( NRS 449.447 , 449.448 ) 1. The outpatient facility shall develop a plan of correction for each deficiency and submit the plan to the Bureau for approval within 10 days after receipt of the statement of deficiencies compiled by the Division pursuant to NRS 449.446 . The plan of correction must include specific requirements for corrective action, which must include times within which the deficiencies are to be corrected. 2. If the plan is not acceptable to the Bureau, the Bureau may: (a) Direct the outpatient facility to resubmit a plan of correction; (b) Develop a directed plan of correction with which the outpatient facility must comply; or (c) Revoke the outpatient facility’s permit. 3. Failure to submit the plan of correction to the Bureau within 10 days after receipt of the statement of deficiencies constitutes a separate deficiency subject to monetary penalties with severity and scope rated at the same levels as the highest deficiency identified on the notice of deficiencies. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999476 Monetary penalties: Criteria for imposition; imposition of initial and daily penalties; exception for de minimis deficiency. ( NRS 449.447 , 449.448 ) 1. Except as otherwise provided in subsection 4, the Bureau may impose a monetary penalty including interest thereon on any outpatient facility that is not in compliance with a requirement of NRS 449.435 to 449.448 , inclusive, and NAC 449.9994 to 449.999489 , inclusive, regardless of whether the deficiency constitutes an immediate and serious threat. 2. If a monetary penalty is imposed, the initial amount of the penalty must be based on the severity and scope score of the deficiency and must be imposed as provided in NAC 449.999479 . 3. In addition to the initial monetary penalty, the Bureau may impose a monetary penalty for each day of noncompliance from the date the noncompliance occurs or is identified until compliance is verified. 4. An outpatient facility is not subject to a monetary penalty for a de minimis deficiency. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999477 Monetary penalties: Imposition of initial penalty pending hearing or appeal; stay of payment of penalties pending appeal. ( NRS 449.447 , 449.448 ) 1. The Bureau shall impose an initial monetary penalty pending a hearing or appeal. The payment of the initial penalty must not be stayed during the pendency of any administrative appeal. 2. The payment of any daily monetary penalties or interest that accrues while the outpatient facility has a hearing pending on the initial determination of deficiencies leading to the imposition of sanctions must be stayed pending the appeal. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999478 Monetary penalties: Procedure for imposition; interest on total penalty assessed. ( NRS 449.447 , 449.448 ) 1. If the Bureau imposes a monetary penalty, the penalty must be imposed as provided in NAC 449.999478 to 449.999482 , inclusive. 2. In imposing the monetary penalty, the total penalty assessed against any facility bears interest at the rate of 10 percent per annum on the unpaid balance of the penalty, beginning on the due date. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999479 Monetary penalties: Determination of amount of penalties. ( NRS 449.447 , 449.448 ) 1. In determining the amount of an initial monetary penalty, the Bureau shall consider the severity alone if the severity level is four. In determining the amount of the monetary penalty where the severity level is less than four, both severity and scope must be considered. In determining whether to impose a daily monetary penalty, the Bureau shall consider the severity and scope and the factors indicated for increased and decreased penalties provided in NAC 449.99948 and 449.999482 . 2. For initial deficiencies with a severity level of four, an initial monetary penalty of $1,000 per deficiency must be imposed. 3. For initial deficiencies rated with a severity level of three and a scope level of three, a monetary penalty of $800 per deficiency must be imposed. 4. For initial deficiencies with a severity level of three and a scope level of two or less, an initial monetary penalty of $400 per deficiency must be imposed. 5. For initial deficiencies with a severity level of two and a scope level of three, an initial monetary penalty of $200 per deficiency may be imposed. The payment of this monetary penalty must be suspended if the outpatient facility has corrected the deficiencies within the time specified in the plan of correction approved by the Bureau. 6. In addition to any monetary penalty imposed pursuant to this section, the Bureau may impose a monetary penalty of not more than $1,000 per deficiency per day for each day the deficiency continues. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.99948 Monetary penalties: Increase in penalty for repeated deficiencies or falsely alleged compliance. ( NRS 449.447 , 449.448 ) 1. Penalties must be increased for repeated deficiencies or if compliance is falsely alleged. 2. For each repeat deficiency present within 18 months after an initial deficiency, the monetary penalty must be computed at the rate of one and one-half times the rate that was or could have been assessed initially for a deficiency of that severity and scope, not to exceed $1,000 per deficiency per day. 3. The Bureau may double the daily monetary penalty, not to exceed $1,000 per deficiency per day, that was or could have been assessed if the outpatient facility alleges compliance and the Bureau finds during an inspection that, at the time compliance was alleged, the deficiencies continued to exist. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999481 Monetary penalties: Presumption regarding deficiencies identified on subsequent inspection. ( NRS 449.447 , 449.448 ) There is a rebuttable presumption that deficiencies identified on a subsequent inspection conducted to evaluate compliance with a plan of correction were present on each day between the date of the initial deficiency and the date the subsequent deficiency was found in the subsequent inspection. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999482 Monetary penalties: Reduction of penalty. ( NRS 449.447 , 449.448 ) If an outpatient facility against which a monetary penalty is imposed: 1. Waives the right to a hearing; 2. Corrects the deficiencies that were the basis for the sanction; and 3. Pays the monetary penalty within 15 days after receipt of the notice of the penalty, Ê the penalty must be reduced by 25 percent, and no interest may be charged. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999483 Monetary penalties: Effective beginning date. ( NRS 449.447 , 449.448 ) The effective beginning date of a daily monetary penalty is: 1. In the case of an immediate and serious threat, the date the deficiency occurred; or 2. In any other case, the day the deficiency is identified. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999484 Monetary penalties: Date and period of computation; notice to outpatient facility. ( NRS 449.447 , 449.448 ) 1. Daily penalties and interest must be computed after compliance has been verified or the outpatient facility has been sent notice of termination of a permit. A daily monetary penalty must end on the effective date of compliance or termination of the permit of the outpatient facility. 2. If an outpatient facility achieves compliance, the Bureau shall send a separate notice to the outpatient facility containing: (a) The amount of the penalty per day; (b) The number of days involved; (c) The due date of the penalty; and (d) The total amount due. 3. If the permit of an outpatient facility is to be terminated, the Bureau shall send the information required by subsection 2 in the notice of termination. 4. If the Bureau’s decision of noncompliance is upheld on appeal or the outpatient facility waives its right to a hearing, the monetary penalty must be imposed for the number of days between the effective date of the penalty and the date of correction of the deficiencies or, if applicable, the date the permit of the outpatient facility is terminated. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999485 Monetary penalties: Termination of daily penalties. ( NRS 449.447 , 449.448 ) 1. The daily accrual of a monetary penalty must end if the outpatient facility demonstrates that deficiencies have been corrected and that the health, safety and well-being of patients are adequately protected and safeguarded. 2. A monetary penalty may be imposed on a daily basis for not longer than 6 months, after which the Bureau shall deny, suspend or revoke the permit of the outpatient facility. 3. If the outpatient facility can supply credible evidence that substantial compliance with requirements was attained on a date preceding that of the inspection, monetary penalties accrue only until that date of correction for which there is credible evidence. As used in this subsection, “credible evidence” means actual documentation that compliance has been achieved. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999486 Monetary penalties: Time for payment. ( NRS 449.447 , 449.448 ) 1. Initial monetary penalty assessment payments are due within 15 days after the notice of the penalty and must be paid irrespective of any administrative appeal. 2. The daily monetary penalty is due and must be paid within 15 days after compliance is verified or termination of a permit is effective and the outpatient facility is notified of the amount of the total daily monetary penalty and interest due. 3. If the outpatient facility has appealed a decision imposing a monetary penalty, the daily penalty is due and must be paid after the final administrative decision is rendered and 15 days after the outpatient facility has been notified of the amount of the total daily penalty and interest due. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999487 Recovery of expenses incurred by Bureau or Division for implementing and enforcing administrative penalties, bringing actions for enforcement and collecting monetary penalties. ( NRS 449.447 , 449.448 ) Any expenses incurred by the Bureau or the Division in implementing and enforcing administrative sanctions, bringing an action in a course of competent jurisdiction for enforcement or collecting any monetary penalty may be recovered from the outpatient facility, including, without limitation, attorney’s fees, filing fees, fees for service of notices or process and all expenses of litigation recoverable as costs pursuant to chapter 18 of NRS. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999488 Failure to pay monetary penalty: Suspension of permit. ( NRS 449.447 , 449.448 ) 1. If the outpatient facility fails to pay a monetary penalty, the Division may suspend the permit of the outpatient facility. 2. The Division shall, in accordance with the requirements of NAC 439.345 , provide notice of its intention to suspend the permit of the outpatient facility. 3. If the outpatient facility fails to pay the monetary penalty, including any expenses set forth in NAC 449.999487 , in collection of the penalty, within 10 days after receipt of the notice, the Division shall suspend the permit of the outpatient facility. The suspension must not be stayed during the pendency of any administrative appeal. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) NAC 449.999489 Disposition of money collected. ( NRS 449.447 , 449.448 ) Money collected by the Division as administrative sanctions must be deposited into a separate fund and applied to the protection of the health, safety, rights, welfare and well-being of patients. (Added to NAC by Bd. of Health by R179-09, eff. 7-22-2010) STAR RATINGS OF CERTAIN HEALTH CARE FACILITIES NAC 449.99984 Definitions. ( NRS 449.2425 ) As used in NAC 449.99984 to 449.999848 , inclusive, unless the context otherwise requires, the words and terms defined in NAC 449.999842 and 449.999844 have the meanings ascribed to them in those sections. (Added to NAC by Div. of Pub. & Behavioral Health by R156-18, eff. 1-30-2019) NAC 449.999842 “Deficiency” defined. ( NRS 449.2425 ) “Deficiency” means a violation of NRS 449.241 to 449.2428 , inclusive, as determined by the Division pursuant to an inspection conducted pursuant to NRS 449.132 or an investigation conducted pursuant to NRS 449.0307 . (Added to NAC by Div. of Pub. & Behavioral Health by R156-18, eff. 1-30-2019) NAC 449.999844 “Facility” defined. ( NRS 449.2425 ) “Facility” means a health care facility located in a county whose population is 100,000 or more and which is licensed to have more than 70 beds. (Added to NAC by Div. of Pub. & Behavioral Health by R156-18, eff. 1-30-2019) NAC 449.999845 “Unit” defined. ( NRS 449.0302 , 449.2418 ) As used in NRS 449.241 to 449.2428 , inclusive, unless the context otherwise requires, “unit” means a component of a health care facility for providing patient care that is defined by the scope of health care service provided. The term includes, without limitation, a group, department, section or wing of a hospital. (Added to NAC by Div. of Pub. & Behavioral Health by R039-20, eff. 4-14-2021) NAC 449.999846 Criteria for assignment of ratings; issuance of placard with rating. ( NRS 449.2425 ) After each inspection or investigation described in paragraph (a) of subsection 1 of NRS 449.2425 , the Division will: 1. Assign to the facility that was inspected or investigated a rating of: (a) Five stars if the Division determined from the inspection or investigation that the facility has no deficiencies. (b) Four stars if the Division determined from the inspection or investigation that the facility has at least one deficiency designated as severity level one and no deficiencies designated as severity level two, three or four pursuant to NAC 449.99861 . (c) Three stars if the Division determined from the inspection or investigation that the facility has at least one deficiency designated as severity level two and no deficiencies designated as severity level three or four pursuant to NAC 449.99861 . (d) Two stars if the Division determined from the inspection or investigation that the facility has at least one deficiency designated as severity level three and no deficiencies designated as severity level four pursuant to NAC 449.99861 . (e) One star if the Division determined from the inspection or investigation that the facility has at least one deficiency designated as severity level four pursuant to NAC 449.99861 . 2. Issue to the facility that was inspected or investigated a placard that: (a) States the name of the facility and the star rating assigned to the facility pursuant to subsection 1; (b) Is not less than 8.5 inches in height and 11 inches in width, with margins not greater than 1 inch on any side; (c) Is written using a single typeface in not less than 20-point type; and (d) Is titled “Nevada Division of Public and Behavioral Health - Requirements Relating to Staffing based on NRS 449.241 to 449.2428 , inclusive - Star Rating.” (Added to NAC by Div. of Pub. & Behavioral Health by R156-18, eff. 1-30-2019) NAC 449.999848 Follow-up inspections and appeals. ( NRS 449.2425 ) 1. A facility may request a follow-up inspection or an appeal within 30 days after an investigation or inspection described in paragraph (a) of subsection 1 of NRS 449.2425 by submitting, in the form prescribed by the Division, a request for a follow-up inspection or appeal, as applicable. 2. A request for an appeal made pursuant to subsection 1 must: (a) Specify each finding of a violation to be appealed, as identified by the number ascribed to the violation by the Division in the statement of deficiencies provided to the facility; (b) State the reasons that the facility is disputing the finding of a violation; (c) Include any evidence to support reversing the finding of the Division; and (d) Be submitted separately from the plan of correction submitted to the Bureau pursuant to NAC 449.9987 . 3. A facility shall not request a follow-up inspection or an appeal pursuant to this section for the purpose of delaying the imposition or effective date of an administrative sanction pursuant to NAC 449.9982 to 449.99939 , inclusive. 4. Not later than 30 days after receiving: (a) A request for an appeal pursuant to subsection 1 that meets the requirements of subsection 2, the Division will notify the facility that submitted the request of the determination of the Division concerning the appeal. (b) A request for a follow-up inspection pursuant to subsection 1, the Division will complete a follow-up inspection of the facility that submitted the request. 5. A facility aggrieved by a determination of the Division pursuant to paragraph (a) of subsection 4 may appeal that determination to the Administrator of the Division by submitting a request for a final appeal to the Administrator, in the form prescribed by the Division, not later than 30 days after receiving notification of the determination. The determination of the Administrator concerning such an appeal is a final decision for the purpose of judicial review. (Added to NAC by Div. of Pub. & Behavioral Health by R156-18, eff. 1-30-2019)