Ga. R. & Regs. 111-8-56

Nursing Homes

This regulation establishes comprehensive licensing and operating standards for nursing homes in Georgia, covering governance, administration, nursing services, professional staffing, dietary and social services, pharmacy management, physical therapy, medical and dental care, recordkeeping, equipment, safety, sanitation, employee health, recreation, patient capacity, and physical plant requirements. Nursing home operators must maintain continuous medical supervision, adequate nursing staff ratios, and comply with all applicable state and federal laws. Facilities must hold a valid permit from the Georgia Department of Community Health and carry required liability insurance. These rules do not apply to nursing homes owned or operated by the Federal Government.

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Chapter 111-8

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Subject 111-8-56 NURSING HOMES

Rule 111-8-56-.01 Definitions

Unless a different meaning is required by the context, the
 following terms as used in these rules and regulations shall have the meaning
 hereafter respectively ascribed to them; except, however, same do not apply to
 nursing homes owned or operated by the Federal Government:

(a)

 "Nursing Home" is a facility which admits
 patients on medical referral only and for whom arrangements have been made for
 continuous medical supervision; it maintains the services and facilities for
 skilled nursing care, rehabilitative nursing care, and has a satisfactory
 agreement with a physician and dentist who will be available for any medical
 and/or dental emergency and who will be responsible for the general medical and
 dental supervision of the home; it otherwise complies with these rules and
 regulations;

(b)

 "Skilled Nursing
 Care" means the application of recognized nursing methods, procedures, and
 actions directed toward implementation of the physician's prescribed
 therapeutic and diagnostic plan, detection of changes in the human body's
 regulatory system, preservation of such body defenses, prevention of
 complications, and promotion of emotional well-being, including but not limited
 to the following: 

1.

 The administration of
 oral or injectable medications which cannot be self-administered. Other
 examples include the administration of oxygen, the use of suction, the
 insertion or changing of catheters, the application of medicated dressings, the
 use of aseptic technique and preparation of the patient for special
 procedures;

2.

 Observation in the
 care of the patient for symptoms and/or physical and mental signs that may
 develop and which will require attention of the physician and a revision in the
 patient's treatment regimen.

(c)

 "Rehabilitative Nursing" means the use of
 nursing skills and techniques to combat deformities and helplessness, to
 maintain or restore body functions, and to promote independence in self-care.
 Such techniques will include but not be limited to the following: 

1.

 Positioning patients in or out of bed to
 maintain good body alignment (unless contraindicated by physician's orders),
 the use of range of motion exercises to maintain joint mobility;

2.

 Arranging a progression of self-care
 activities such as transfer and walking, and attention to bowel and bladder
 schedules together with retraining when indicated.

(d)

 The term "Distinct Part" means a
 physically identifiable unit of a medical facility such as an entire ward or
 contiguous wards, wing, floor, or building. It consists of all beds and related
 facilities in the unit;

(e)

 The
 term "Nursing Unit" means the number of patient beds assigned to a nurses'
 station;

(f)

 The term "Nurses'
 Station" means a circumscribed location containing communication and recording
 tools and equipment essential for the operation of nursing services;

(g)

 The terms "Patient" and "Resident" mean
 any person residing in and receiving care or treatment in a nursing
 home;

(h)

 The terms "Patient Care
 Plan" or "Plan of Care" mean a personalized daily plan of care indicating what
 care is needed, how it can be best accomplished for each patient, how each
 patient likes things done, what methods and approaches are most successful, and
 what modifications are necessary to ensure best results;

(i)

 The term "Patient Activities Program"
 means a schedule of events which are regularly planned and available for all
 patients, including social and recreational activities involving active
 participation by the patient, entertainment of appropriate frequency and
 character, and opportunities for participation in community activities as
 possible and appropriate;

(j)

 The
 term "Transfer Agreement" means a written contract with other facilities
 providing for transfer of patients between the facilities and for interchange
 of medical and other information when the facility cannot provide the level of
 care needed by the patient;

(k)

 "Physician" shall mean a doctor of medicine and/or a doctor of osteopathy duly
 licensed to practice in this State by the Composite State Board of Medical
 Examiners, under the provision of the Georgia Medical Practice Act, O.C.G.A. § 
43-34-20
et
 seq.
;

(l)

 "Dentist" means
 any person who is licensed to practice in this State under the provisions of
 the Dentists and Dental Hygienists Act;

(m)

 "Pharmacist" shall mean an individual
 licensed to practice pharmacy in accordance with the provisions of O.C.G.A. § 
26-4-1
et
 seq.
;

(n)

 "Physical
 Therapist" shall mean an individual who practices physical therapy, and who is
 registered with the Board of Physical Therapy of the State of Georgia, O.C.G.A.
 § 
43-33-1
et
 seq.
;

(o)

 A "Registered
 Nurse" is a person who holds a current and valid license as a registered nurse
 issued by the State of Georgia;

(p)

 A "Licensed Undergraduate Nurse" is a person who holds a current and valid
 license as a licensed undergraduate nurse issued by the State of
 Georgia;

(q)

 A "Licensed Practical
 Nurse" is a person who holds a current and valid license as a licensed
 practical nurse by the State of Georgia;

(r)

 The term "Full-time Employee" means any
 person employed who normally works forty (40) hours per week in the
 home;

(s)

 The term "Governing Body"
 means the Board of Trustees, the partnership, the corporation, the association,
 the person or group of persons who maintain and control the home and who is
 legally responsible for the operation;

(t)

 The term "Administrator" means an
 individual who is licensed by the Georgia State Board of Nursing Home
 Administrators and who has the necessary authority and responsibility for
 management of the home;

(u)

 "Permit" means authorization by the Department to the Governing Body to operate
 a home and signifies satisfactory compliance with these rules and
 regulations;

(v)

 "Provisional
 Permit" means authorization by the Department to the Governing Body to operate
 a home on a conditional basis for a period not to exceed six months to allow a
 newly established home a reasonable but limited period of time to demonstrate
 operational procedures in satisfactory compliance with these rules and
 regulations; or to allow an existing home a reasonable length of time to comply
 with these rules and regulations, provided said home shall first present a plan
 of improvement acceptable to the Department. Successive Provisional Permits may
 be granted to any home having deficiencies only in exceptional cases, in which
 cases the Governing Body must present a plan of improvement acceptable to the
 Department;

(w)

 The term "Plan of
 Improvement" means a written plan submitted by the Governing Body and
 acceptable to the Department. The plan shall identify the existing
 noncompliance of the institution, the proposed procedures, methods, means and
 period of time to correct the noncompliance;

(x)

 The term "Board" means the Board of
 Community Health of the State of Georgia;

(y)

 The term "Department" means the
 Department of Community Health of the State of Georgia;

(z)

 The term "Commissioner" means the chief
 executive of the Department.

(aa)

 The term "Dining Assistant" means an individual employed or compensated by the
 nursing home, or who is used under an arrangement with another agency or
 organization, to provide assistance with feeding and hydration to residents in
 need of such assistance. Such individual shall not provide other personal care
 or nursing services unless certified as a nurse aide or licensed as a
 registered nurse or practical nurse.

(bb)

 "Certified Medication Aide" is a person
 who is a Georgia certified nurse aide and in good standing with the Department
 who has successfully completed a state-approved medication aide training
 program, successfully passed a written competency examination and has
 demonstrated the requisite clinical skills to serve as a medication aide and
 who is registered on the Georgia Certified Medication Aide Registry.

Rule 111-8-56-.02 Governing Body

(1)

 There shall be a governing body which
 assumes full legal responsibility for the overall conduct of the
 home.

(2)

 The ownership of the home
 shall be fully disclosed to the Department. In the case of corporations,
 partnerships and other bodies created by statute the corporate officers and all
 others owning ten percent or more of the corporate stock or ownership shall be
 made known to the Department.

(3)

 The governing body shall be responsible for compliance with all applicable laws
 and regulations pertaining to the home.

(4)

 The governing body shall certify to the
 Commissioner, the name of the person to whom is delegated the responsibility
 for the management of the home, including the carrying out of rules and
 policies adopted by the governing body. This person shall be known as the
 administrator.

(5)

 The word
 hospital, sanitorium or sanitarium shall not be used in the official title of
 any home permitted under the provisions of these rules and
 regulations.

Rule 111-8-56-.03 Administration

(1)

 Each nursing
 home shall be under the supervision of a licensed nursing home administrator.
 An administrator may serve as the administrator of not more than one facility,
 except that two facilities having common ownership or management located on the
 same premises may be served by a single administrator. Distinct part facilities
 sharing a common roof shall be considered one facility. In exceptional
 circumstances, a waiver may be granted by the Department for a period of six
 months. Existing facilities not currently meeting this requirement would be
 exempt for a period of two years from the effective date of this regulation. If
 an existing facility should undergo a change of administrators during this
 two-year period, such facility would be required to comply with the
 regulations.

(2)

 Each home shall be
 operated in accordance with policies approved by the Department. These policies
 shall include but not be limited to those governing admissions, transfers,
 discharges, physicians' services, nursing services, dietary services,
 restorative services, pharmaceutical services, diagnostic services, social
 services, environmental sanitation services, recreational services and clinical
 records.

(3)

 Each home shall have a
 written transfer agreement in effect with one or more hospitals. Nursing homes
 that are a Distinct Part of a hospital will be considered to meet this
 requirement if acceptable provisions for the transfer of patients are included
 in the facility's policies.

(4)

 There shall be a separate personnel folder maintained for each employee. This
 folder shall contain all personal information concerning the employee,
 including the application and qualifications for employment, physical
 examination and job title assigned. A current job description shall be
 available for each classification of employee, but may be maintained separately
 from the personnel folder. The nursing home shall also maintain all
 documentation of successful completion of the entire certified medication aide
 training program for each certified medication aide it employs. In addition to
 all other documents required by state or federal regulations, the nursing home
 shall maintain documentation of successful completion of the dining assistant
 training program for each dining assistant.

(5)

 The home and its premises shall be used
 only for the purposes for which the home is operated and permitted.

(6)

 Each home shall, as a condition precedent
 to obtaining or maintaining a permit to operate a nursing home, carry or be
 covered by liability insurance coverages or establish or have established for
 its benefit a self-insurance trust for a nursing home claim. If a home fails to
 carry or be covered by liability insurance coverages or establish or have
 established for its benefit a self-insurance trust for a nursing home claim,
 the Department shall provide notice to such home of its noncompliance and allow
 such home 60 days in which to comply. A home's failure to maintain such
 coverage or establish such trust shall result in the Department: 

(a)

 Revoking such home's permit issued to
 operate the nursing home;

(b)

 Denying any application to renew such permit; and

(c)

 Denying any application for a change of
 ownership of the nursing home.

(7)

 In response to a reasonable request by a
 patient or visitor, privacy shall be afforded for conversation and/or
 consultations.

Rule 111-8-56-.04 Nursing Services

(1)

 A registered nurse shall be employed full
 time as director of nursing services. She shall not also be the
 administrator.

(2)

 The director of
 nursing services shall normally be employed on the daytime shift and shall
 devote full time to the administration of the nursing service which includes a
 reasonable amount of time with all nursing shifts.

(3)

 The director of nursing services may also
 serve as the director of nursing services in another facility in close
 proximity to the home provided she has a registered nurse assistant who is
 assigned to each facility full time as supervisor of nursing care. The
 director's assistant shall devote full time to the supervision of nursing
 care.

(4)

 There shall be at least
 one nurse, registered, licensed undergraduate, licensed on duty and in charge
 of all nursing activities during each eight-hour shift.

(5)

 A nursing home may employ certified
 medication aides for the purpose of performing the technical aspects of the
 administration of certain medications in accordance with O.C.G.A. § 
31-7-12.7
. A nursing home shall
 not employ an individual as a certified medication aide unless such individual
 is listed in the medication aide registry established and maintained by the
 Department pursuant to paragraph (2) of subsection (g) of O.C.G.A § 
31-7-12.2
, and is in good standing
 with the Department, and has met all of the qualifications in paragraph (3) of
 subsection (g) of O.C.G.A § 
31-7-12.2
. 

(a)

 A certified medication aide who meets the
 criteria established in O.C.G.A. § 
31-7-12.7
 shall be permitted to
 perform the following tasks in a nursing home in accordance with the written
 instructions of a physician: 

i.

 Administer
 physician ordered oral, ophthalmic, topical, otic, nasal, vaginal, and rectal
 medications;

ii.

 Administer
 insulin, epinephrine, and B12 pursuant to physician direction and protocol;

iii.

 Administer medications via a
 metered dose inhaler;

iv.

 Conduct
 finger stick blood glucose testing following established protocol;

v.

 Administer a commercially prepared
 disposable enema as ordered by a physician; and

vi.

 Assist residents in the supervision of
 self-administration of medications.

(b)

 A certified medication aide shall record
 in the medication administration record all medications that such certified
 medication aide has personally administered to a resident of a nursing home and
 any refusal of a resident to take a medication. A certified medication aide
 shall observe a resident to whom a medication has been administered and shall
 report any changes in the condition of such resident to a charge
 nurse.

(c)

 All medications
 administered by a certified medication aide in accordance with O.C.G.A. § 
31-7-12.7
 shall be in unit or
 multidose packaging.

(d)

 Nothing in
 this rule or O.C.G.A. § 
31-7-12.7
 shall authorize
 certified medication aides employed by a nursing home to administer any
 Schedule II controlled substance that is a narcotic.

(e)

 A nursing home that employs one or more
 certified medication aides to administer medications in accordance with
 O.C.G.A. § 
31-7-12.7
 shall secure the
 services of a licensed pharmacist to perform the following duties as part of
 the nursing home's peer review, medical review, and quality assurance
 functions: 

(i)

 Perform a quarterly review of
 the drug regimen of each resident of the nursing home and report any
 irregularities to the nursing home administrator;

(ii)

 Remove for proper disposal any drugs
 that are expired, discontinued, in a deteriorated condition, or when the
 resident for whom such drugs were ordered is no longer a resident;

(iii)

 Establish or review policies and
 procedures for safe and effective drug therapy, distribution, use, and control;
 and

(iv)

 Monitor compliance with
 established policies and procedures for medication handling and storage.

(f)

 A nursing home that
 employs one or more certified medication aides to administer medications in
 accordance with this Code section shall ensure that each certified medication
 aide receives ongoing medication training as prescribed by the Department. A
 registered professional nurse or pharmacist shall conduct quarterly unannounced
 medication administration observations and report any issues to the nursing
 home administrator.

(g)

 A nursing
 home that employs certified medication aides the nursing home shall annually
 conduct a comprehensive clinical skills competency review of each certified
 medication aide employed by such nursing home.

(6)

 There shall be sufficient nursing staff
 on duty at all times to provide care for each patient according to his needs. A
 minimum of 2.0 hours of direct nursing care per patient in a 24-hour period
 must be provided. For every seven (7) total nursing personnel required, there
 shall be not less than one registered nurse or licensed practical nurse
 employed. Dining assistants are to be used to supplement, not replace, existing
 nursing staff requirements and as such are not considered nursing staff and are
 not to be included in computing the required minimum hours of direct nursing
 care.

(7)

 The nursing staff shall
 be employed for nursing duties only.

(8)

 There shall be sufficient qualified
 personnel in attendance at all times to ensure properly supervised nursing
 services to the patients, including direct supervision of dining assistants in
 accordance with these rules. This includes staff members dressed, awake and on
 duty all night.

(9)

 All nursing
 care and related services shall be carried out in accordance with the
 facility's patient care policies. The lines of administrative authority and
 supervisory responsibility shall be clearly stated. Duties assigned to staff
 members shall be clearly defined and consistent with their training and
 experience. Policies and procedures governing nursing care shall be assembled,
 available and understood by the staff members and shall be the basis for staff
 education and practice.

(10)

 An
 active in-service nursing education program shall be in effect for all nursing
 personnel. This program shall be developed and conducted by a registered nurse
 who may be employed part-time and under the direction of the director of
 nursing services.

(11)

 The
 in-service nursing educational program shall be in writing and shall show the
 frequency of training. Attendance and progress records shall be kept for each
 person receiving instruction.

Rule 111-8-56-.05 Professional Service

(1)

 There shall be an organized professional
 staff, with one physician designated as chief of staff. The professional staff
 shall consist of at least one physician, one dentist and one registered nurse.
 Other professional personnel such as the dietitian, social worker, physical
 therapist, pharmacist, etc. may be included on the professional staff. This
 organization shall function under appropriate bylaws and shall meet at
 regularly scheduled intervals not less than semiannually. It shall be the
 responsibility of this staff to develop and review care policies and to advise
 administration on matters pertaining to patient care. The minutes of the
 meetings of this staff shall be available for inspection by the
 Department.

(2)

 Patients shall be
 admitted only on referral of a physician.

(3)

 Each patient shall be under the
 continuing care of a physician who sees the patient at least once every thirty
 (30) days following admission. The patient's total program of care (including
 medications and treatment) is reviewed during a visit by the attending
 physician at least once every thirty (30) days for the first ninety (90) days,
 and revised as necessary. A progress note is written and signed by the
 physician at the time of each visit and he signs all his orders. Subsequent to
 the ninetieth day following admission, an alternate schedule for physician
 visits may be adopted where the attending physician determines and so justifies
 in the patient's medical record that the patient's condition does not
 necessitate visits at thirty-day intervals.

(4)

 A home shall admit only those patients
 for which it can provide needed care and only if the home has a permit covering
 that type of care. When a patient develops a condition requiring care of a
 level or type not provided at that home, the administration shall arrange for
 transfer of the patient to another home, hospital or home health agency which
 has a permit or is certified to provide such care or shall make satisfactory
 arrangements for the needed care if the condition is to be of short
 duration.

Rule 111-8-56-.06 Dietary Service

(1)

 Each home shall employ the services of a
 qualified dietitian (American Dietetic Association or equivalent
 qualifications). The services of the dietitian shall not be less than eight (8)
 hours per month.

(2)

 Meals,
 adequate as to quantity and quality, shall be served in sufficient numbers with
 a maximum of five (5) hours apart with no longer than fourteen (14) hours
 between the evening meal and breakfast. Between meal and bedtime snacks shall
 be offered each patient.

(3)

 A
 nutritionally adequate diet shall be provided all patients and adjusted to
 patient's age, sex, activity, and physical condition. Nutrient concentrates and
 supplements shall be given only on written order of a physician.

(4)

 Menus shall be planned or approved by a
 qualified dietitian and dated. Used menus shall be kept on file for a period of
 thirty days for reference by the patient's physician and personnel of the
 home.

(5)

 Modified diets shall be
 provided in accordance with written orders of a physician or dentist. An
 approved diet manual shall be readily available to food service
 personnel.

(6)

 Sufficient
 perishable foods for a twenty-four hour period and nonperishable foods for a
 three-day period shall be on the premises for use in an emergency.

Rule 111-8-56-.07 Social Service

(1)

 Each home shall provide services to
 assist all patients in dealing with social and related problems through one or
 more case-workers on the staff of the facility or through arrangements with an
 appropriate outside agency.

(2)

 Social service information concerning each patient shall be obtained and kept.
 This information shall cover social and emotional factors related to the
 patient's condition and information concerning his home situation, financial
 resources and relationships with other people.

(3)

 All nursing personnel and employees
 having contact with patients shall receive social service orientation and
 in-service training toward understanding emotional problems and social needs of
 patients.

(4)

 One person in each
 home shall be designated as being responsible for the social services aspects
 of care in the home.

Rule 111-8-56-.08 Pharmacy Management and Administration

Each home shall provide pharmaceutical services in full
 compliance with State and Federal laws and regulations.

Rule 111-8-56-.09 Physical Therapy Service

(1)

 When a home has a physical therapy
 program, the services must be provided or directly supervised by a physical
 therapist.

(2)

 A therapy record
 will be kept as a part of the medical record on each patient receiving physical
 therapy. Information in the medical record shall include referral, diagnosis,
 precautions, initial physical therapy evaluation treatment plan and objectives,
 frequency and dates of medical reevaluations.

(3)

 The physical therapist shall keep
 progress notes on each patient including progress or lack of progress, symptoms
 noted, and changes in treatment plans.

Rule 111-8-56-.10 Medical, Dental and Nursing Care

(1)

 Each patient shall have a physician's
 written statement of his or her condition at time of admission or within
 forty-eight (48) hours thereafter and it shall be kept on file with the
 patient's medical record.

(2)

 Each
 patient shall have a physician's orders for treatment and/or care upon
 admission to the facility.

(3)

 Each
 home shall have an adequate arrangement for medical and dental
 emergencies.

(4)

 Reports of all
 evaluations and examinations shall be kept with the patient's medical
 records.

(5)

 The home shall have a
 microbial and infection control program. Policies and procedures for infection
 control shall be written, assembled and available to all staff members.
 Procedures shall be specific for practice in the home and shall be included in
 the training of every staff member. As a minimum, procedures shall include the
 following control measures:

(a)

 Prevention of
 spread of infection from personnel to patient: Any person whose duties include
 direct patient care, handling food, or handling clean linen, and who has an
 acute illness such as "strep" throat, or an open sore or boil, shall not be
 allowed to work until he is fully recovered;

(b)

 Prevention of spread of infection from
 visitors to patients;

(c)

 Prevention of spread of infection from patient to personnel or other patients:
 Isolation techniques to be observed according to the source of infection and
 the method of spread;

(d)

 Reporting
 of communicable diseases as required by the rules and regulations for
 notification of diseases which have been promulgated by the
 Department.

(6)

 All
 medications, administered to patients must be ordered in writing by the
 patient's physician or oral orders may be given to a licensed nurse,
 immediately reduced to writing, signed by the nurse and countersigned by the
 physician as soon as practical. 

(a)

 Medications not specifically limited as to time or number of doses, when
 ordered, must be automatically stopped in accordance with written policy
 approved by the organized professional staff.

(b)

 The patient's attending physician shall
 be notified of stop order policies and contacted promptly for renewal of such
 orders so that continuity of the patient's therapeutic regimen is not
 interrupted.

(7)

 All
 medications must be administered by medical or nursing personnel in accordance
 with the Medical and Nurse Practice Acts of the State of Georgia. Each dose
 administered shall be properly recorded in the clinical records: 

(a)

 The nurses' station shall have readily
 available items necessary for the proper administration of
 medication;

(b)

 In administering
 medications, medication cards or other State approved systems must be used and
 checked against the physician's orders;

(c)

 Legend drugs prescribed for one patient
 shall not be administered to any other patient unless ordered by a
 physician;

(d)

 Self-administration
 of medications by patients should be discouraged except for emergency drugs on
 special order of the patient's physician or in a predischarge program under the
 supervision of a licensed nurse;

(e)

 Medication errors and drug reactions
 shall be immediately reported to the patient's physician and an entry thereof
 made in the patient's clinical records as well as on an incident
 report;

(f)

 Up-to-date medication
 reference texts and sources of information shall be available.

(8)

 Nursing care shall be provided
 each patient according to his needs and in accordance with his patient care
 plan.

(9)

 Restraint and/or forcible
 seclusion of a patient will be used only on a signed order of a physician,
 except in emergency and then only until the advice of a physician can be
 obtained.

(10)

 Provisions shall be
 made for proper sterilization of supplies, utensils, instruments, and other
 materials as needed for the patients.

(11)

 When a patient dies in the facility, a
 physician assistant, a nurse practitioner, or a registered professional nurse
 licensed in this state and employed by the facility at the time of the
 patient's apparent death, may make the determination and pronouncement of death
 in the absence of a physician. When it appears that a patient died from other
 than natural causes, only a physician may make the determination or
 pronouncement of death. The determination or pronouncement shall be made in
 writing on a form approved by the department.

Rule 111-8-56-.11 Records

(1)

 Each home shall
 maintain a complete medical record on each patient containing sufficient
 information to validate the diagnosis and to establish the basis upon which
 treatment is given. All active medical records shall be maintained at the
 nurses' station. The completed record shall normally contain the following: 

(a)

 Name, address, birth date, sex, marital
 status of the patient and religion; the name, address and telephone number of
 physician; the name, address and telephone number of the responsible party to
 contact in emergency;

(b)

 Date and
 time of admission;

(c)

 Date and
 time of discharge or death;

(d)

 Admitting diagnosis;

(e)

 Final
 diagnosis;

(f)

 Condition on
 discharge;

(g)

 History and physical
 examination;

(h)

 Treatment and
 medication orders;

(i)

 Physicians'
 progress notes (at least monthly);

(j)

 Nurses' notes;

(k)

 Special examination and
 reports.

(2)

 Each home
 shall keep patient statistics, including admissions, discharges, deaths,
 patient days, and percent of occupancy. Statistical records shall be open for
 inspection and upon request, data shall be submitted to the
 Department.

Rule 111-8-56-.12 Equipment

(1)

 Patient beds
 shall be single, at least thirty-six inches wide, with firm even springs
 covered by a mattress not less than four inches thick.

(2)

 The home shall provide all linens and
 blankets essential to the treatment and comfort of patients.

(3)

 Wheelchairs, walkers, and mechanical
 lifters shall be provided by the home when needed.

(4)

 Each patient shall have necessary
 furniture which shall include a bedside table, a reading lamp, a chair, drawer
 space for clothes, enclosed space for hanging clothing, and individual towel
 rack, soap dish, drinking glass, and access to a mirror. Each patient shall
 have a suitable signaling device.

(5)

 Individual equipment shall be cleaned
 after each use and disinfected at least once each week. Equipment such as
 bedpans, urinals and wash basins, if not individual, should be disinfected
 after each use.

(6)

 Each patient
 shall be provided adequate supplies and equipment for proper oral hygiene
 including a toothbrush or a denture brush and denture receptacle when
 needed.

(7)

 Bedrails shall be
 available for use as required by the patient's condition.

(8)

 There shall be an electric clock with a
 bold face that can be read from a distance of twenty (20) feet installed in the
 lobby of each home.

(9)

 Disposable
 equipment and supplies shall be used only once and disposed of in an approved
 manner.

Rule 111-8-56-.13 Safety

(1)

 All buildings
 and equipment shall be maintained in such condition that no hazards to the life
 and safety of the patients exist.

(2)

 Adequate parking shall be available
 nearby. Parking areas and service entrances shall be so designated that fire
 fighting equipment will have unobstructed access to all parts of the
 building.

(3)

 Handrails shall be
 provided on all stairways and ramps. Stairways shall be made of or covered with
 safe nonslip material. Doors opening onto stairways shall not open directly
 onto risers, but shall open onto a landing not less than the width of the
 door.

(4)

 Safety barriers at the
 head of stairways, and handrails in hallways shall be provided. There shall be
 no low windows, open porches, changes in floor levels or similar
 hazards.

(5)

 Doors to rooms used by
 patients shall be equipped with locks or other devices which will not allow the
 room to be locked from the inside.

(6)

 Floor surfaces shall be smooth and level;
 scatter rugs and highly polished floors in patient areas are
 prohibited.

(7)

 Showers, tubs and
 toilets shall have grab bars firmly installed convenient to patient use; the
 floor in bathing areas shall be provided with a nonslip surface. No patient
 shall be permitted to bathe without an available attendant to regulate water
 temperature and to provide generally for the safety of the patient, unless the
 patient's physician has provided a written statement to the effect that the
 patient is sufficiently responsible to bathe himself. Shower heads shall not be
 installed above bathtubs.

(8)

 Warning signs shall be posted prohibiting smoking or open flames of any kind in
 areas where oxygen is in use or stored.

Rule 111-8-56-.14 Environmental Sanitation and Housekeeping

(1)

 Equipment and supplies for proper
 sanitation will be maintained on the premises.

(2)

 Laundry shall be handled, stored, and
 processed so that spread of infection will be minimized. A sufficient clean
 linen supply shall be insured at all times. Soiled linen shall not be permitted
 to accumulate.

(3)

 The premises and
 all areas within the home shall be kept clean and free from debris. Ventilation
 openings, such as ports for exhaust fans, shall be equipped with covers that
 close automatically when the fan is not in operation. Doors and other openings
 shall be equipped and maintained to minimize ingress of flies, insects and
 rodents.

(4)

 Sanitary containers,
 sputum cups, and other satisfactory individual containers must be provided when
 needed.

(5)

 Each home shall have an
 infection control program which provides for policies, procedures and training
 programs. Great care should be exercised to prevent spread of infection by
 fomites or by infected person to person.

Rule 111-8-56-.15 Health of Employees

(1)

 Health Screenings. Each home shall have in place a health screening program designed to identify conditions that may place patients at risk for infection, injury, or improper care. The program shall include requirements and processes for initial, routine, and targeted health screenings of employees and contractors who interact with patients or conduct other activities with environmental impact.

(2)

 Screening for Tuberculosis (TB). Prior to starting work, all employees must be screened for TB in accordance with Centers for Disease Control and Prevention (CDC) guidance for baseline screening and testing for health care personnel.

(3)

 Records. Copies or certificates of health screenings shall be kept in the employee's personnel file.

Rule 111-8-56-.16 Recreation

(1)

 An individual
 shall be designated as being in charge of patient activities. This individual
 shall have experience and/or training in group activities, or shall have
 consultation made available from a qualified recreational therapist or group
 activity leader.

(2)

 Provisions
 shall be made for suitable recreational and entertainment activities for
 patients according to their needs and interests. These activities are an
 important adjunct to daily living and are to encourage restoration to self-care
 and resumption of normal activities. Variety in planning shall include some
 outdoor activities in suitable weather.

(3)

 Patients shall be encouraged but not
 forced to participate in patient activities.

(4)

 The facility shall make available a
 variety of supplies and equipment adequate to satisfy the individual interests
 of residents. Examples are: books, magazines, daily newspapers, games,
 stationery, radio, television and the like.

(5)

 An active patient activities program
 shall be carried out that will meet the needs of all patients.

Rule 111-8-56-.17 Patient Capacity

(1)

 The number of beds provided shall be
 indicated on each permit and provisional permit.

(2)

 The number of patients receiving care
 within the home shall not exceed the number of beds shown on the permit. In
 exceptional cases, temporary waivers, not to exceed thirty (30) days, may be
 granted by the Department.

Rule 111-8-56-.18 Physical Plant Standards

(1)

 Requirements under this rule "Physical
 Plant Standards" will be enforced with the effective date of these regulations
 EXCEPT that homes holding a valid permit prior to the effective date of these
 regulations, shall comply with the regulations in effect at the time the home
 was issued a permit or the plans were approved. Provided however, that any such
 homes which hold a valid permit prior to the effective date of these
 regulations must comply with these regulations when improvements or
 modifications are made within any twelve (12) month period and the cost of such
 improvements or modifications exceeds a total of twenty percent (20%) of the
 fair market value of the home. If no such improvements are made, the homes
 holding a valid permit prior to the effective date of these regulations must
 then comply with these regulations within fifteen (15) years of the effective
 date of these regulations. In exceptional cases and upon application to the
 Department by the governing body of the home, variances may be granted at the
 discretion of the Department (if it determines that these requirements will
 place an undue burden or extreme hardship on the home or its occupants),
 provided that the health and safety of the patients is not
 jeopardized.

(2)

 At least two rooms
 per fifty (50) beds shall be designed for single occupancy (one bed). At least
 one room designed for single occupancy shall have an adjoining private
 bathroom, containing a lavatory, water closet and a bathtub or shower equipped
 with grab bars.

(3)

 All patient
 rooms shall open into corridors leading to the exterior of the building. No
 patient room will be so located as to make it necessary for a patient to pass
 through another room to gain entrance to a corridor leading to the
 exterior.

(4)

 Each patient room
 shall be an outside room with window space equal to at least one-eighth of the
 floor area with opening in area large enough to remove patient by
 mattress.

(5)

 Patient bedrooms
 shall contain not less than one hundred (100) square feet of usable floor space
 in private or single rooms and no less than eighty (80) square feet per bed of
 usable floor space in multibed rooms. Usable floor space is in addition to area
 provided for closets, toilet rooms and entry ways.

(6)

 Not less than three (3) feet of space
 shall be provided between beds and between the foot of the bed and wall or
 other obstruction. There shall be sufficient space so beds may be made
 accessible from both sides for nursing care when needed.

(7)

 An individual clothes closet or wardrobe
 with door shall be provided per bed in every patient room. Clothes closets or
 wardrobes shall be at least twenty-two (22) inches deep and twenty (20) inches
 wide with at least one shelf above a hanging space equipped with a device for
 clothes hangers.

(8)

 Each patient
 room having more than one bed shall have permanently installed curtain tracks
 to permit closing each bed with curtains to allow for the privacy of each
 patient without obstructing the passage of other patients either to the
 corridor or to the toilet or lavatory adjacent to the patient room. Curtains
 used for enclosing patient beds shall be rendered and maintained flame
 resistant.

(9)

 Employees, staff and
 visitors shall not use water closets provided for patients. Toilets, including
 a water closet, lavatory, soap, paper towels and dispensers shall be provided
 near or adjacent to the following locations: 

(a)

 Nurses' station or medication
 area;

(b)

 Kitchen;

(c)

 Lobby area or waiting room.

(10)

 Patient bathing and toilet
 facilities:

(a)

 There shall be a general
 bathing area in each nursing unit. This area shall contain at least one bathtub
 accessible from three sides, one stall shower equipped with grab bars with
 adjacent drying space, one lavatory and one water closet. This unit shall be of
 sufficient size to provide space for dressing, a wheelchair, and an attendant.
 Unless the bathing fixtures are located in separate rooms, compartments must be
 provided to permit independent use to afford privacy for each sex. Special
 institutional tubs or showers may be approved for use if the program of service
 indicates;

(b)

 At least one
 enclosed water closet and one lavatory shall be provided for each eight beds or
 major fraction thereof;

(c)

 At
 least one bathing facility (bathtub or shower) shall be provided for each
 fifteen (15) beds, or major fraction thereof, located in patient bedrooms that
 do not adjoin a toilet room in which a bathing facility is located;

(d)

 Unless bathtubs in bathrooms adjoining
 patient rooms are located so as to be accessible from three sides, handrails or
 grab bars on the tub or on the wall by the tub shall be provided;

(e)

 All shower stalls shall be at least four
 feet by four feet square and must have handrails on three sides, be equipped
 with curtains and be designed for wheelchair use. Thresholds to showers must be
 flush with the floor. The floor of the shower shall be designed to drain
 properly;

(f)

 Grab bars, securely
 attached to walls and conveniently located, adjacent to all bathtubs, showers
 and water closets intended for patient use shall be provided.

(11)

 A nurses' station shall be
 provided in each nursing unit. It shall contain a nurses' call system, charting
 desk and supplies, medicine storage, lavatory with soap, towels and towel
 dispenser, preparation area and a refrigerator. The nurses' station shall not
 be more than 120 feet from the entrance of the most remote room
 served.

(12)

 There shall be
 separate clean and soiled utility rooms in each nursing unit located near the
 nurses' station. The clean utility room shall contain wall and base cabinets
 and stain resistant counter top, a small sink set into the counter or with
 drain boards. The soiled utility room shall contain a counter with a stain
 resistant top and storage cabinets underneath. In addition, it shall contain a
 deep service sink with stopper for chemical sterilization of bedpans, urinals
 and commode pails. The deep service sink with stopper may be omitted if a steam
 autoclave for sterilizing is available to the home.

(13)

 At least one bedpan cleansing device
 shall be provided in each nursing unit. It may be located in the soiled utility
 room or in a special bedpan closet conveniently located in each nursing unit.
 The bedpan cleansing device may be omitted if water closets in patient toilets
 are equipped with bedpan lugs, spray hose and elevated vacuum
 breaker.

(14)

 Sufficient space
 shall be provided in each nursing unit for stretcher and wheelchair parking.
 Such space shall be out of corridor traffic.

(15)

 There shall be a floor pantry in each
 nursing unit located near or adjacent to the nurses' station. The floor pantry
 shall contain a hot plate, sink, counter, cabinets and a refrigerator that
 shall not be used to store drugs, biologicals or laboratory
 specimens.

(16)

 A drinking fountain
 which shall not impair any passageway shall be provided in each nursing
 unit.

(17)

 There shall be a
 treatment room convenient to patient rooms containing a treatment table,
 lavatory equipped with soap, paper towels and dispenser, instrument table and
 storage cabinet and providing adequate room for transfer of patients. A
 treatment room may be used for consultation if appropriately
 enlarged.

(18)

 There shall be a
 patient dining and recreation area provided in each home. The minimum total
 area shall be twenty (20) square feet of floor space per bed. One-half the
 required space shall be for dining.

(19)

 A room with sufficient space for
 patients' active exercise regimens including such equipment as a full-length
 mirror, parallel bars, a wall-mounted wheel, and an exercise table shall be
 provided. The room shall also contain a lavatory with gooseneck spout and wrist
 controls. Soap, paper towels and towel dispenser shall also be
 provided.

(20)

 There shall be a
 lobby and/or waiting room in each home. The size of this area shall be
 determined in relation to the size of the home and the program of
 service.

(21)

 There shall be at
 least one building exit at ground level and at least one building exit shall be
 provided with a suitable ramp designed for a stretcher and a wheelchair. There
 shall be one such exit leading to the outdoor recreation area.

(22)

 A public telephone shall be located near
 the lobby. At least one telephone shall be arranged to be convenient for a
 wheelchair user.

(23)

 The central
 kitchen area shall be located to permit efficient service to the dining rooms
 and the nursing units. It must be arranged and equipped for adequate food
 storage; preparation and serving of foods in proper sequence; dish and utensil
 cleaning and storage, and refuse storage and removal. Homes that are a distinct
 part of another home may utilize the service of a central kitchen provided it
 is of adequate size and adequately equipped to serve the total patient
 population. Storage space shall be sufficient to store a 24-hour supply of
 perishable foods and a 3-day supply of nonperishable foods.

(24)

 Separate and adequate clean laundry
 storage and separate and adequate soiled laundry storage rooms shall be
 provided appropriate to the frequency of deliveries and linen needs.

(25)

 Janitor's closets shall be provided on
 the basis of at least one closet for the dietary area and one for the remainder
 of the home. This room shall be of sufficient size to include racks for
 equipment, storage space and a service sink.

(26)

 General storage space for the storage of
 supplies, furniture, equipment and patients' possessions shall be provided.
 Such space may be provided in one or more rooms and shall be commensurate with
 the needs of the home, but not less than five (5) square feet per
 bed.

(27)

 Maintenance area or areas
 commensurate with the needs of the home, including storage space for building
 and grounds maintenance equipment, tools, supplies and materials and shop space
 for mechanical, painting and carpentry work shall be provided.

(28)

 Floor, wall and ceiling finishes shall
 be smooth, easily cleaned and be wear-resistant appropriate to location. In
 addition, the floors of the following spaces shall be waterproof: toilets,
 baths, bedpan rooms, floor of pantries, kitchens, utility rooms, janitors'
 closets and treatment rooms. Areas subject to wetting shall have nonslip
 flooring. Carpeting, wall and ceiling finishes shall be approved by the State
 Fire Marshal.

(29)

 Stairways, doors
 and corridors: 

(a)

 Stairways serving patient
 areas shall not be less than forty-four (44) inches in clean width;

(b)

 Stairs shall be individually enclosed and
 be separated from any public hall;

(c)

 A landing shall be provided at the top
 and bottom of every stair run. Doors shall swing with exit travel to provide
 safe exit;

(d)

 The minimum
 dimension of landing shall be as wide as the required width of the stairway it
 serves. A door swinging into a landing, when open, shall not overlap the
 required width of the landing;

(e)

 The width of stair to risers shall not be less than ten (10) inches plus a one
 (1) inch nosing;

(f)

 Winders and
 single risers are not acceptable;

(g)

 Stairs and landings shall have a non
 slippery finish;

(h)

 Patients' room
 corridor entrances and all required exits shall be not less than forty-four
 (44) inches in clean width. All other doors through which patients must pass
 shall be not less than thirty-six (36) inches in clean width except that doors
 to toilets in patient bedrooms may not be less than thirty-two (32) inches
 wide. Doors through which patients or equipment do not pass shall be not less
 than thirty (30) inches wide, except that doors to patient closets may not be
 less than twenty (20) inches wide;

(i)

 When a door swings out on any platform,
 balcony, or porch or terrace, the minimum width of the platform, balcony, porch
 or terrace shall be thirty (30) inches plus the width of the door, measured at
 right angles to the wall containing the door. Exit doors, other than for living
 units shall swing in the direction of exit from the structure;

(j)

 Corridors in areas used by patients shall
 not be less than eight (8) feet in clean width. Handrails may project into
 corridors, but drinking fountains, desk or other projections or obstructions
 may not reduce the eight (8) foot minimum dimension;

(k)

 Ramps shall be not less than forty-four
 (44) inches wide. Where ramps provide a change of corridor level, the minimum
 width shall be not less than that of the corridor;

(l)

 The maximum slope of ramps shall be not
 greater than ten (10) percent. Changes in direction, if any, shall be on level
 landings with a minimum width the same as the ramp width;

(m)

 Ramps shall have a nonslip finish. Ramps
 serving as a required means of egress shall be enclosed or protected as
 indicated for required stairways;

(n)

 Handrails shall be provided on each side
 of all patient corridors and on each side of stairways and ramps.

(30)

 Light and Ventilation: 

(a)

 The total glass area in patient bedrooms
 shall be not less than one-eighth of the floor area of the room. The
 ventilating area shall be not less than four (4) percent of the floor
 area;

(b)

 Openings providing
 required natural light, which open on a covered porch whose depth exceeds four
 (4) feet, shall be increased in area ten (10) percent per foot of depth over
 four (4) feet;

(c)

 The heads of
 windows (sash opening) shall not be more than one foot below the finished
 ceiling unless they are at least six (6) feet eight (8) inches above the
 finished floor. The lower level of the window glass shall be not more than
 forty-eight (48) inches above the floor level;

(d)

 Ceiling lights shall be not less than
 eight (8) feet except that seven (7) feet six (6) inches may be used in
 corridors, halls, toilet rooms and bathrooms;

(e)

 The lower edge of patient bedroom windows
 shall in every instance be above grade.

(31)

 Mechanical: 

(a)

 All bathrooms and toilet rooms shall be
 provided with mechanical ventilation capable of producing a minimum of ten (10)
 air changes per hour. Utility rooms, community rooms and corridors shall be
 provided with not less than four (4) changes per hour with at least two (2) of
 the air changes being outside air. Ducts ventilating bathrooms or toilet rooms
 shall not be interconnected with other duct systems but shall be discharged to
 the outside. Patient rooms shall be provided with at least two (2) air changes
 per hour of outside air. Corridors and exit halls shall not be used as a plenum
 for supply or return air to heating or air-conditioning system;

(b)

 Kitchens, laundries, non-refrigerated
 garbage storage rooms, and rooms used to store combustible materials, shall be
 provided with an independent system of mechanical ventilation discharging above
 the roof and remote from any window. A minimum of ten (10) air changes per hour
 shall be provided. Exhaust hoods shall be installed over cooking
 ranges;

(c)

 All buildings shall be
 provided with a heating system designed to maintain a temperature of 75 degrees
 Fahrenheit in all habitable rooms and corridors when the outside temperature is
 at design level. The heating system should provide warm floors;

(d)

 All steam-operated equipment such as
 sterilizers, laundry and kitchen units, shall be provided with steam at
 temperatures and pressures as recommended by the equipment
 manufacturers;

(e)

 The quality and
 quantity of the water supply and the method of sewage disposal shall have the
 approval of the Department;

(f)

 The
 method employed to heat water shall provide an adequate supply of hot water at
 necessary temperatures for all purposes, in a safe manner;

(g)

 Temperature controls shall be provided so
 that hot water for personal uses shall not exceed 110 degrees
 Fahrenheit;

(h)

 Hot water
 temperatures for other uses shall be as required by the equipment
 served;

(i)

 The quantity of hot
 water for kitchens and laundries shall be adequate to serve the equipment
 installed;

(j)

 Wrist control
 handles shall be provided for sinks or lavatories in floor pantries, medicine
 preparation rooms, clean utility rooms, soiled utility rooms, treatment or
 examination rooms, rehabilitation or physical therapy rooms and at handwashing
 fixtures in the kitchen area;

(k)

 Gooseneck spouts shall be provided for sinks or lavatories in treatment or
 examination rooms, physical therapy or rehabilitation rooms and at handwashing
 fixtures in the kitchen area;

(l)

 Vacuum breakers shall be provided for any plumbing fixture having a hose or
 hoses attached or to any plumbing fixture having trim to which a hose may be
 attached, including shampoo sinks, service sinks, combination hot and cold
 water outlets at can wash areas. Hose bibs shall be provided for clean-up
 purposes in the dishwash area of kitchens;

(m)

 Aerators shall not be included as part of
 trim for plumbing fixtures;

(n)

 With relationship to adjacent areas, a positive air pressure shall be provided
 for clean utility rooms, floor pantries and medicine preparation
 rooms;

(o)

 With relationship to
 adjacent areas, a negative air pressure shall be provided for soiled utility
 rooms, physical therapy or rehabilitation rooms, janitor's closets, soiled
 laundry rooms and bathrooms or toilets. Air from these rooms shall not be
 recirculated; air shall be exhausted;

(p)

 Floor grilles shall not be used for
 supply or return air openings in heating, air-conditioning or ventilating
 systems;

(q)

 Ventilation openings,
 such as ports for exhaust fans, etc., shall be equipped with covers that close
 automatically when the fan is not in operation; 

(r)

 Intake air ducts shall be designed and
 maintained so as to prevent the entrance of dust and insects;

(s)

 Hot air ducts from the heating system
 shall not emit temperatures in excess of 150 degrees Fahrenheit.

(32)

 Electrical: 

(a)

 All areas shall be adequately lighted as
 required for duties performed in each space. Bedrooms and combination
 living-bedrooms shall have a night light, a light for general illumination and
 a reading light at the head of each bed. The outlets for general illumination
 and night lights shall be switched at the door. The reading light shall be
 controlled at the bedside. Each stairway, hall, corridor or general passage
 shall have five (5) foot candles of illumination, doubled at building and stair
 entrance, or change of floor level, or at ramps;

(b)

 Receptacles appropriate for the designed
 space use shall be located where plug-in service is required. There shall be
 not less than one duplex receptacle at the head or near the head of each bed.
 All other spaces shall have general and special purpose outlets suited to the
 need of the space; including an outlet in the lobby for an electric clock and
 receptacles for cleaning and maintenance equipment spaced not more than fifty
 (50) feet apart in corridors;

(c)

 Emergency lighting supplied by an emergency generator or a battery with
 automatic switch, shall be provided for exits, stairs and corridors;

(d)

 Each toilet room and bathroom and each
 bed location shall be furnished with an electrical or mechanical nurses' call
 audible or visible at the nurses' station. A duplex unit may be used for two
 beds.

(33)

 Elevators and
 Dumbwaiters:

(a)

 Where patients' rooms are
 located on more than one floor at least one elevator shall be provided. Other
 elevators shall be provided, depending upon the needs and size of the
 home;

(b)

 At least one elevator in
 multistory buildings shall be arranged of sufficient size to admit a stretcher
 and an attendant;

(c)

 Elevator
 doors shall be automatic slide type with safety interlock. Elevators shall be
 equipped with hand rails and automatic self-leveling control which will
 automatically bring car platforms level with the landing;

(d)

 Dumbwaiter cabs shall be not less than
 twenty-four (24) by thirty-six (36) inches of steel with one shelf.

Rule 111-8-56-.19 Application for Permit

(1)

 The governing body shall submit to the
 Department an application for a permit.

(2)

 The application for a permit shall be
 made on forms provided by the Department and shall be filed at least thirty
 (30) days prior to the anticipated date of opening and commencement of
 operation of a new home.

(3)

 Each
 application shall be accompanied by a copy of the bylaws of the professional
 staff, a copy of the policies for operating the home and a certification from
 each member appointed to the professional staff that he has accepted the
 appointment including the name and license number of the administrator and the
 name and license number of the director of nursing. In homes with a
 professional staff of ten (10) or more physician members, only the physician
 members elected as officers need submit a certification as to their
 appointment.

(4)

 A plan for
 progressive employment of personnel to match increase bed occupancy and to
 assure compliance with these rules and regulations shall be submitted at the
 time established for the preopening inspection.

(5)

 Proof of ownership shall accompany the
 application.

(a)

 Corporations shall submit a
 copy of their charter and the name and address of all owners with ten (10)
 percent or more of the stock and shall identify each corporate
 officer;

(b)

 Nonprofit associations
 and hospital authorities shall submit legal proof of the organization, the name
 and address of each trustee and the office held, if any;

(c)

 All others shall submit the name and
 address of each person owning any part of the facility.

(6)

 Proof of an active liability insurance
 policy or a self-insurance trust for the home's benefit for a nursing home
 claim.

Rule 111-8-56-.20 Nursing Home Permit Requirements

(1)

 To be eligible for a permit the nursing
 home must be in satisfactory compliance with these rules and regulations and
 the provisions at law which apply to the locations, construction and
 maintenance of homes and the safety of the patients therein.

(2)

 Prior to the issuance of a permit and at
 the request of the Commissioner, the governing body or operator shall furnish
 to the Department evidence of satisfactory compliance with any laws or
 regulations thereunder applicable to homes but the enforcement of which is the
 responsibility of a department or agency of government other than the
 Department.

(3)

 The permit shall be
 framed and publicly displayed at all times.

(4)

 Permits are not transferable from one
 governing body or operator to another, nor valid when the home is moved from
 one location to another.

(5)

 Nursing homes shall provide the Department at least ninety (90) days prior
 written notice of the following events via electronic mail at
 HFRD.NH@dch.ga.gov (or such other updated address posted on the Department's
 website), and, for applicable events, shall take the following required
 actions:

(a)

 Date of a proposed transfer of
 ownership and/or change of the operator of the nursing home. The transferring
 nursing home owner and/or the owner of the real estate upon which the nursing
 home is located shall provide to the Department a copy of the acquisition
 agreement, operator or management agreement, lease agreement, and any other
 documents regarding the transfer as requested by the Department.

(b)

 Date of closure of the nursing home or
 anticipated interruption of nursing home operations. Prior to ceasing
 operations, a nursing home shall timely notify the Department of the planned
 storage location for residents' medical records, medical staff information, and
 other critical information. The nursing home shall publish on its webpage in a
 prominent location and in a widely circulated newspaper(s) in the nursing home
 service area a notice indicating where medical records and other critical
 information can be retrieved. The nursing home shall also provide this
 information to its residents or their designated representatives in writing.
 Following its closure, the nursing home shall promptly notify the Department in
 writing of any change in location of the residents' medical records, medical
 staff information, and other critical information;

(c)

 The effective date of a transaction
 involving a nursing home's acquisition, sale, divestment, transfer of
 operations, or merger with another nursing home or other business entity;
 or

(d)

 Effective date of material
 changes affecting nursing home operations, including but not limited to the
 addition of any services, reduction or elimination of bed capacity, or other
 material change(s) regarding the nursing home's delivery of services. Such
 notification shall include a detailed description of the material changes. 
 
A nursing home may be fined by the Department in an amount of
 $1000.00 per day that any notification required by Ga. Comp. R. & Regs. r.
 is late, subject to
 waiver or reduction of such notice requirement by the Department for good
 cause, as it determines in its sole discretion. A nursing home may also be
 fined $1000.00 per day that it fails to take any other action required by Ga.
 Comp. R. & Regs. r.
 , after receipt of
 written notice by the Department. The Department shall review all proposed
 events and actions in accordance with its regulatory authority. A nursing home
 must also promptly respond to information requests issued by the
 Department.

(6)

 The permit shall be surrendered to the Department upon occurrence of any of the
 following events:

(a)

 The final onsite
 inspection by the Department on the last day of operation for the nursing
 home;

(b)

 The nursing home's
 cessation of operations;

(c)

 A
 nursing home's relocation of its facility to a new premises;

(d)

 A change of more than fifty percent (50%)
 of the nursing home's ownership or governing body, or any change of operator of
 the nursing home; or

(e)

 The
 Department's suspension or revocation of the nursing home's permit.

(7)

 A permit shall be required for
 each nursing home located on different premises where more than one home is
 operated under the same governing body. When a nursing home operates as
 distinct parts, then a permit shall be required for each distinct
 part.

(8)

 Each nursing home shall
 be in compliance with O.C.G.A. § 
26-2-370
 et seq., entitled "Food
 Service Establishments" and the Rules and Regulations as adopted and
 promulgated thereunder entitled "Rules and Regulations for Food Service" and
 with any amendment to the law or rules promulgated thereunder.

Rule 111-8-56-.21 Provisional Permits

(1)

 Provisional permits may be granted to the
 governing body of a newly established home to demonstrate operational
 procedures in satisfactory compliance.

(2)

 A provisional permit may be granted to
 the governing body of an existing home to demonstrate operational procedures in
 satisfactory compliance.

(3)

 Provisional permits granted to allow a reasonable time to demonstrate
 satisfactory compliance of operational procedure shall be limited to a period
 of not more than six (6) months.

(4)

 A provisional permit may be granted to
 the governing body of an existing home to give reasonable time to comply with
 violations of regulations and standards which relate to the structural or
 physical condition of the home. Provisional permits granted to allow time for
 correction of structural or physical conditions shall not exceed twelve (12)
 months.

(5)

 No provisional permits
 shall be granted to the governing body of a newly established home which is in
 substantial noncompliance with rules, regulations and standards relating to the
 structural or physical condition of the home.

(6)

 A provisional permit shall not be issued
 when there are noncompliances of any type which present an immediate hazard to
 the life, health or safety of the patients.

(7)

 No provisional permit shall be granted to
 an existing home unless the governing body shall first present to the
 Commissioner a plan of improvement which shall list each noncompliance to be
 corrected, the time required to demonstrate acceptable operational procedures
 or to correct noncompliances which relate to the structural or physical
 condition of the home and the means, methods and procedures to be used in the
 correction of the noncompliances.

(8)

 The governing body of a home operating
 under a provisional permit may petition the Department for an extension of time
 if needed to correct noncompliances where the failure to make such corrections
 within the time allotted is an extenuating circumstance beyond the control of
 the governing body. Such petitions shall be submitted to the Department at
 least thirty (30) days prior to expiration date of the provisional
 permit.

Rule 111-8-56-.22 Inspections

(1)

 The home shall
 be available at reasonable hours for observation and examination by properly
 identified representatives of the Department.

(2)

 The administrator or authorized
 representative shall notify the Department of the anticipated opening date of a
 newly constructed home in order that a pre-opening licensure survey of the home
 may be conducted to determine compliance with these rules and
 regulations.

(3)

 The administrator
 or his representative shall accompany the Department representative on tours of
 inspection.

Rule 111-8-56-.23 New Construction

(1)

 General Requirements: 

(a)

 A program narrative and all plans and
 specifications for construction, including additions, alterations and
 renovations, shall be approved by the Department prior to commencing work on
 the building;

(b)

 The program
 narrative shall be submitted prior to or along with the schematic or initial
 plans for construction. The program narrative should include the following: 

1.

 The names and addresses of each owner. If
 the owner is a public stock corporation, the names and addresses of each
 officer shall be included;

2.

 The
 geographical area to be served;

3.

 Admission policies;

4.

 Cooperative
 programs of service with local agencies, including hospitals;

5.

 Arrangements for medical and dental care,
 e.g., physicians on contract and agreements with hospital for patient
 referral;

6.

 List of personnel by
 types of employees and proposed salaries;

7.

 Plans for securing the services of
 professional personnel including registered nurses, licensed practical nurses,
 social workers, dietitians, pharmacists, physicians and therapists;

8.

 A description of the service to be
 provided the community, i.e., the level of care to be provided and the economic
 segments of the population to be served;

9.

 Source and amount of financing;

10.

 Anticipated first two-year cost of
 operation, income and source of operating funds;

11.

 Exact location of proposed
 site;

12.

 Utilities available,
 i.e., electricity, gas, water, sewage and waste disposal and
 transportation;

13.

 The name,
 address and telephone number of the person selected to represent the owner
 during the period of planning construction.

(c)

 Any individual or group planning
 construction shall submit complete architectural, structural, mechanical and
 electrical plans and specifications to the Department for review and approval
 prior to any new construction, addition, alteration or renovation. Final plans
 submitted shall be in sufficient detail to show the building site, driveways
 and parking areas, type of construction, mechanical and electrical systems, the
 type and location of major items of equipment, the intended use of each room,
 the proposed location of beds, the type and source of utilities, food service
 system, and the proposed system of garbage and refuse disposal;

(d)

 Plans for addition and/or remodeling of
 an existing building will be submitted in sufficient detail to include type of
 construction and layout of the existing building to show overall relationship.
 Any changes in the approved final plans shall also be submitted to the
 Department for approval.

(2)

 Location and Site: 

(a)

 The site shall be approved by the
 Department;

(b)

 The site shall have
 proper drainage. Sewage disposal, water, electrical, telephone and other
 necessary facilities shall be available to the site.

Rule 111-8-56-.24 Enforcement

The administration and enforcement of these rules and
 regulations shall be as prescribed in O.C.G.A. §§ 
31-2-8
 and
 
50-13-13
et
 seq.

Rule 111-8-56-.25 Dining Assistants

(1)

 Dining assistants shall work under the
 direct supervision of a registered nurse or a licensed practical nurse. Direct
 supervision means that the registered nurse or licensed practical nurse is
 present in the same room and available to respond to the need for
 assistance.

(2)

 Dining assistants
 are to be used to supplement, not replace, existing nursing staff requirements
 and as such are not considered nursing staff and are not to be included in
 computing the required minimum hours of direct nursing care.

(3)

 Dining assistants shall: 

(a)

 Be at least 16 years of age;
 and

(b)

 Have successfully completed
 the dining assistant training program in accordance with these rules.

(4)

 Dining assistants shall
 provide feeding and hydration assistance only to those residents who have been
 determined to meet the following criteria:

(a)

 A nursing home's registered professional nursing staff shall determine which
 residents a dining assistant may safely assist with feeding and hydration. The
 determination shall be based on the resident's latest nursing assessment and
 plan of care, which is performed in accordance with generally accepted
 standards of practice and applicable laws and regulations;

(b)

 The resident's plan of care shall clearly
 reflect the nurse's determination that the resident may be safely assisted with
 feeding and hydration by a dining assistant; and

(c)

 Dining assistants shall not provide
 feeding and hydration assistance to residents who have complicated feeding
 problems, including, but not limited to, difficulty swallowing, recurrent lung
 aspirations, and tube or parenteral/IV feedings.

(5)

 The nursing home's dining assistant
 training program shall be conducted under the direction of a registered nurse
 and shall require participants to perform return demonstrations, as applicable,
 to demonstrate competencies on program components.

(6)

 The minimum requirements of the dining
 assistant training program shall include a minimum of 16 hours of training. The
 training shall include practical application of feeding and hydration skills
 and shall include at least the following components: 

(a)

 Feeding techniques;

(b)

 Assistance with feeding and
 hydration;

(c)

 Communication and
 interpersonal skills;

(d)

 Appropriate responses to resident behavior;

(e)

 Safety and emergency procedures,
 including the Heimlich Maneuver;

(f)

 Infection control;

(g)

 Recognizing changes in residents that are
 inconsistent with their normal behavior and the importance of reporting such
 changes to the supervisory nurse;

(h)

 Reporting requirements as specified by
 Article 4 of Chapter 8 of Title 31 of the Official Code of Georgia Annotated,
 the "Long-term Care Facility Resident Abuse Reporting Act"; and

(i)

 Resident rights, including abuse and
 neglect prevention.

(7)

 The nursing home shall maintain a written record of all individuals who have
 successfully completed the dining assistant training program. At a minimum,
 such written record maintained by the nursing home must include the dining
 assistant's complete name and address, the name and address of the nursing
 home, the name and signature of the registered nurse directing the training
 program, and the date the training program was successfully completed. The
 nursing home shall provide a copy of such written record in a timely manner to
 any dining assistant who has successfully completed the training program upon
 the dining assistant's written request.

(8)

 A copy of the written record of the
 satisfactory completion of the dining assistant training program may be used by
 a subsequent nursing home hiring the dining assistant in lieu of repeating the
 training, provided that the dining assistant satisfactorily performs return
 demonstrations of the minimum skills required of dining assistants as specified
 in these rules for the hiring nursing home. Such satisfactory demonstrations of
 skills shall be documented by a registered nurse and retained by the nursing
 home in the dining assistant's record along with a copy of the initial
 documentation of successful completion of the training program as specified in
 these rules.

(9)

 In addition to all
 other documents required by state or federal regulations, the nursing home
 shall maintain the following records:

(a)

 A
 copy of the nursing home's dining assistant training program; and

(b)

 Documentation of successful completion of
 the training program for each dining assistant.

Rule 111-8-56-.26 Background Screening and Employees

(1)

 Criminal History Background Checks for Owners Required. Prior to the issuance of any new license, the owner of the business or agency applying for the license must comply with the requirements of the Rules and Regulations for Criminal Background Checks, Chapter 111-8-12.

(2)

 Criminal History Background Checks for Administrators Required. The home must obtain a satisfactory fingerprint records check determination for the person being considered for employment as an administrator. The records check determination must be done in compliance with the Rules and Regulations for Criminal Background Checks, Chapter 111-8-12.

(3)

 Criminal History Background Checks for Direct Access Employees Required. Prior to serving as a direct access employee, the home must obtain a satisfactory fingerprint records check determination for the person to be hired in compliance with the Rules and Regulations for Criminal Background Checks, Chapter 111-8-12.

(4)

 Documentation of the nursing home's background screening shall be maintained for each employee.

Rule 111-8-56-.27 Vaccines

(1)

 Unless
 contraindicated, all nursing homes shall annually offer an influenza virus
 vaccine, contingent on availability, to all Medicare and Medicaid eligible
 residents and private pay residents in their facilities and a pneumococcal
 bacteria vaccine, contingent on availability, to all Medicare eligible
 residents and all private pay residents, 65 years of age or older, in their
 facilities.

(2)

 Vaccines and other
 medications shall only be administered by the nursing home's licensed personnel
 in accordance with applicable state laws and regulations.

(3)

 Vaccines and other medications shall be
 stored safely and appropriately monitored to prevent unauthorized use or
 access.

(4)

 Vaccines and other
 medications shall be properly labeled and handled in accordance with current
 accepted standards of practice and applicable laws and regulations. Outdated,
 mislabeled, or otherwise unusable vaccines and other medications shall not be
 available for resident use.

(5)

 Vaccines and other medications shall be kept in original containers with
 original labels intact.

Rule 111-8-56-.01 Definitions
Rule 111-8-56-.02 Governing Body
Rule 111-8-56-.03 Administration
Rule 111-8-56-.04 Nursing Services
Rule 111-8-56-.05 Professional Service
Rule 111-8-56-.06 Dietary Service
Rule 111-8-56-.07 Social Service
Rule 111-8-56-.08 Pharmacy Management and Administration
Rule 111-8-56-.09 Physical Therapy Service
Rule 111-8-56-.10 Medical, Dental and Nursing Care
Rule 111-8-56-.11 Records
Rule 111-8-56-.12 Equipment
Rule 111-8-56-.13 Safety
Rule 111-8-56-.14 Environmental Sanitation and Housekeeping
Rule 111-8-56-.15 Health of Employees
Rule 111-8-56-.16 Recreation
Rule 111-8-56-.17 Patient Capacity
Rule 111-8-56-.18 Physical Plant Standards
Rule 111-8-56-.19 Application for Permit
Rule 111-8-56-.20 Nursing Home Permit Requirements
Rule 111-8-56-.21 Provisional Permits
Rule 111-8-56-.22 Inspections
Rule 111-8-56-.23 New Construction
Rule 111-8-56-.24 Enforcement
Rule 111-8-56-.25 Dining Assistants
Rule 111-8-56-.26 Background Screening and Employees
Rule 111-8-56-.27 Vaccines

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