This chapter establishes comprehensive licensing and operating standards for nursing facilities in Hawaii, covering skilled nursing facilities (SNFs) and intermediate care facilities (ICFs). Operators must obtain a state license, meet staffing, administration, resident care, medical records, quality assurance, environmental health, and physical facility requirements. The regulation also sets out enforcement procedures, penalties, and waiver processes applicable to all licensed nursing facilities.
View official sourceDEPARTMENT OF HEALTH
Repeal of Chapter 11-94.1, "Nursing Facilities"
and the
Adoption of Chapter 11-94.2, "Nursing Facilities,"
Hawaii Administrative Rules
September 16, 2022
SUMMARY
1. Chapter 11-94.1, Hawaii Administrative
Rules, entitled "Nursing Facilities", is repealed.
2. Chapter 11-94.2, Hawaii Administrative
Rules, entitled "Nursing Facilities", is adopted.
HAWAII ADMINISTRATIVE RULES
TITLE 11
DEPARTMENT OF HEALTH
CHAPTER 94.2
NURSING FACILITIES
Subchapter 1 General Provisions
§11-94.2-1 Purpose
§11-94.2-2 Definitions
§§11-94.2-3 to 11-94.2-5 (Reserved)
Subchapter 2 Licensing Requirements
§11-94.2-6
§11-94.2-7
§11-94.2-8
§11-94.2-9
§11-94.2-10
§11-94.2-11
§§11-94.2-12
Licensing
Application
Maximum time period for processing
complete license appl i cation
Denial of licensure
Inspection
Waiver
to 11-94.2-15 (Reserved)
Subchapter 3 Administration Requirements
§11-94.2-16
§11-94.2-17
§11-94.2-18
§11-94.2-19
§11-94.2-20
§11-94.2-21
§11-94.2-22
§11-94.2-23
Governing body and management
Administrator
Medical director
Ownership and financial capability
In-service education
Arrangement for services
Medical record system
Quality assurance and performance
improvement
§§11 - 94.2-24 to 11-94.2-26 (Reserved)
94.2-1
of a
Subchapter 4 Resident Care Requirements
§11-94.2-27
§11-94.2-28
§11-94.2-29
§11-94.2-30
§§11-94.2-31
Resident rights and facility practices
Resident accounts
Resident abuse, neglect, and
misappropriation of resident property
Resident care
to 11-94.2-35 (Reserved)
Subchapter 5 Program Requirements
§11-94.2-36
§11-94.2-37
§11-94.2-38
§11-94.2-39
§11-94.2-40
§11-94.2-41
§11-94.2-42
§11-94.2-43
§11-94.2-44
§11-94.2-45
§11-94.2-46
§11-94.2-47
§§11-94.2-48
Admission, transfer, and discharge
Social work services
Activities
Nursing services
Dietary services
Storage and handling of food
Physician services
Interdisciplinary care process
Specialized rehabilitation services
Dental services
Pharmaceutical services
Adult day health services
to 11-94.2-52 (Reserved)
Subchapter 6 Environmental Health Standards
§11-94. 2 -53
§11-94.2-54
§11-94.2-55
§11-94.2-56
§11-94.2-57
§11-94.2-58
§§11-94.2-59
Infection control
Sanitation
Housekeeping
Laundry service
Life safety
Emergency preparedness
to 11-94.2-63 (Reserved)
Subchapter 7 Physical Facility Standards
§11-94.2-64 Engineering and maintenance
§11-94.2 - 65 Construction requirements
§§11-94.2-66 to 11-94.2-68 (Reserved)
94.2-2
§11-94.2-1
Subchapter 8 Administrative Enforcement
§11-94.2-69
§11-94.2-70
§§11-94.2-71
§11-94.2-75
§11-94.2-76
Enforcement
Penalties and remedies
to 11-94. 2-74 (Reserved)
Severability
Transition
SUBCHAPTER 1
GENERAL PROVISIONS
§11-94.2-1 Purpose. The purpose of this chapter
is to establish minimum requirements for the
protection of the health, welfare, and safety of
residents, personnel, and the public in nursing
facilities that provide care and services for
residents at the skilled nursing and intermediate care
facility level of care. This chapter shall not be
construed to lower standards, ordinances, or rules
established by other divisions or subdivisions of
State government; in all i6ifaic&~02rhe more stringent
rules shall apply. [Eff ] (Auth: HRS
§§321-9, 321-10, 321-11) {Imp: HRS §§321-9, 321-10,
321-11)
§11-94.2-2 Definitions. As used in this
chapter:
"Activities professional" or "qualified
therapeutic recreational specialist" means:
(1) A qualified professional who has two years
of experience in a social or recreational
program within the last five years, one of
which was full-time in a resident activities
program in a health care setting;
(2) An occupational therapist or occupational
therapy assistant;
(3) A person who has completed a training course
approved by the department; or
94.2-3
§11-94.2-2
(4) A person who is eligible for certification
as a therapeutic recreation specialist or as
an activities professional by a recognized
accrediting body on or after October 1, 1990 .
"Advanced directive" means a written or oral
declaration made by a competent adult, instructing his
or her physician to provide, withhold, or withdraw
life-sustaining procedures under certain conditions
such as a terminal condition or where the resident has
a permanent loss of ability to communicate with others
due to irreversible brain injury or coma. (An
advanced directive is often referred to as an advanced
health care directive or as a living will.)
"Advanced practice registered nurse" or "APRN"
means a registered nurse who is licensed pursuant to
chapter 457, HRS.
"Bed hold policy" means a written policy that
specifies legal readmission rights of a resident who
transfers from the facility for a hospitalization or
therapeutic leave and a payment schedule to hold the
bed during that resident's absence.
"Certified nursing assistant" or "CNA" or "nurse
aide" means a person who is currently certified as a
nurse aide pursuant to chapter 457A, HRS.
"Comprehensive assessment" means an evaluation
completed by the interdisciplinary team to identify a
resident's functional capacity, including the
resident's strengths, preferences, and needs in the
areas including but not limited to activities of daily
living (ADLs), cognition, continence, mood, behavior,
nutritional status, communication, vision, and
psychosocial well-being.
"Controlled drugs" means drugs listed as being
subject to high incidences of abuse as defined in
chapter 329, HRS.
"Dental services" means an annual inspection of
the oral cavity for signs of disease, diagnosis of
dental disease, dental radiographs as needed, dental
cleaning, fillings (new and repairs), minor dental
plate adjustments, smoothing of broken teeth, and
limited prosthodontic procedures, e.g., taking
impress ions for dentures and fitting dentures.
94.2-4
§11-94.2-2
"Dentist" means any person holding a valid
license to practice dentistry, pursuant to chapter
448, HRS.
"Department" means the department of health,
State of Hawaii.
"Dietary manager" means:
(1) A dietitian who meets the requirements of
section 448B-5, HRS;
(2) A graduate of a dietetic technician training
program approved by the American Dietetic
Association;
(3) An individual certified by the Certifying
Board for Dietary Managers of the Dietary
Managers Association; or
(4) An individual who has successfully completed
an approved course curriculum in any of the
following, and has taken annual continuing
education credits to keep up with current
food service trends and practices, as set
forth by the Dietary Managers Association:
(A) State approved course that includes at
least ninety or more hours of classroom
or correspondence instruction, plus two
years of work experience of which at
minimum, nineteen months were at t he
managerial level and the remainder as a
nutritionist;
(B) A two- or four-year college degree in
foodservice management and nutrition; or
(C) A United States military training
program in foodservice management with
the attainment of a grade of E-5 or its
equivalent according to the brand of
service.
"Dietitian" means a person who:
(1) Is registered by the Commission on Dietetics
Registration; or
(2 ) Is eligible for such registration.
"Director of health" or "director" means the
director of the department of health, State of Hawaii,
or the director's designee.
94.2-5
§11-94.2-2
"Discharge" means movement of a resident from a
facility to the resident's home or other location in
the community, when return to the facility is not
expected or planned.
"Disinfect" means to render inactive virtually
all recognizable pathogenic microorganisms but not
necessarily all microbial forms, e.g., bacterial
endospores.
"Drug administration" means the act in which a
single dose of a prescribed drug or biological
substance is given to a resident by an authorized
person in accordance with all existing laws and rules
governing those acts.
"Drug dispensing" means the furnishing of drugs
pursuant to a prescription in a suitable container,
appropriately labeled for subsequent administration to
or use by a resident or other individual entitled to
receive the drug.
"Emergency dental service'' includes dental
services to control bleeding, relieve pain, eliminate
acute infection, and treatment of injuries to the
teeth o r supporting structures, and other medically
urgent dental services.
"Evacuation capacity designation" means the
designation determined by the current county building
and fire codes that indicates whether the physical
structure of the facility is safe for residents to
remain i n the building, or whether they must be
evacuated from a facility in an emergency or disaster.
"Govern i ng body" means the policy-making group
authority that exercises general direction or
fiduciary responsibilities over the affairs of a
facility and establishes policies concerning its
operation and the welfare of the residents the
facility serves.
"Infectious waste" or "regulated waste" or
"medica l waste" or "pathological waste" means any
waste that may contain pathogens capable of causing an
infecti o us di sease and shall include but is not
limited t o wastes categorized in section 11-104.1-4.
94.2-6
§11-94.2-2
"Interdisciplinary" means the integration of two
or more professional disciplines working together to
provide the greatest benefit to the resident.
"Legal guardian" means a person who has the legal
authority (and the corresponding duty) to care for the
personal or property interests, or both, of another
person, referred to as a ward.
"Licensed practical nurse" or "LPN" means a
person who is licensed as a practical nurse pursuant
to chapter 457, HRS.
"Licensed social worker" or "social worker" or
"LSW" means a person who is licensed to practice
social work pursuant to chapter 467E, HRS.
"Nursing facility" means a skilled nursing
facility or "SNF", intermediate care facility or
"ICF", or a skilled nursing and intermediate care
facility or "SNF/ICF".
(1) "Intermediate care facility" means a health
facility to which a physician has referred
individuals who do not need twenty-four hour
a day skilled nursing care but who do
require the following services for
appropriate care:
{A) Twenty-four hours a day assistance with
the normal activities of daily living;
and
(B) Care provided by licensed nursing and
paramedical personnel on a regular,
long-term basis.
(2 ) "Skilled nursing facility" means a heal th
facility that provides skilled nursing and
related services to residents who require
twenty-four hour a day medical or nursing
care, or rehabilitation services, including
but not limited to physical therapy,
occupational therapy, and speech therapy
services.
"Nursing home administrator" means a person
licensed pursuant to chapter 457B, HRS.
94 . 2- 7
§11-94.2-2
"Nursing plan of care" means an individualized
treatment plan developed at the time of admission,
based on the initial nursing assessment of the
resident in conjunction with the physician's admission
physical examination and initial orders .
"Occupational therapist" means a person licensed
pursuant to chapter 457G, HRS.
"Occupational therapy assistant" means a person
who is currently certified or eligible for
certification by the National Board for Certification
in occupational therapy.
"Overall plan of care" means an integrated plan
of care that includes the interventions and care or
services to be provided by nurses, social workers,
rehabilitative therapists, physicians, APRNs,
physician assistants, dietitians and other
professionals as determined by a comprehensive
assessment. The overall plan of care shall have
measurable goals and objectives with specific
timelines directed to attain or maintain the
resident's highest practicable physical, mental, and
psychosocial well-being. The plan shall also includ e
appropriate discharge planning.
"Performance improvement" or "PI" means the
continuous study and improvement of processes with the
intent to improve services or outcomes, and prevent or
decrease the likelihood of problems, by identifying
opportunities for improvement, and testing new
approaches to fix underlying causes of persistent or
systemic problems or barriers to improvement. PI aims
to improve facility processes involved in care
delivery and enhanced resident quality of life.
"Pharmacist" means a person who is licensed as a
registered pharmacist pursuant to chapter 461, HRS.
"Physical therapist" means a person who is
licensed as a physical therapist pursuant to chapter
461J, HRS.
"Physical therapy assistant" means a person who
has graduated from a two-year college-level program
approved by the Section on Education of the American
Physical Therapy Association.
94.2-8
§11-94.2-2
"Physician" means a person who is licensed to
practice medicine or osteopathy pursuant to chapter
453, HRS.
"Physician assistant" means a person who is
licensed pursuant to chapter 453, HRS.
"Plan of correction" means a plan developed by
the facility that includes actions that will be taken
to address deficiencies cited or detected by the
department pursuant to a survey, inspection, or
complaint investigation that shall include preventive
measures to ensure compliance with this chapter and
chapter 321, HRS, and the timeframe in which these
corrections shall take place.
"Quality assurance" or "QA" means the
specification of standards for quality of care,
service and outcomes, and systems throughout the
facility for assuring that care is maintained at
acceptable levels in relation to those standards. QA
is on-going and both anticipatory and retrospective in
its efforts to identify how the facility is
performing, including where and why facility
performance is at risk or has failed to meet
standards.
"Quality assurance and performance improvement"
or "QAPI" means the coordinated application of
mutually-reinforcing aspects of quality managemen t
that takes a systematic, interdisciplinary,
comprehensive, and data-driven approach to maintaining
and improving safety and quality.
"Registered health information administrator" or
"RHIA" means a person who successfully passed a
national qualifying examination offered by the
American Health Information Management Association and
is currently certified by the association as a RHIA.
"Registered h e alth information technician" or
"RHIT" means a person who successfully passed a
national qualifying examination offered by the
American Health Information Managemen t Association and
is currently certified by the association as a RHIT.
94.2-9
§11-94.2-2
"Registered nurse" or "RN" means a person who is
licensed as a registered nurse pursuant to chapter
457, HRS.
"Rehabilitative plan of care" means a treatment
plan based on the attending physician's, physician
assistant's, or APRN's orders and assessment of a
resident's needs in regard to specialized
rehabilitative procedures.
"Reputable and responsible character" means the
character of an individual who has not been:
(1) Convicted of a relevant crime as defined in
section 321-15.2(a), HRS; or
(2) Confirmed by the State as a perpetrator of
adult or child abuse, neglect, financial
exploitation, or domestic violence.
"Social work plan of care" means a plan of
services based on an assessment completed by the
social worker or designee to address social,
behavioral, or treatment interventions required to
assist the resident to maintain his or her highest
practicable physical, mental, or psychosocial well
being, with plans for appropriate and timely discharge
as practical.
"Social worker designee" means a person who is
supervised by a licensed social worker.
"Special diet" or "therapeutic diet" means a diet
ordered by a physician or APRN that is prescribed as
part of the medical nutrition therapy of a nursing
facility resident.
"Speech pathologist" or "speech therapist" or
"audio l ogist" means a person who is licensed pursuant
to chapter 468E, HRS, and:
(1 ) Is eligible for a certificate of clinical
c ompetence granted by the American Speech
Language-Hearing Association in speech
therapy, pathology, or audiology; or
(2) Meets the educational requirements for
certification and is in the process of
accumulating the supervised experience
required to take the examination for
certification.
94.2-10
§11-94.2-2
"Statement of deficiencies" means a listing of
citations given to the facility that describes the
extent to which the facility is not compliant with the
requirements of this chapter, and that is issued to
the facility at the completion of a survey or
licensing inspection or complaint investigation.
"Surrogate" means an individual other than the
nursing facility's agent or legal guardian who is
authorized under chapter 327E, HRS, to make a
healthcare decision for the resident.
"Transfer" means the movement of a resident from
one facility to another facility for continued care
regardless of whether the resident is expected or
planned to return to the original facility. It does
not refer to movement between beds within the same
licensed facility.
"Waiver" means an exemption to a rule.
[Eff SEP 1 6 2022 ] (Auth: HRS §§321-9, 321-11)
(Imp: HRS §§321-9, 321-11)
§§11-94.2-3 to 11-94.2-5 (Reserved).
SUBCHAPTER 2
LICENSING REQUIREMENTS
§11-94 . 2-6 Licensing. (a) No person or group of
persons may operate a nursing facility unless the
facility is licensed by the department.
(b) All nursing facilities shall be licensed
pursuant to this chapter and meet all requirements for
licensure under state law prior to admitting any
residents, except those operated by the federal
government or agency thereof.
{c) The department may accept accreditation by
the Joint Commission or other nationally recognized
accreditation or certification organizations
including, but not limited to, the U.S. Centers for
Medicare and Medicaid Services, as demonstrating a
94.2-11
§11-94.2-6
facility's compliance with all relicensing inspections
required by the department.
(d) The department shall inspect each nursing
facility at least annually, or at a time interval as
determined by the department for relicensing. The
department, without prior notice, may enter the
premises at any time to secure compliance with or to
prevent a violation of this chapter.
(e) The department may exempt a facility from a
relicensing inspection when the facility is accredited
or certified in accordance with this section under the
following conditions:
(1) The facility provides a certified copy
of the facility's official
accreditation or certification report
to the department;
{2 ) The facility continuously holds full
accreditation or certification by the
accreditation or certification
organization; and
(3) The facility holds a current and valid
state license.
(f) The most current licensing statement of
deficiencies and plan of correction shall be kept on
file in the facility, and the facility shall:
(1) Make the statement of deficiencies and
plan of correction available for
examination in a place readily
accessible to residents; and
(2) Post a notice of the availability of
the statement of deficiencies and plan
of correction.
(g) All facilities shall not discriminate
against any individual as per all federal and state
civil rights and anti-discrimination regulations.
Should the facility not be able to provide care and
services to individuals based on their age, i.e.,
infants and youth, or specific disability, the
facility will need to indicate so in their policies
and procedures and by-laws.
94 . 2-12
§11-94.2-6
(h) The department shall prescribe the content
and form of the license and may authorize a waiver or
waivers for a particular facility.
(i) In the event of a change of administration,
name, location, ownership, or the number and type of
operational beds, the facility shall notify the
department fifteen days prior to the change, an
inspection at the discretion of the department shall
be conducted, and if the provisions of this chapter
are met, a new license shall be issued.
(j) Every regular license shall continue in
force for a period of one year unless otherwise
specified, or unless it is suspended or revoked.
(k) The current license shall be posted in a
conspicuous place visible to the public within the
facility.
(1) A provisional license may be issued at the
discretion of the department to allow sufficient time
for correction to deficiencies cited.
(m) When a facility intends to voluntarily
close, the following shall apply:
(1) The licensee shall notify the
department in writing at least thirty
days prior to an intended closure;
(2) All residents, legal guardians,
surrogates, and other responsible
agencies shall be notified at least
thirty days prior to an intended
closure;
(3) All residents shall be transferred to
appropriate licensed facilities prior
to closure; and
(4) The licensee shall notify the
department that all residents have been
transferred and provide a listing of
residents' names, name of facility
transferred to, and date of transfer.
[Eff SEP 1 6 2022 ) (Auth: HRS §§321-
9, 321-11; SLH 2021, Act 28) (Imp: HRS
§§321-9, 321-11; SLH 2021, Act 28)
94.2-13
§11-94.2-7
§11-94.2-7 Application. The applicant shall
submit:
( 1)
( 2)
( 3)
( 4)
( 5)
( 6)
( 7)
An application on a form approved by the
department with the following supporting
documentation or information:
(A) Name, address, and contact information
of the owner(s);
(B) Registration of corporation, artic l es
of incorporation, limited liability
company with a list of officers,
directors, trustees, members, or
advisory board members;
(C) Bylaws;
(D) Copy of documents recognizing the
applicant's ability to do business in
the State;
(E) An annual budget including all
anticipated income and expenses
demonstrating the facility's financial
capability to ensure the health,
safety, and welfare of residents; and
(F) Building plans indicating accurate
measurements to scale of the entire
facility with certificate of occupancy
as appropriate;
Documented compliance with current county
building and land use codes;
Documented compliance with current county
fire code requirements;
Documented clearance by the sanitation
branch of the department;
Documented clearance by the wastewater
branch of the department;
A certificate of need from the state health
planning and development agency as
determined by the State;
All prospective applicants, licensees,
operators, administrators, and direct
resident access employees, and volunteers
shall be screened for a history of abuse,
neglect, or misappropriation of funds that
94.2-14
§11-94.2-7
includes but is not limited to fingerprint
record checks through the Federal Bureau of
Investigation and the Hawaii criminal
justice data center, obtaining information
from previous and current employers, and
checking with the appropriate licensing
boards and registries. [Eff SEP 1 6 2022 ]
(Auth: HRS §§321-9, 321-11, 321-15.2) (Imp:
HRS §§321-9, 321-11, 321-15.2}
§11-94.2-8 Maximum time period for processing of
a complete license application. (a) The department
shall grant or deny an application and inform the
applicant of its decision within ninety days of
receipt of a complete application.
(b) If the department does not grant a license
or deny an application within ninety days of receipt
of the complete application, the application for
issuance of a license shall be deemed approved on the
ninetieth day. After the expiration of the ninety
days, the department shall issue the license within
thirty days.
(c} Notwithstanding the requirements of
subsections (a) and (b}, the maximum period of ninety
days shall be extended indefinitely in the event of a
national disaster, state emergency, or union strike
that would prevent the applicant, the agency, or the
department from fulfilling application review in a
timely manner. [Eff SEP 1 6 2022 ] (Auth: HRS §§321-
9, 321-11} (Imp: HRS §§321-9, 321-11}
§11-94.2-9 Denial of licensure. An application
for a license may be denied for any of the reasons
that include but are not limited to the following:
(1) Failure of the applicant to comply with this
chapter or chapter 321, HRS;
(2} Failure of the applicant to provide all
requirements specified in section 11-94.2-7;
94.2-15
§11-94.2-10
(3) Failure of the applicant to possess and
provide evidence of financial capability to
operate the facility pursuant to this
chapter;
(4) The fraudulent representation or
misrepresentation of facts by the applicant;
(5) Failure to comply with and provide criminal
history record check information pursuant to
section 321-15.2, HRS; and
(6) Determination by the department that the
applicant does not possess a reputable or
responsible character. [Eff SEP 1 6 2022
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-
9, 321-11)
§11-94.2-10 Inspection.
complaint investigations shall
be conducted outside of normal
State.
(a) All inspections and
be unannounced and may
business hours of the
(b) The department may conduct inspections and
investigations of an exempt facility regarding
complaints, adverse accreditation or certification
findings, or periodic validation surveys.
(c) Following an inspection, a statement of
deficiencies, if any, shall be presented to the
facility. The facility shall return a plan of
correction to the department within ten days of the
receipt of the statement of deficiencies. Receipt of
the statement of deficiencies is presumed to be within
five days from the date of the notice. Facilities
shall be allowed a reasonable time to implement the
plan of correction. A follow-up inspection may be
made by the department to assess the progress in the
plan of correction. If there has not been substantial
progress in carrying out the plan of correction, the
license shall be revoked or shall not be renewed. A
provisional license may be issued should the
department determine that good faith efforts are being
made by the facility to carry out the plan of
correction and the facility requires additional time
to meet the requirements.
94.2-16
§11-94.2-10
(d) The department shall charge appropriate fees for
the processing of an application, issuance of a new
license, and a license renewal. The department shall
provide prior notice of the amount of the fee to the
licensee. (Eff SEP 1 6 2022 ] (Auth: HRS §§321-9,
321-11; SLH 2021, Act 28) (Imp: HRS §§321-9, 321-11;
SLH 2021, Act 28)
§11-94. 2-11 Waiver. (a) Every request for a
waiver from an otherwise applicable licensing
requirement shall be set forth in writing and
submitted to the department for approval. The
licensee shall submit the information required in this
subsection to enable the department to make a decision
on the request for a waiver.
(1) The department shall not act upon or
consider any incomplete requests for
waivers. A waiver request shall be
deemed complete only when all required
and requested information, including a
reason for the waiver and a proposal
for an alternate plan to ensure the
health, safety, welfare, and civil
rights of the resident(s), including
resident care and life safety
safeguards, is received by the
department;
(2) Every request shall be signed by the
licensee and shall constitute an
acknowledgment and agreement that the
licensee will comply with all terms and
conditions of the waiver and this
chapter upon approval of the request;
(3) The department may require the
submission of additional information
after the request has been submitted;
(4) A waiver shall no t be t ransferable;
(5) The failure of the department to act on
a completed request for a waiver within
94 . 2-17
§11-94.2-11
sixty days of receipt of request shall
be deemed an approval of the request,
provided that the licensee acts in
accordance with the request process;
(6) Notwithstanding the requirements of
paragraph (5), the maximum period of
time of sixty days shall be extended
indefinitely in the event of a national
disaster, state emergency, or union
strike that would prevent the
applicant, the agency, or the
department from fulfilling application
review in a timely manner; and
(7) Waivers may be granted on a case-by
case basis and shall not be construed
as a precedent for any other
circumstances or situations.
(b) The waiver request will be reviewed by the
department giving due consideration to the effect or
probable effect the waiver would have on the health,
safety, and welfare of the residents.
(c) Whenever a request is approved by the
department, the department shall issue a waiver
authorizing the operation of a nursing facility
pursuant to the conditions specified in the request
for the waiver, or conditions specified by the
department, or both. No waiver shall be granted by
the department unless the request and the supporting
information clearly show that:
(1) Granting the waiver will not endanger
the health, safety, or welfare of the
resident(s);
(2) Granting the waiver will not affect the
requirements of licensure provided in
section 11-94.2-6; and
(3) Granting the waiver will not affect the
nursing services provided in section
11-94.2-39.
(d) Any approved waiver shall be granted within
the requirements of this section, for time periods and
under conditions consistent with this chapter, and
with the following limitations:
94.2-18
§11-94.2-11
(1) The department may issue a waiver for a
period not exceeding one year;
(2) The department may revoke the waiver at
any time if the waiver creates a threat
to the health, safety, or welfare of
the resident(s);
(3) For every waiver granted under this
section, the department shall, on a
case-by-case basis, require the
licensee to submit to the department
additional information as may be
necessary or appropriate such as:
(A) Resident diagnosis, physician or
APRN order, training to be
provided to licensee, plan for
monitoring, oversight, and
evaluation of resident status;
(B) Conditions under which any
structural changes to the facility
will be completed, specific
timeframe for construction
completion, and plan to ensure the
safety of the residents during
construction; and
(C) Procedure to be undertaken to
ensure the health, safety, and
welfare of residents as
necessitated by staffing changes
or training to meet the
requirements of this chapter;
(4) For every waiver granted under this
section, the department shall perform a
thorough review of known and available
means of protecting the health, safety,
or welfare of the resident(s} to which
the waiver applies.
(e} Renewal of waivers shall be requested in
writing and shall be submitted to the department at
least sixty days prior to the expiration of the
waiver. The department shall act on a request for
renewal within sixty days of the receipt of the
request.
94.2-19
§11-94.2-16
(f) Any waiver granted pursuant to this section
may be renewed on the same terms and conditions on
which the waiver was initially granted, for a period
not exceeding one year, provided that:
(1) The request for renewal has met all of
the conditions specified in the
immediately preceding waiver; and
(2) The request for renewal and the waiver
issued in response to that request
shall provide for the protection of the
health, safety, and welfare of the
resident(s) in a manner that is
consistent with the terms of the
immediately preceding waiver at its
expiration.
(g) No waiver shall be
limit the application of any
procedures provided by law.
(Auth: HRS §§321-9, 321-11)
construed to prevent or
emergency provisions and
[Eff SEP 1 6 2022 J
(Imp: HRS §§321-9, 321-11)
§§11-94.2-12 to 11-94.2-15 (Reserved).
SUBCHAPTER 3
ADMINISTRATION REQUIREMENTS
§11-94 . 2-16 Governing body and management. (a)
Each facility shall have an organized governing body,
or designated persons functioning as the governing
body, that has overall responsibility for the conduct
of all activities. The governing body may include the
administrator. The facility shall maintain methods of
administrative management that assure that the
requirements of this section are met.
(b) The facility shall ensure that:
(1) Staff sufficient in number and
qualifications shall be on duty twenty
four hours a day to carry out the
policies, responsibilities, assessed
care needs of the residents and program
of the facility; and
94.2-20
§11-94.2-16
(2) The numbers and categories of personnel
shall be determined by the number,
acuity level, and needs of residents.
(c) The facility shall have written personnel
policies available to staff, residents, and the public
that govern all services provided by the facility and
include but are not limited to:
(1) Written job descriptions available for
all positions. Each employee sha ll be
informed of the employee's duties and
responsibilities at the time of
employment;
(2) Requirements that all employees have
appropriate licenses or certification
as required by law, and their licenses
or certification shall be readily
available for examination by the
department;
(3) Ethical standards of professional
conduct that shall apply in the
facility; and
(4) An organization chart showing the major
operating programs of the facility,
with staff division, administrative
personnel in charge of programs and
divisions, and their lines of
authority, responsibility 'SE'f.111 6 2022
communication .. [Eff
(Auth: HRS §§321-9, 321-11) (Imp: HRS
§§321-9, 321-11)
§11-94.2-17 Administrator. All freestanding and
hospital-based nursing facilities shall be
administered by:
(1) A person appointed by the governing body and
responsible for the management of the
facility; and
(2) Licensed by the State as a nursing home
administrator; or
(3) In the absence of the administrator, an
employee who has been designated, in
94.2-21
13483
§11-94.2-19
writing, to act on the administrator's
behalf for a determined period of time as
approved by the department. [Eff SEP 1 6 2024
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-
9, 321-11)
§11-94.2-18 Medical director. The facility must
designate a physician to serve as medical director.
The medical director is responsible for:
(1) Development, implementation, and evaluation
of resident care policies;
(2) Coordination of medical care in the
( 3)
facility; and
Consultation and training to licensed
as necessary. [Eff SEP 1 6 2022
(Auth: HRS §§321-9, 321-11) (Imp: HRS
9, 321-11)
staff
l
§§321-
§11-94.2-19 Ownership and financial capability.
(a) The facility shall provide the department with
current information about ownership of the facility
including:
(1) The name of each person who has an ownership
interest of ten per cent or more in the
facility;
(2) The name of each person who is the owner (in
whole or in part) of any mortgage, deed or
trust, note, or other obligation secured (in
whole or in part) by the facility;
(3) The officers and directors of the
corporat i on, if the facility is organized as
a corporation, is incorporated, or is a
limited liability company, and any changes
in the officers and directors; and
(4) The name of each partner if the facility is
organized as a partne r sh i p .
(b) The owner shall provide eviden ce as deemed
necessary by the department to establish that the
financial resourc e s of the owner are sufficient to
94 .2 - 22
§11-94.2-19
operate and maintain the facility according to the
standards set forth in this chapter. [ Eff SEP 1 6 7022
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-11)
§11-94. 2-20 In-service education. (a) There
shall be a staff in-service education program that
includes the following:
(1) Orientation for all new employees that shall
include:
(A) Information to acquaint them with the
philosophy, organization, program,
policies and procedures, practices, and
goals of the facility; and
(B) Competency evaluation to ensure that
staff are able to carry out their
respective duties;
(2) In-service training for employees who have
not achieved the desired level of
competence, and continuing in-service
education to update
and improve the skills and competencies of
all employees;
(3) In-service training that shall include
annually, at minimum, prevention and control
of infections, fire prevention and safety,
disaster preparedness for all hazards,
accident prevention, resident rights
including prevention of resident abuse,
neglect and financial exploitation, and
problems and needs of the aged, ill, and
disabled;
(4) Competency testing for cardiopulmonary
resuscitation to annually certify the
nursing staff;
(5) Training in oral hygiene and denture care,
which shall be given to the nursing staff at
least annually; and
(6) Appropriate personal hygiene instructions at
regular intervals shall be given to all
personnel providing direct care and handling
food.
94.2-23
§11-94.2-22
(b) Records shall be maintained and available
for departmental review for all orientation and staff
in-service and development programs.
(c) The facility shall have in place a system to
ensure S!P1\ ~12022taff receive in-service training.
[Eff ] (Auth: HRS §§321-9, 321-11)
(Imp: HRS §§321-9, 321-11)
§11-94.2-21 Arrangement for services. When the
facility does not employ a qualified person to render
a required or necessary service, it shall have a
written agreement or contract with a qualified outside
person CS£jl)~o~iffitf to provide the needed service.
[Eff ] (Auth: HRS §§321-9, 321-11)
(Imp: HRS §§321-9, 321-11)
§11-94. 2-22 Medical record system. (a) The
facility shall have available sufficient appropriately
qualified staff and necessary supporting personnel to
facilitate the accurate processing, auditing and
analysis, indexing, filing, and prompt retrieval of
records, record data, and resident health information.
(b) If the employee who supervises medical
records is not a registered health information
administrator or registered health information
technician, there shall be regularly scheduled visits
by a qualified consultant who shall provide reports to
the administrator.
(c) The following information shall be obtained
and entered in the resident's record at the time of
admission to the facility:
(1) Personal information such as name,
date, and time of admission, date and
place of birth, citizenship status,
marital status, social security number,
or an admission number that can be used
to identify the resident without use of
name when the latter is desirable;
94.2-24
§11-94.2-22
(2) Name and address of next of kin, legal
guardian, surrogate, or representative
holding a power of attorney;
(3) Sex, height, weight, race, and
identifying marks;
(4) Reason for admission or referral;
(5) Language spoken and understood;
(6) Information relevant to religious
affiliation, if any;
(7) Admission diagnosis, summary of prior
medical care with listing of physicians
providing care, recent physical
examination, tuberculosis status, and
physician's orders; and
(8) Advanced directives, as applicable.
(d) Records to be maintained and updated, as
necessary, for the duration of each resident's stay
shall also include:
(1) Appropriate authorizations and consents
for medical procedures;
(2) Records of all periods, with physician
orders, of use of physical or chemical
restraints with justification and
authorization for each and
documentation of ongoing assessment of
resident during use of restraints;
(3) Copies of initial and periodic
examinations and evaluations, as well
as progress notes at appropriate
intervals;
(4) Regular review of an overall plan of
care setting forth goals to be
accomplished through individually
designed activities, therapies, and
treatments, and indicating which
professional services or individual is
responsible for providing the care or
service;
(5) Entries describing all care,
treatments, medications, tests,
immunizations, and all ancillary
services provided; and
94.2-25
( e)
facility
§11-94 . 2-22
(6) All physician ' s, physician assistant's,
or APRN's orders completed with
appropriate documentation (signature,
title, and date).
When a resident is transferred to another
or discharged, there shall be:
(1) Written documentation of the reason for
the transfer or discharge and efforts
made by the facility to mitigate any
stress that may arise due to the
transfer;
(2) Documentation to indicate that the
resident understood the reason for
transfer, or that the duly authorized
healthcare decision maker and family
were notified;
(3) A complete summary including current
status and care, final diagnosis, and
prognosis; and
(4) Documentation of efforts made for
effective discharge planning.
(f) The facility shall have available a master
alphabetical index that is a permanent record of all
residents admitted to the facility. The index shall
include but not be limited to name, date of birth,
facility medical record number, name of physician, and
dates of admission and discharge.
(g) All entries in a resident's record shall be:
(1) Accurate and complete;
(2) Legible and typed or written in black
or blue ink;
( 3) Dated;
(4) Authenticated by signature and title of
the individual making the entry; and
(5) Written completely without the use of
abbreviations except for those
abbreviations approved by a medical
consultant or the medical doctor.
94 . 2-26
§11-94.2-22
(h) All information contained in the resident's
record, including any information contained in an
automated data bank, shall be considered confidential
and adhere to requirements as set forth by the Health
Insurance Portability and Accountability Act of 1996.
(i) The record shall be the property of the
facility, whose responsibility shall be to secure the
information against loss, destruction, defacement,
tampering, or use by unauthorized persons.
(j) There shall be written policies and
procedures governing the management of resident health
information including but not limited to access to,
duplication of, and dissemination of information from
the record, and the retention of the medical records
and disposal methods as appropriate.
(k) Written consent of the resident, if
competent, or the duly authorized healthcare decision
maker if the resident is not competent, shall be
required for the release of information to persons not
otherwise authorized to receive it. Consent forms
shall include:
(1) The use for which the information is
requested;
(2) Sections or elements of information to
be released and specific period of time
during which the information is to be
released; and
(3) Consent of the resident, legal
guardian, or surrogate for release of
any medical record information .
(1) Records shall be readily accessible and
available to authorized department personnel for the
purpose of determining compliance with this chapter.
(m) The facility shall retain medical records
pursuant to section 622-58, HRS, in the original or
reproduced form for a minimum of seven years after the
last data entry, except in the case of minors, whose
records shall be retained during the period of
minority plus seven years a~ftei0'2¼nor reaches the
age of majority. [Eff ] (Auth: HRS
§§321-9, 321-11) (Imp: HRS §§321-9, 321-11)
94.2-27
§11-94.2-27
§11-94.2-23 Quality assurance and performance
improvement. (a) The facility shall develop,
implement, and maintain an effective, comprehensive,
data-driven quality assurance and performance
improvement program that focuses on indicators of the
outcomes of care and quality of life for the full
range of care and services provided by the facility.
(b) The administrator shall be responsib l e and
accountable for ensuring the program is defined,
implemented, and maintained, and addresses identified
priorities, and is annually approved by the governing
body.
(c) The program shall be described in a written
plan containing the process that will guide the
facility's efforts in assuring care and services are
maintained at acceptable levels osEPeftg:,~m1ce and
continuous improvement. [Eff ]
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-11)
§§11-94.2-24 to 11-94.2-26 (Reserved).
SUBCHAPTER 4
RESIDENT CARE REQUIREMENTS
§11-94.2-27 Resident rights and facility
practices. Written policies regarding the rights and
responsibilities of residents during the resident's
stay in the facility shall be established and shall be
made available to the resident, resident family, legal
guardian, surrogate, sponsoring agency or
representative payee, and the public upon request. A
facility must protect and promote the rights of each
resident, including:
(1) The free exercise of rights as a resident of
the facility and as a citizen or resident of
the United States;
(2) The right to be free of interference,
coercion, discrimination, and reprisal from
94.2-28
§11-94.2-27
the facility that shall include the right to
be free of chemical or physical restraints
not medically indicated;
(3) The right to be fully informed, both orally
and in writing in a language understood by
the resident, or in a manner that allows for
the resident's understanding, of the
resident's rights and all rules and
regulations governing resident conduct and
responsibilities;
(4) The right to a dignified existence, self
determination, and communication with and
access to persons and services inside and
outside the facility;
(5) The right to access all records pertaining
to the resident, including current clinical
records, and to purchase copies of those
records at a cost not to exceed community
standards;
(6) The right to be informed in a language, or
in a manner that the resident understands,
of the resident's health status and medical
condition;
(7) The right to refuse treatment, to refuse to
participate in experimental research, and to
formulate an advance directive;
(8) The right to be informed of medicaid
benefits and requirements and procedures for
establishing eligibility;
(9) The right to names, addresses, and telephone
numbers of pertinent resident advocacy
groups;
(10) The right to manage the resident's fi nancial
affairs to the extent the resident is
competent and capable of doing so;
(11) The right to choose a personal physician to
the extent the resident is competent and
capable of doing so;
(12) The right to be fully informed in advance
about ca r e and treatment and of any changes
94 . 2-29
§11-94.2-28
in that care and treatment and the right to
participate in planning care and treatment,
unless adjudged incompetent or
incapacitated;
(13) The right to be fully informed, prior to or
at the time of admission and during the
resident's stay of services available in or
through the facility and of related charges,
including any charges for services not
covered by the facility's basic per diem
rate;
(14) The right to personal privacy and
confidentiality of personal and cl~nical
records; and
(15) The right to translation or interpretation
services or other communication assistance
as necessary. [Eff SEP 1 6 2022 l
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-
9, 321-11)
§11-94.2-28 Resident accounts. (a) In the
event the resident or family member requests the
facility to manage the resident's personal funds, an
itemized account shall be made available in writing to
the resident or the legal guardian or surrogate, and
shall be maintained and kept current for the resident,
including:
(1) Written receipts for all personal
possessions and funds received by or
deposited with the facility; and
(2) Written receipts for all disbursements made
to, or on behalf of, the resident.
(b) Upon request of each resident or legal
guardian or surrogate, articles kept for safekeeping
shall be released.
(c) Neither the administrator nor any staff
member nor any member of the governing board, nor any
owner of a facility shall serve as legal guardian o r
surrogate for a resident. [Eff SEP 1 6 7022 )
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9,321-11 )
94.2-30
§11-94.2-29
§11-94.2-29 Resident abuse, neglect, and
misappropriation of resident property . (a) The
facility shall develop and implement written policies
and procedures that prohibit mistreatment, neglect,
and abuse of residents and misappropriation of
resident property.
(b) All alleged violations involving
mistreatment, neglect, or abuse, including injuries of
unknown source or origin, and alleged misappropriation
of resident property shall be reported immediately to
the administrator of the facility, and to other
officials in accordance with state law through
established procedures.
(c) The resident involved, and the resident's
family, legal guardian, or surrogate shall be informed
of the alleged violation and the investigation that is
being conducted.
(d) The facility shall maintain a record that
all alleged violations were thoroughly investigated
and shall take all reasonable steps to prevent further
abuse while the investigation is in progress.
(e) The results of all investigations shall be
reported to the administrator of the facility or the
designated representative and to other officials,
including the department, in accordance with state law
within five working days of the incident.
(f) If the alleged violation is verified,
appropriate corrective action shall be taken to
protect the resident's safety as well as other
residents in the facility. [Eff SEP 1 6 2022 1
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-11)
§11-94.2-30 Resident care. The facility shall
have written policies and procedures that address all
aspects of resident care needs to assist the resident
to attain and maintain the highest practicable health
and medical status, including but not limited t o:
(1) Respiratory care including ventila t o r use;
( 2) Dialysis;
(3) Skin care and prevention of skin breakdown;
94.2-31
3 483
(4) Nutrition and hydration;
(5) Fall prevention;
(6) .Use of restraints;
(7) Communication; and
§11-94.2-36
(8) Care that addresses appropriate growth and
development when the faci l ity provides care
to infants, children, and youth.
[Eff ~FP 1 6 2022 ] (Auth: HRS
§§321-9, 3".71-fl) (Imp: HRS §§321-9, 321-11)
§§11-94.2-31 to 11-94.2-35 (Reserved).
SUBCHAPTER 5
PROGRAM REQUIREMENTS
§11-94.2-36 Admission, transfer, and discharge.
(a) There shall be written policies and procedures
available to staff, residents, and the public that
govern:
(1) All services provided by the facility;
(2) The admission, transfer, and discharge
of residents; and.
(3) Notification to the resident,
resident's representative, and the
state long term care ombudsman of
transfer or discharge initiated by the
facility.
(b) These policies shall ensure that:
(1) The facility shall not discriminate
against admission of any individual as
per all federal and state civil rig hts
and anti-discrimination regulations.
Should the facility not be able to
provide care and services to
ind ivi duals based on their age, i. e .,
infants and youth, or specific
disability, the facility will nee d to
indicate so in their policies and
procedures and by-laws;
94 . 2-32
§11-94.2-36
(2)
( 3)
( 4)
( 5)
(c) The
remain in the
discharge the
( 1)
( 2)
(3)
The facility shall accept only those
residents whose needs can be met by the
facility directly or in cooperation
with community resources or other
providers of care with which it is
affiliated or has contracts;
As changes occur in a resident's
physical or mental condition
necessitating a different level of
service or care that cannot be
adequately provided by the facility,
the residents shall be transferred
promptly to a facility capable of
providing an appropriate level of care;
Except in the case of an emergency, the
resident or the resident's legal
guardian, family, or surrogate and the
attending physician shall be informed
in advance of the transfer or discharge
to another facility; and
The facility's buildings are
constructed, equipped, and maintained
to protect the resident's health, and
assure the safety of residents,
personnel, and visitors.
facility shall permit each resident to
facility and shall not transfer or
resident from the facility unless:
The transfer or discharge is necessary
for the resident's welfare, or the
resident's needs cannot be met in the
facility;
The transfer or discharge is
appropriate because the resident's
health has improved sufficiently such
that the services provided by the
facility are no longer needed;
The health and safety of individuals in
the facility are, or would otherwise
be, endangered;
94.2-33
§11-94.2-37
(4) The resident has failed, after
reasonable and appropriate notice, to
pay for all costs attendant to
residency at the facility; or
(5) The facility license is terminated,
revoked, or suspended.
(d) The facility shall provide supportive
counseling and preparation to the resident to ensure
safe and orderly transfer or discharge from the
facility to mitigate possible relocation stress.
(e) At the time of transfer for hospitalization
or therapeutic leave, the facility shall provide
written information to the resident concerning the
facility's bed hold policy. [Eff SEP 1 6 2022 ]
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-11)
§11-94. 2-37 Social work services. (a) The
facility shall provide medically related social work
services to help residents attain or maintain the
residents' highest practicable physical, mental, and
psychosocial well-being.
(b) The number of hours of social work services
shall be determined by the resident capacity, acuity
level, and needs.
(c) Social work services provided to each
resident shall be documented in each resident's
medical record and shall include but not be limited
to:
(1) A social history and assessment of
current social and emotional needs;
(2) A social work plan of care for each
resident recorded in the medical record
and integrated into the comprehensive
assessment and overall care plan
coordinated or integrated with other
various disciplines;
(3) A discharge plan, as appropriate; and
(4) Evidence of regular review of social
work services and discharge plan in
94.2-34
§11-94.2-37
conjunction with the overall plan of
care. [Eff SEP 16 2022 ] (Auth:
HRS §§321-9, 321-11) (Imp: HRS §§321-9,
321-11)
§11-94.2-38 Activities. (a) The facility must
provide for an ongoing program of age-appropriate
activities designed to meet the interests, physical,
mental, and psychosocial well-being of each resident.
(b) The activities program shall be directed by
an activity professional.
(c) A schedule of activities shall be made
available Lw: 1
r~v~~X" by the department as requested.
[Eff ~tt' t> LULL ] (Auth: HRS §§321-9, 321-11)
(Imp: HRS §§321-9, 321-11
§11-94. 2-39 Nursing services. (a) Each
facility shall have nursing staff sufficient in number
and qualifications to meet the nursing needs of the
residents. There shall be at least one registered
nurse at work full-time on the day shift, for eight
consecutive hours, seven days a week, and at least one
licensed nurse at work on the evening and night
shifts, unless otherwise determined by the department.
(b} Nursing services shall include but are not
limited to the following:
(1) A comprehensive nursing assessment of
each resident and the development and
implementation of a plan of care within
five days of admission. The nursing
plan of care shall be developed in
conjunction with the physician's
admission physical examination and
initial orders. A nursing plan of care
shall be integrated with an overall
plan of care developed by an
interdisciplinary team no later than
the twenty-first day after, or
simultaneously, with the initial
interdisciplinary care plan conference;
94.2-35
§11-94.2-39
(2) Written nursing observations and
summaries of the resident's status
recorded, as appropriate, due to
changes in the resident's condition,
but no less than quarterly; and
(3) Ongoing evaluation and monitoring of
direct care staff to ensure quality
resident care is provided.
(c) There shall be a registered nurse designated
as the nursing administrator or director of nursing
who will be responsible for all nursing services.
(d) Should drug or medication administration be
delegated pursuant to chapter 16-89, subchapter 15,
there shall be documented evidence of a training
program, individuals receiving training, and ongoing
monitoring and evaluation to assess compliance with
requirements.
(e) There shall be a policies and procedures
manual that is kept current and consistent with
current nursing and medical practices and approved by
the medical advisor or director and the person
responsible for nursing procedures. The policies and
procedures shall include but not be limited to:
(1) Written procedures for personnel to
follow in an emergency including:
(A) Care of the resident;
(B) Notification of the attending
physician and other persons
responsible for the resident; and
(C) Arrangements for transportation,
hospitalization, or other
appropriate services;
(2) All treatment and care provided
relative to the resident's needs and
requirements for documentation; and
(3) Medication or drug administration
procedures that clearly define drug
administration process, documentation,
94.2-36
§11-94.2-39
and authorized individuals able to
administer medications or drugs.
[Eff SEP 1 6 2022 ] (Auth: HRS
§§321-9, 321-11) (Imp: HRS §§321-9,
321-11)
§11-94.2-40 Dietary services. (a) The food and
nutritional needs of the residents shall be met
through a nourishing, well-balanced diet in accordance
with the recommended dietary allowances of the Food
and Nutrition Board of the National Research Council,
and shall be adjusted for age, sex, activity, and
disability.
(1) At least three meals shall be served
daily at regular times with not more
than a fourteen hour span between a
substantial evening meal and breakfast
on the following day;
(2) Between meals nourishment that is
consistent with the resident's needs
shall be offered routinely and shall
include a regular schedule of hydration
to meet each resident's needs;
(3) Appropriate substitution of foods shall
be promptly offered to all residents as
necessary;
(4) Food shall be served in a form
consistent with the needs of the
resident and the resident's ability to
consume it;
(5) Food shall be served with appropriate
utensils;
(6) Residents needing special equipment,
implements, or utensils to assist them
when eating shall have the items
provided by the facility; and
(7) There shall be a sufficient number of
competent personnel to fulfill the food
94.2-37
(b) All
( 1)
§11-94.2-40
and nutrition needs of residents. Paid
feeding attendants shall be trained as
per the facility's state-approved
training protocol.
diets prepared for residents shall be:
Prescribed by the resident's physician,
physician assistant, or APRN with a
record of the diet as ordered kept on
file;
(2) Planned, prepared, and served by
qualified personnel according to diet
prescription. The current Hawaii
Dietetic Association Manual or The
Manual of Clinical Dietetics of the
American Dietetic Association or both
shall be readily available to all
medical, nursing, and food service
personnel;
(3) All diets shall appropriately meet the
nutrient, texture, and fluid needs of
each resident; and
(4) Therapeutic or special diets shall be
planned by a dietitian and served
accordingly as prescribed by the
resident's physician, physician
assistant, or APRN.
(c) A nutritional assessment and care plan shall
be recorded in each resident's medical record and
integrated into the overall comprehensive assessment
and overall plan of care coordinated/integrated with
all disciplines. The nutritional assessment and care
plan shall be reviewed on a regular basis and adjusted
as needed.
(d) The food service shall be directed by a
dietary manager. If the food service is directed by a
dietary manager who is not a dietitian, there shall be
frequent and regularly scheduled consultation with,
and in-service education by, a dietitian.
Consultation and in-service education shall be
appropriate to the needs of the dietary personnel and
94.2-38
§11-94.2-40
residents of the facility, and this shall be
documented. In-service education specific to the
needs of the dietary staff shall be provided at least
on a semi-annual basis.
(e) A facility may provide for food service by
contract with an outside supplier. The method of
transport, storage, preparation, and serving of food,
as well as the method of providing prompt, appropriate
substitution of foods in therapeutic or special diets
shall be approved by the dietitian or dietary manager
prior to the implementation of the contract.
(f) The facility shall have a food service plan
documented and available for department review that
shall include but not be limited to the following:
(1) Menus shall be written at least one
week in advance;
(2) Menus shall provide a sufficien t
variety of foods served in adequate
amounts at each meal, and be adjusted
for seasonal changes along with
resident preference;
(3) A different menu shall be followed for
each day of the week. If a cycle menu
is used, the cycle shall cover a
minimum of four weeks;
(4) All menus shall be filed and maintained
with any recorded changes for at least
three months; and
(5) Menus shall be in place for at least
three to five days of meal service in
case of a natural or external disaster.
A plan for meal service in the event of
an internal disaster such as
interruption of power or water supply
shall also be in place and available
for departmental review.
[Eff SEP 1 6 2022 ] (Aut h : HRS
§§3 21-9, 321-11) (Imp: HRS §§321-9,
321-11)
94.2- 3 9
§11-94.2-42
§11-94.2-41 Storage and handling of food. (a)
All food shall be procured, stored, prepared,
distributed, and served under sanitary conditions.
(1) Dry or staple food items shall be
stored above the floor in a ventilated
room not subject to seepage or
wastewater backflow, or contamination
by condensation, leakages, rodents, or
vermin; and
(2) Perishable foods shall be stored at the
proper temperatures to conserve
nutritive value and prevent spoilage.
(b) Effective procedures to promptly and
consistently clean all equipment and work areas shall
be enforced.
(c) Hand-washing facilities, including hot and
cold water, soap, and paper towels adjacent to the
work areas shall be provided.
(d) In the kitchen and food preparation areas,
receptacles shall be kept closed by tight-fitting
covers, except in the kitchen during hours of food
preparation and serving. [Eff SEP 1 6 2021 l
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-11)
§11-94. 2-42 Physician services. (a) Admission
orders and ongoing orders by a physician, physician
assistant, or APRN and plan of treatment shall be i n
writing and carried out by the staff of the facility
including arrangement for transfer to other facilities
when indicated.
(b) Each resident admitted to the facility shall
be under the care of a physician selected by the
resident, legal guardian, or surrogate.
(c) The facility shall ensure that arrangements
have been made for all physician, physician assistant,
or APRN visits and services.
(d) Physicians, physician assistants, or APRNs
shall visit the facility as necessary to assure that
adequate medical care is being provided, review plan
of care, mak e pertinent recommendations, and determine
appropriate level of care of resident.
94.2-40
§11-94.2-42
(e) Physician visits shall be made at least once
every thirty days for the first ninety days of stay.
After ninety days, a schedule of no less than
quarterly visits may be adopted; however, this does
not apply to residents who require specialized
rehabilitative services. APRN, physician assistant,
and physician visits may be alternated after the
initial physician visit.
(f) Physicians, physician assistants, or APRNs
shall provide an annual health evaluation of each
resident.
(g) Each resident shall have a physical
examination by a physician, physician assistant, or
APRN within five days prior to admission or within one
week after admission, and shall have had a
tuberculosis clearance within the previous year,
pursuant to section 11-164-10.
(h) The facility shall promptly notify the
physician, physician assistant, or APRN of any
accident, injury, or change in the resident's
condition.
(i) The physician, physician assistant, or APRN
shall write a discharge summary to ensure adequate
continuing care when a resident is transferred to
another primary care provider.
(j) Each resident shall receive age-appropriate
immunizations or vaccinations including but not
limited to pneumococcal and annual influenza vaccines
and any necessary immunizations following the
recommendations of the Advisory Committee of
Immunization Practices unless otherwise
contraindicated, or refused by the resident, legal
guardian, or surrogate. All immuni zations provided
shall be ~~PuTe~11orz in each resident's medical record.
[Eff ] (Auth: HRS §§321-9, 321-11)
(Imp: HRS §§321-9, 321-11)
§11-94.2-43 Interdisciplinary care process .
(a} A comprehensive assessment shall be completed for
each resident by an interdisciplinary team at least
94.2-41
§11-94.2-44
annually and updated as appropriate, based on the
resident's condition.
(b) An individualized, interdisciplinary overall
plan of care shall be developed to address prioritized
resident needs including nursing care, social work
services, medical services, rehabilitative services,
restorative care, preventative care, dietary or
nutritional requirements, and resident/family
education.
(c) The overall plan of care shall be reviewed
periodically by the interdisciplinary team to
determine if goals have been met, if any changes are
required to the overall plan of care, and as
necessitated by changes in the resident's condition.
shall
[Eff
(Imp:
(d) Implementation of the overall plan of care
be documented in each resident's medical record.
SEP 1 6 2022 ] (Auth: HRS §§321-9, 321-11)
HRS §§321-9, 321-11)
§11-94.2-44 Specialized rehabilitation services.
(a) The facility shall provide for specialized and
supportive rehabilitation services, including
occupational therapy, physical therapy, and speech
therapy, according to the needs of each resident,
either directly by qualified staff or through
arrangements with qualified outside resources .
Services shall be programmed to:
(1) Preserve and improve the resident's
maximal abilities for independent
function;
(2) Prevent, insofar as possible,
irreversible or progressive
disabilities; and
(3) Provide for the procurement and
maintenance of assistive devices as
needed by the resident to adapt and
function within the resident's
environment.
(b) A written rehabilitative plan of care
integrated into the overall plan of care, shall be
94.2-4 2
§11-94.2-44
provided that is based on the attending physician's,
physician assistant's, or APRN's orders and assessment
of a resident's needs in regard to specialized
rehabilitative procedures. It shall be developed by
the rehabilitative staff and incorporated in, and
regularly reviewed in conjunction with, the overall
care plan for the resident.
(c) Physician's orders for evaluation and
treatment shall be documented in each resident's
medical record.
(d) Rehabilitation services shall have adequate
space, facilities, equipment, supplies, and other
related resources.
(e) Rehabilitation services may be ordered by or
recertified by APRNs and physician assistants! if
within their scope of practice. [Eff SEP 6 2022 ]
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-11)
§11-94. 2-45 Dental services. (a) Emergency and
restorative dental services shall be available to each
resident.
(b) Each resident or resident's legal guardian,
or surrogate shall select the dentist of his or her
choice, and the facility shall assist each resident to
obtain necessary dental care by making arrangements
for appoint~nfq..,M transportation, as requested.
[Eff ~tr O 011 ] (Auth: HRS §§321-9, 321-11 }
(Imp: HRS §§321-9, 321-11)
§11-94.2-46 Pharmaceutical services. (a) Each
facility shall employ a licensed pharmacist or shall
have a written contractual arrangement with a licensed
pharmacist, to provide consultation on methods and
procedures for ordering, storing, administering,
disposing, and recordkeeping of drugs and biologicals,
and provisions for emergency service.
(b) A facility shall have a current pharmacy
policy manual consistent with current pharmaceutical
94.2-43
§11-94 . 2-46
practices developed and approved by the pharmacist,
medical director/medical advisor, and director of
nursing that:
(1) Includes policies and procedures, and
defines the functions and
responsibilities relating to pharmacy
services, including the safe
administration and handling of all
drugs and self-administration of drugs.
Policies and procedures shall include
pharmacy functions and
responsibilities, formulary, storage,
administration, documentation, verba l
and telephone orders, authorized
personnel, recordkeeping, and disposal
of drugs;
(2) Is reviewed at least every two years
and revised as necessary to keep
abreast of current developments in
overall drug usage; and
(3) Has a drug recall procedure that can be
readily implemented.
(c) As authorized by facility policy and state
law, a physician, physician assistant, or APRN shal l
order medications, either in writing or verbally, to
be administered to a resident.
{d) A physician's, physician assistant's, or
APRN's verbal orders for prescription drugs shall be
given only to a licensed nurse, pharmacist, or another
physician.
(e) All verbal or telephone orders for
medication shall be recorded and signed by the
licensed person receiving them and shall be
authenticated by the prescribing physician according
to the policies and procedures of the facility.
(f) The physic i an, physician assistant, or APRN
shall review all orders at the time of the visit to
the resident.
(g) Each drug shall be rechecked and identified
immediately prior to administration.
94.2-44
§11-94.2-46
(h) Prescription medication shall not be used
for any resident other than the resident for whom it
was issued. Stock supply items may be administered
per facility protocol.
(i) Appropriately licensed and trained staff
shall be responsible for the entire act of medication
administration, which entails removing an individual
dose from a container properly labeled by a pharmacist
or manufacturer (unit dose included), verifying the
dosage with the physician's orders, giving the
specified dose to the proper resident, and prompt l y
recording the time, route, and dose given to the
resident, and signing the record. Only a licensed
nurse, physician, or other individual to whom the
licensed professional has delegated the responsibility
pursuant to chapter 16-89, subchapter 15, may
administer medications.
(j) Medication errors and drug reactions shall
be recorded in the resident's chart and reported
immediately to the physician, physician assistant, or
APRN who ordered the drug, and a medication error
report shall be prepared and given to the
administrator of the facility or director of nursing
for review and appropriate action, according to
facility policy.
(k) Drugs shall be stored under proper
conditions of sanitation, temperature, light,
moisture, ventilation, segregation, and security.
(1) All drugs, including drugs that are stored
in a refrigerator, shall be kept under lock and key,
except when authorized personnel are in attendance.
The facility shall be in compliance with all security
requirements of federal and state laws as they relate
to storerooms and pharmacies.
(m) Drugs for external and internal use s hall be
kept separate and stored i n l ocked, well-marked,
separate cabinets.
(n) Discontinued and outdated prescriptions and
containers with worn, illegible, or missing labels
shall be disposed of according to facility policy.
94.2-45
§11-94.2-52
(o) A pharmacist shall, on a monthly basis,
review the record of all residents receiving
medications to determine potential adverse reactions,
interactions, and contraindications . The review and
any concerns identified shall be documented in the
resident's record.
(p) When appropriateness of drugs or dosage of
drugs as ordered are questioned by the pharmacist or
licensed nurse, the licensed nurse or the pharmacist
shall consult the physician, and a record of the
consultation shall be made available to the
administrator of the facility or director of nursing.
[Eff SEP 1 6 2022 ] (Auth: HRS §§321-9, 321-11)
(Imp: HRS §§321-9, 321-11)
§11-94.2-47 Adult day health services. (a) If
a nursing facility chooses to provide adult day health
services in its facility, the space and staff
requirements for the adult day health service
activities shall not reduce the space and staff
requirements of the nursing facility.
(b) Client records in adult day health services
shall include a pertinent medical history, nursing
assessment, emergency telephone numbers, and a plan of
care. Adult day health service client records shall
be kept separate from the medical records of the
nursing facility residents.
(c) All care and services provided to the
adult day health service client shall be
consistent with the assessment and plan of care and
physician orders, as applicable. [Eff SEP 1 6 2022
] (Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-
11)
§§11-94.2-48 to 11-94.2-52 (Reserved).
94.2-46
§11-94.2-53
SUBCHAPTER 6
ENVIRONMENTAL HEALTH STANDARDS
§11-94.2-53 Infection control. (a) There shall
be appropriate policies and procedures written and
implemented for the prevention and control of
infectious diseases that shall be in compliance with
all applicable laws of the State, rules of the
department relating to infectious diseases and
infectious waste, and national standards such as the
Centers for Disease Control and Prevention and Centers
for Medicare & Medicaid Services.
(b) The facility shall have provisions for
isolating residents with infectious diseases until
appropriate transfers can be made.
(1) The facility shall have a written
policy that outlines proper isolation
and infection control techniques and
practices;
(2) At least one single bedroom shall be
designated as an isolation room as
needed and shall have:
(A) An adjoining toilet room with
nurses' call system, a lavatory,
and a toilet;
(Bl Appropriate hand-washing
facilities available to all staff;
and
(C) Appropriate methods for cleaning
and disposing of contaminated
materials and equipment;
(3) The facility shall ensure that visual
observations of the resident can be
made
(A)
( B)
in each isolation room:
By means of the view window in
each isolation room; or
By an approved mechanical system
e.g., closed circuit television
monitoring;
94.2-47
§ 11 -94.2-54
(4) The facility shall have documented
evidence that every employee has both
an initial employment evaluation and an
annual health evaluation. These
evaluations shall be specifically
oriented to determine the presence of
any infectious disease liable to harm a
resident;
(5) Skin lesions, respiratory tract
symptoms, and diarrhea shall be
considered presumptive evidence of
infectious disease. Any employee who
develops evidence of an infection must
be immediately excluded from any duties
relating to food handling or direct
resident contact until such time as a
physician certifies it is safe for the
employee to resume such duties;
(6) There shall be a documented record that
every employee and resident have an
initial and an annual tuberculosis (TB)
clearance. Facilities shall comply
with the most current and updated
guidelines as set forth in chapter 11-
164, Exhibit A; and
(7) When a known negative tuberculin skin
test on an employee or resident
converts to a positive test, it shall
be considered a new case of
tuberculosis infection and shall be
reported t~EPhf ~~fftment.
[Eff ] (Auth: HRS
§§321-9, 321-11) (Imp: HRS §§321-9,
321-11)
§11-94.2-54 Sanitation. (a) The facility shall
comply with all applicable laws of the State and rules
of the department relating to sanitation.
94 . 2-48
§11-94.2-54
(b) Written summary reports of inspections by
state or county health authorities, and records of
action taken in response to deficiencies and
recommendations shall be kept on file at the facility.
(c) Every facility shall provide a sufficient
number of watertight receptacles of metal or other
material acceptable to the department for rubbish,
garbage, refuse, and other discarded matter . An area
shall be provided for the washing and cleaning of
garbage containers and the storage of garbage, trash,
and solid waste.
(d) Every facility shall maintain an effective
pest control program so that the facility is free of
pests and rodents. [Eff ) (Auth:
HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-11)
§11-94. 2-55 Housekeeping. (a) Each facility
shall have a plan for routine periodic cleaning of the
entire building and premises.
(b) After discharge of any resident, the
resident's bedroom and equipment shall be thoroughly
cleaned prior to reuse.
(c) Floors, sinks, toilets, and showers in
resident areas shall be cleaned at least once daily.
(d) The facility shall be kept free of
unreasonable accumulation of personal possessions.
(e) All floors, walls, ceilings, windows, and
fixtures shall be kept clean and in good repair.
(f) All areas that have contained infectious
residents and materials shall be thoroughly cleaned
with appropriate sanitizing methods.
(g) All combustible, potentially hazardous, or
poisonous agents used for the cleaning of the facility
shall be stored in a secured and locked area.
[Eff SEP 1 6 2022 ) (Auth: HRS §§321-9, 321-11)
(Imp: HRS §§321-9, 321-11)
§11-94. 2-56 Laundry service. (a) Laundry
service shall be managed so that daily clothing and
linen needs are met without delay and in compliance
94.2-49
§11-94.2-56
with facility policies and procedures for infection
control.
(b) Personnel must handle, store, process, and
transport linens so as to prevent the spread of
infection.
(1) Provisions shall be made for the
handling, storage, and transportation
of soiled and clean laundry and for
satisfactory cleaning procedures;
(2) Provisions may be made for contract
service outside the facility in a
laundry approved by the department;
(3) Laundry contaminated with blood, blood
products, or infectious waste shall be
handled in accordance with U.S.
Department of Labor, Occupational
Safety and Health Administration (OSHA}
regulation 29 C.F.R., Part 1910.1030;
(4) Clean linen shall be stored in enclosed
areas; and
(5) Hampers shall be provided for soiled
linen.
[Eff SEP 1 6 202'2 ] (Auth:
HRS§§321-9, 321-11) (Imp: HRS §§321-9,
321-11)
§11-94. 2-57 Life safety. (a} Facilities
licensed under this chapter shall be inspected by
appropriate fire authorities for compliance with the
current state and county life safety rules and
ordinances.
(b) Smoking rules shall be adopted in accordance
with applicable state, federal, and county laws,
statutes, and regulations. "No Smoking" signs shall
be posted where flammable liquids, combustible gases,
or oxygen are used or stored . Smoking by residents
shall be permitted only under supervision in
designated areas, and ashtrays shall be provided.
(c) Electric heating pads shall be prohibited.
(d) Facilities shall have written procedures in
case of fire, disasters, and emergenc i es.
94.2-50
§11-94.2-57
(e) The facility evacuation plan shall be posted
in prominent locations on each floor.
(f) Fire drills shall be conducted at least
quarterly, for each shift, under varied conditions.
At least twelve drills shall be held every year and
reports filed in the facility and available for review
by the department.
(g) All employees shall be instructed and kept
informed regarding their duties under the fire,
disaster, and emergency programs.
(h) The facility shall establish procedures to
ensure that water is available to essential areas when
there is a loss of normal water supply.
(i) The facility shall ensure the availability
of emergency power:
(1) An emergency electrical power system
shall be available and shall, at a
minimum, supply power adequate for
lighting all entrances and exits and
the equipment to maintain the fire
detection, alarm, and extinguishing
systems, and life support systems in
the event the normal electrical supply
is interrupted; and
(2) When life support systems are used, the
facility must provide emergency
electrical power to those life support
systems with an emergency generator (as
defined in the most current National
Fire Protection Association Code,
Health Care Facilities) that is located
on the premises. [ Eff SEP 1 6 2022 ]
Auth: HRS §§321-9, 321-11) (Imp: HRS
§§321-9, 321-11)
§11-94.2-58 Emergency preparedness. (a) There
shall be written policies and procedures to follow in
an emergency that shall include provisions for the
following:
(1) Arranging for rapid primary care
provider assistance;
94.2-51
§11-94.2-58
(2) Transportation arrangements for
hospitalization or other services that
are appropriate;
(3) Maintenance of an appropriate emergency
preparedness kit for all emergencies or
disasters; and
(4) Preparedness for all hazards to include
but not be limited to:
(A) Natural disasters such as tropical
storm, hurricane, flooding,
tsunami, earthquake, and any
island-specific disaster such as
volcanic eruption and lava flow;
(B) Fire;
(C) Medical emergencies;
(D) Terrorist threat;
(E) Pandemic flu; and
(F) Public health emergencies.
(b) The facility shall develop and maintain a
written disaster preparedness plan consistent with
state and local civil defense guidelines that includes
the evacuation capacity designation to be followed in
case of an emergency or disaster. A copy of the plan
shall be readily available at all times within the
facility. The plan shall include procedures for
evacuating all individuals in the facility to an
approved point of safety as designated by the county
authority or designated shelter as determined by the
state or local civil defense unless the facility has
been determined by the State to be capable of
sheltering in place. The plan shall include the
following:
(1) Fire drills that include the
transmission of a fire alarm signal and
that shall be held at least quarterly
for each shift, under varied
conditions. At least twelve drills
shall be held every year and reports
filed in the facility;
(2) Specific provisions and plan for
evacuating residents with specific
94 . 2-52
§11-94.2-58
details for residents with impaired
mobility or cognitive impairments;
(3) Specific provisions and plan for
transporting all of the residents of
the facility to a pre-determined
appropriate facility or facilities that
will accommodate all the residents of
the facility in case of a disaster
requiring evacuation of the facility;
(4) Specific provision to determine the
safety of the facility post-disaster
prior to the return of evacuated
residents;
(5) Specific provisions for transfer of
residents should the facility not be
determined to be structurally sound
post-disaster and plan for continuing
operations;
(7) Evacuation drills shall be conducted at
least quarterly and documented; and
(8) A written transfer agreement with the
appropriate facility or facilities for
accommodating all of the residents of
the facility in case of a disaster
requiring evacuation of the facility.
[Eff SEP 1 6 2012 ) (Auth: HRS
§§321-9, 321-11) (Imp: HRS §§321-9,
321-11)
§§11-94.2-59 to 11-94.2-63 (Reserved).
SUBCHAPTER 7
PHYSICAL FACILITY STANDARDS
§11-94.2-64 Engineering and maintenance. (a)
The facility shall maintain all essential mechanical,
electrical, and resident care equipment in safe
operating condition.
(b) The facility shall have an appropriate
written preventive maintenance program.
94.2-53
§11-94.2-65
(c) The facility shall provide sufficiently
trained and experienced personnel to accomplish the
required engineering and maintenance functions within
the facility or available through contract with an
appropriate provider(s).
(d) The facility shall maintain records that
document that inspection of all devices essential to
the health and safety of residents and personnel shall
be carried out at sufficient intervals to ensure
proper operational performance. [Eff SEP 1 6 2022 1
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-11)
§11-94. 2-65 Construction requirements. (a) The
facility's buildings shall be constructed and equipped
to protect the health and assure the safety of
residents, personnel, and visitors.
(b) The facility shall be fully accessible to,
and functional for, physically disabled residents,
personnel, and the public.
(1) Resident l ivi ng areas shall be designed
and equipped for the comfort and
privacy of the resident;
(2) Temperature and humidity shall be
maintained within a normal comfort
range;
(3) There shall be provisions within the
facility for one or more areas of
resident dining, diversional, and
social activities. Total area for
recreat i onal and dining activities
shall be not less than thirty-seven and
one-half square feet per bed;
{A) Dayrooms shall be equipped with
reading lamps, adequate lighting,
tables, chairs, or their
equivalent, for the use and
comfort of the residents;
(B) Dining areas shall be equipped
with tables and safe chairs. A
94.2-54
§11-94.2-65
( 4)
( 5)
(c) The
accessibility
( 1)
sufficient number of tables shall
be of proper height to accommodate
wheelchair residents. As
possible, residents shall be
transferred from wheelchairs to
safe chairs during meals;
(C) If a multi-purpose room is used
for dining, diversional, and
social activities, there shall be
sufficient space to accommodate
all activities and prevent their
interference with each other; and
(D) In the event that adult
nonresidents (including adult day
health services) use part of the
facility twenty-four hours or more
a week on a regular basis,
additional space must be provided
on the following basis for those
persons:
(i) Twenty square feet per person
in dining areas;
(ii) Thirty square feet per person
in recreational areas;
(iii)One conveniently located
toilet for each eight
persons; and
(iv) Sufficient additional staff
shall be provided to care for
the needs of the persons;
Illumination shall be provided for the
comfort and safety of residents and
personnel; and
Wall or door mirrors shall be provided
and placed at convenient heights for
resident use.
facility shall ensure resident
to living and service areas:
There shall be adequate space to allow
free movement of occupants using
94.2-55
§11-94.2-65
wheelchairs, walkers, canes, and
crutches to beds, bathrooms, closets,
and common hallways;
(2) Areas used for recreation, cooking,
dining, storage, bathrooms, laundries,
foyers, corridors, lanais, libraries,
and other areas not suitable for
sleeping shall not be used as bedrooms;
(3) Access from each bedroom to a bathing
room, toilet or lavatory, or corridor
shall not require passing through
another bedroom, cooking, dining, or
recreational area; and
(4) All occupants of any bedroom shall be
of the same sex except for those semi
private rooms that may be occupied by
married couples or long-time non
married couples upon request.
(d) The facility shall have adequate toilet and
bath facilities:
(1) One toilet room shall serve not more
than eight residents;
(2) The toilet room shall contain a toilet
and washbasin. The washbasin may be
omitted from a toilet room that serves
single or multi-bed rooms if each
resident room contains a washbasin;
(3) There shall be one shower or tub for
each fourteen beds that are not
otherwise served by bathing facilities
within the resident room;
(4) Appropriately placed and mounted
safety-grab bars shall be provided in
each toilet, bathtub, or shower
enclosure;
(5) Curtains or doors to ensure privacy
shall be provided;
(6) An adequate supply of potable running
water shall be provided at all times.
Temperatures of hot water at plumbing
fixtures used by the residents shall be
94.2-56
§11-94.2-65
automatically regulated and shall not
be below 100 or above 120 degrees
Fahrenheit;
(7) Each toilet and bath facility shall
have a call system that permits the
occupant to signal the nursing station
in an emergency;
(8) Where bedpans are used, equipment for
their care shall be provided in an
appropriate area of the facility;
(9) Provisions shall be made for
disinfecting of permanent personal care
equipment unless disposables are used;
and
(10) Separate toilet facilities shall be
provided for the use of residents and
personnel.
(e) The facility shall have resident bedrooms
that ensure the health and safety of residents:
(1) Each room shall be at or above grade
level;
(2) Each resident bedroom shall have window
coverings to provide an adequate means
of ensuring privacy;
(3) Resident bedrooms shall have not more
than four beds;
(4) Single resident bedrooms shall measure
at least one hundred square feet of
usable space, excluding closets,
bathrooms, alcoves, and entryways;
(5) Multi-resident bedrooms shall provide a
minimum of eighty square feet per bed
of usable space, excluding closets,
bathrooms, alcoves, and entryways;
(6) Bedside screens or curtains shall be
provided in multi-bed bedrooms to
ensure privacy for each resident;
(7) Beds shall be placed at least three
feet apart; and
(8) Each resident shall be provided with:
94.2-57
§11-94.2-65
(A) A separate bed of proper size and
height for the convenience of the
resident and that permits an
individual in a wheelchair to get
in and out of bed unassisted;
(B) A comfortable mattress with
impermeable mattress cover, and a
pillow with an impermeable cover;
(C) Sufficient clean bed linen and
blankets to meet the resident's
needs;
(D) Appropriate furniture, cabinets,
and closets, accessible to and
meeting individual resident's
needs. Locked containers shall be
available upon resident's request;
and
(E) An effective signal call system at
the resident's bedside.
(f) Ramps must be designed to permit use by
residents in wheelchairs. Ramps shall comply with the
American with Disabilities Act requirements (28 C.F.R.
Part 36).
(g)
walls are
(h)
lighting:
The facility shall ensure that floors and
maintained as follows:
(1) Floor coverings shall be of slip
resistant material that does not retain
odors and is flush at doorways; and
(2) Walls, floors, and ceilings of rooms
used by residents shall be made of
materials that shall permit washing,
cleaning, and painting.
The facility shall have adequate windows and
(1) Each resident bedroom shall have at
least one outside window;
(2) Each resident bedroom shall have an
aggregate window area of not less than
one-tenth of the gross floor area;
(3) Resident bedrooms shall have artificial
light adequate for reading at bedside;
94.2-58
§11-94.2-65
(4} There shall be night lighting in
resident bedrooms, toilets, and service
areas; and
(5} In bedrooms containing wheelchair
residents, at least one window shall be
low enough to permit outdoor viewing by
the wheelchair-bound resident.
(i) Where appropriate, screening of doors and
windows shall be provided, using screen having sixteen
meshes per inch.
(j} The facility shall ensure that:
(l} Sliding doors or folding doors shall
not be used as exit doors, and if used
in other areas, shall be of light
material and easy to handle; and
(2} Double acting doors shall be provided
with vision panels of sufficient height
to permit use by walkers as well as
wheelchair riders.
(k} The facility corridors shall:
(l} Have a minimum clear width of forty
four inches, except that corridors
serving one or more non-ambulatory or
semi-ambulatory residents shall be not
less than eight feet in width; and
(2} Stationary handrails shall be installed
along both sides of corridors.
(l} The facility shall have sufficient storage
space:
(l} Locked space shall be provided for
janitorial supplies and equipment; and
(2} Conveniently located space for other
equipment shall be provided.
(m) The water supply shall be in accordance with
chapter 340E, HRS.
(n) Chapter 11-39, relating to air conditioning
and ventilating, shall be followed.
(o} Additions and alterations or repairs to
existing buildings:
(1) Where the structure was in use for this
type of occupancy prior to December 31,
94.2-59
§11-94.2-69
2009, the director, with discretion,
may waive or modify any portion of
these requirements provided such
exceptions do not create a hazard to
residents, personnel, or the public;
(2) The provisions of this section shall
not prohibit the use of equivalent
alternate space use, or new concepts of
plan designs and material or systems if
written approval of those alterations
is granted by the director; and
(3) Facilities shall be constructed and
maintained in accordance with
provisions of state and county zoning,
building, fire safety, and sanitation
laws and ordinances.
(p) There shall be an appropriately equipped
nursing station in each unit.
(1) At a minimum, the nursing station sha ll
include a telephone, writing space,
storage cabinets, and medical record
space;
(2) There shall be a nurses' call system
that registers calls within hearing
range and is directly visible by on
duty personnel; and
(3) There shall be appropriately equipped
utility rooms within each nursing unit
or on each resident floor. [Eff
SEP162022 ](Auth: HRS §§321-9,
321-11) (Imp: HRS §§321-9, 321-11)
§§11-94.2-66 to 11-94.2-68 (Reserved).
SUBCHAPTER 8
ADMINISTRATIVE ENFORCEMENT
§11-94.2-69 Enforcement. (a) If the department
determines that any person has violated any provision
94.2-60
§11-94.2-69
of this chapter, any provision of chapter 321, HRS, or
any term or condition of a license issued pursuant to
this chapter, the department may do one or more of the
following:
(1) Issue an order assessing an
administrative penalty for any past or
current violation;
(2) Require compliance immediately or
within a specific time; or
(3) Suspend or revoke a license to operate
a nursing facility.
(b) Any order issued pursuant to this section
may include a suspension, modification, or revocation
of any license issued pursuant to this chapter and any
administrative penalty assessed in accordance with
section 321-20, HRS. The order shall state with
reasonable specificity the nature of the violation,
the legal bases for the finding of violation, and the
right to request an administrative hearing and retain
legal counsel. The order shall be sent to the alleged
violator by certified mail.
(c) Any order issued under this chapter shall
become final, unless not later than twenty days after
receipt of the notice of order by certified mail, the
alleged violator submits a written request for a
hearing, along with a copy of the notice, to the
Hearings Officer, c/o Director of Health, 1250
Punchbowl St., Third Floor, Honolulu, Hawaii 96813.
The written request for hearing, along with the
notice, must be filed with the hearings office within
the twenty-day period. The hearing request may be
filed in person at the director's office, during
regular business hours, at the above address within
the allotted time. Failure to timely file the hearing
request and related documents may result in a denial
of the hearing request. Any penalty imposed under
this chapter shall b e come due and payable twenty days
after receipt of the notice of order by certified mail
unless the alleged violator requests in writing a
hearing before the director. Whenever a hearing is
94.2-61
§11-94.2-74
requested on any penalty imposed under this chapter,
the penalty shall become due and payable only upon
completion of all review proceedings and the issuance
of a final order confirming the penalty in whole or in
part. Upon receipt of a request for a hearing, the
director or director's designee shall require that the
alleged violator appear before the director or the
director's designee for a hearing at a time and place
specified in a notice of hearing and answer the
charges complained of.
(d) Any hearing conducted under this section
shall be conducted as a contested case hearing under
chapter 91, HRS. If, after a hearing held pursuant to
this section, the director or director's designee
finds that the violation has, or violations have,
occurred, the director or director's designee shall
affirm or modify any penalties imposed or shall modify
or affirm the order previously issued or issue an
appropriate order or orders. If, after the hearing on
an order or penalty contained in a notice, the
director or the director's designee finds that no
violation has occurred or is occurring, the director
or the director's designee shall rescind the order or
penalty or both.
(e) Nothing in this section shall be construed
to nullify or limit other penalties provided
elsewhere. [Eff SEP 1 6 2022 ] (Auth: HRS
§§321-9, 321-10, 321-11, 321-20) (Imp: HRS §§321-9,
321-10, 321-11, 32 1-2 0)
§11-94.2-70 Penalties and remedies. In addition
to any other action to enforce these rules, the
director may initiate either administrative or
judicial proceedings as provided in chapter 321, HRS.
[Eff SEP 1 6 2022 ] (Auth: HRS §§321-9, 321-
10, 321-11, 321-18, 321-20) (Imp: HRS §§321-9, 321-1 0 ,
321-11, 321-18, 321-20)
§§11-94.2-71 to 11-94. 2-74 (Reserved).
94.2-62
§11-94.2-75
§11-94.2-75 Severability. If any provision of
this chapter or the application thereof to any person
or circumstance is held invalid, the remainder of this
chapter, or the application of the provision to other
persons or circumstances shall not be affected.
[Eff ~ ? ] (Auth: HRS §§321-1, 321-9,
321-10, 321-gr +r~JP2~RS §§321-1, 321-9, 321-10, 321-11}
§11-94.2-76 Transition. A nursing facility
licensed at the time of adoption of these rules shall
have a period of six months after July 1, 2022, to
institute required changes to meet the requirements
set forth in this chapter. [Eff SEP 1 6 2022 l
(Auth: HRS §§321-9, 321-11) (Imp: HRS §§321-9, 321-11}
94.2-63
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DEPARTMENT OF HEALTH
The repeal of chapter 11-94.1 and
chapter 11-94.2, Hawaii Administrative
the adoption of
Rules, on the
Summary Page dated ________________ , were
-------------- , following public
at
adopted on
hearings held on ----------after a public notice was published on --------
in the
The repeal of chapter 11-94, Hawaii
Administrative Rules and the adoption of chapter 11-
94.2, Hawaii Administrative Rules, shall take effect
ten days after filing with the Office of the
Lieutenant Governor.
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APPROVED AS TO FORM:
ELIZABETH A. CHAR, M.D.
Director
Department of Health
APPROVED:
DAVID Kig;_/
Governor
State of Hawaii
Date: SEP OE> 2022
De~y Attorney General
JUL 2 9 2022
Filed
94.2-64