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Ä Ä Ä G" Ä Ä Ä Ä ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ç( Ä Ä Ä Ä Ä Ä Ä Ä Ä ò Y K : Title 19—department of health AND SENIOR SERVICES Division 30—Division of Regulation and Licensure Chapter 110—Prescribed Pediatric Extended Care Facilities 19 CSR 30-110.010 Prescribed Pediatric Extended Care Facilities Definitions PURPOSE: This rule defines terms as set forth in this chapter and sections 192.2550 through 192.2560, RSMo. (1) An allowed practitioner is a physician or advanced practice registered nurse licensed in the state of Missouri. (2) The center director is an adult who is responsible for planning, monitoring, and managing the licensed child care facility’s daily program. (3) A child is an individual who is under the age of seventeen (17). (4) Child care staff member shall have the same meaning as defined in 5 CSR 25-500.010. (5) Clinical records are medical records maintained in accordance with accepted professional standards and practices. (6) Department is the Missouri Department of Health and Senior Services. (7) DESE is the Missouri Department of Elementary and Secondary Education. (8) Direct care personnel is a Certified Nursing Assistant or Certified Medical Technician certified by the department under section 198.082, RSMo. (9) The director of nursing is a registered nurse, approved by the department, responsible for the medical oversight of eligible children admitted to the facility. (10) An eligible child is an individual who is under the age of six (6) years admitted to a prescribed pediatric extended care facility that has complex medical needs requiring continuous skilled nursing intervention of at least four (4) hours per day, as ordered by a physician. (11) A licensed practical nurse (LPN) is a person licensed under Chapter 335, RSMo, to engage in the practice of practical nursing. (12) Life support equipment is equipment which if stopped could result in loss of human life or serious injury. (13) A multidisciplinary group is a group with a representative from each of the healthcare disciplines provided to the eligible child. (14) NFPA 99 is the NFPA 99, Health Care Facilities Code (2024), published October 2024. (15) An occupational therapist is a person licensed under Chapter 324, RSMo, to practice occupational therapy. (16) A person is any individual, firm, corporation, partnership, association, agency, incorporated or unincorporated organization, or other legal entity, regardless of the name used. (17) A physician is a person licensed by the State Board of Registration for the Healing Arts pursuant to Chapter 334, RSMo, to practice in this state as a physician and surgeon. (18) A physical therapist is a person who is licensed to practice physical therapy under Chapter 334, RSMo. (19) A plan of care is a comprehensive plan approved by a physician to direct prescribed pediatric extended care (PPEC) staff members in care and treatment of eligible children that contains nutrition orders, medication orders, treatment orders, equipment orders, and interventions for developmental goals. (20) A PPEC staff member is a child care staff member who has medical training and credentials as required by this chapter and is assigned to care for eligible children. (21) A prescribed pediatric extended care facility (PPEC or facility or PPEC facility) is a facility providing medically necessary multidisciplinary services to eligible children no more than twelve (12) hours within a twenty-four- (24-) hour period. The facility must be licensed by DESE under Chapter 210, RSMo. The facility must offer multidisciplinary services to include skilled nursing and personal care and speech, physical, and occupational therapy services, as ordered by a physician. (22) A prescribed pediatric extended care provider (provider) is the person or persons licensed or required to be licensed under sections 192.2550 to 192.2560, RSMo, to establish, conduct, or maintain a PPEC facility. (23) A registered nurse (RN) is a person licensed under Chapter 335, RSMo, to engage in the practice of professional nursing. (24) Skilled nursing includes those services which are required to be provided by a registered nurse or a licensed practical nurse. (25) Speech therapy is therapy provided by a person licensed under section 345.075, RSMo, as a speech-language pathologist. AUTHORITY: section 192.2554, RSMo Supp. 2024.* Original rule filed Dec. 31, 2024, effective July 30, 2025. *Original authority: 192.2554, RSMo 2024. 19 CSR 30-110.020 Prescribed Pediatric Extended Care Facilities Licensure Management PURPOSE: This rule describes the licensure, inspection, plan of correction, and variance processes. (1) Initial Application for License. (A) Persons desiring to receive a license to operate a prescribed pediatric extended care (PPEC) facility in the state of Missouri shall file a written Application to Operate a Prescribed Pediatric Extended Care Facility, included herein. (B) If the applicant has an active License to Operate a Group Child Care Home or Child Care Center for the location that the applicant is applying for PPEC licensure, the applicant shall include— 1. A copy of the License to Operate a Group Child Care Home or Child Care Center; 2. The most recent fire inspection report; 3. The most recent sanitation inspection report; 4. The terms of any discipline applicable to the License to Operate a Group Child Care Home or Child Care Center; and 5. Copies of any variances granted by Department of Elementary and Secondary Education (DESE) to regulations under 5 CSR 25. (C) If the applicant does not have an active License to Operate a Group Child Care Home or Child Care Center, the applicant shall include evidence of a pending application for said license. (D) The applicant shall include a chart or description of the lines of administrative authority. (E) The application shall include confirmation that the applicant can provide multidisciplinary services to include skilled nursing and personal care and speech, physical, and occupational therapy services. (F) Upon receipt of a complete application, the department will initiate the initial licensure process. (G) If the applicant does not complete the initial licensure process within six (6) months, the application shall be void and another application may be filed. (H) No license shall be granted until the applicant has provided proof of compliance with all rules within this chapter. (I) Once granted, the PPEC facility license shall be posted in a public area of the facility. (J) The license shall not be transferable and shall apply only to the person and address shown on the license. (K) The department will not accept an application for PPEC facility licensure for a period of twelve (12) months after revocation or denial of the facility license. (L) The department will not accept an application for PPEC licensure from a provider whose License to Operate a Group Child Care Home or Child Care Center is suspended or pending proposed revocation. (2) Limitations on Facility Location and Operation. (A) The PPEC shall be located within thirty (30) minutes or twenty (20) miles, whichever is less, from a licensed hospital with an emergency department. (B) The PPEC shall be located on the ground floor of any multi-level building. (C) The PPEC facility shall not be located in a mobile home. (D) The PPEC facility shall not be located in a residence. (E) There shall be no nighttime care of eligible children in the PPEC facility. For the purposes of this rule, night shall have the same meaning as defined in 5 CSR 25-500.010. (3) Post Licensing Requirements. (A) Thirty (30) days after either initial licensing or beginning to care for eligible children, whichever is later, the provider shall obtain a sanitation inspection. (B) The provider shall notify the department of any new or changed variances granted by DESE to regulations under 5 CSR 25. (C) Providers shall provide to the department annual proof of compliance with fire safety and sanitation requirements set by DESE. 1. Compliance with fire safety requirements shall be proven with an inspection by the Department of Public Safety, Division of Fire Safety, showing the facility to be in full compliance. 2. Compliance with sanitation requirements shall be proven with an inspection by the Department of Health and Senior Services showing the facility to be in full compliance. (4) Inspection and Plan of Correction Process. (A) The PPEC facility provider and staff shall allow representatives of the department to survey the facility. (B) After completion of each department survey, the department shall prepare a written report of the findings with respect to compliance or noncompliance with the provisions of sections 192.2550 – 192.2560, RSMo, and the regulations within this chapter, as well as a list of deficiencies. (C) The provider or designee shall have ten (10) calendar days following receipt of the written survey report to provide the department with a written plan of correction for the identified deficiencies. (D) Upon receipt of the required plan of correction for achieving license compliance, the department shall review the plan to determine the appropriateness of the corrective action and respond to the facility. If the plan is not acceptable, the department shall notify the provider or designee and indicate the reasons why the plan was not acceptable. A revised plan of correction shall be provided to the department within seven (7) calendar days of this notice. (E) Upon expiration of the completion date for correction of deficiencies specified in the approved plan of correction, the department shall determine if the required corrective measures have been acceptably accomplished. If the department finds the facility to still be noncompliant, the department may request another plan of correction or may take action to discipline the license. (F) The department may proceed with the immediate suspension and proposed revocation of a license prior to receiving a plan of correction if there is an imminent threat of bodily harm to the children in care. (G) The department will not accept a plan of correction and will proceed with the immediate suspension and proposed revocation of a license if DESE immediately suspends the provider’s child care license, or if DESE revokes the provider’s child care license. (5) Variance Request Process. (A) Any provider may request a variance from a rule in this chapter. The request for a variance shall be submitted in writing to the department and shall include the rule(s) for which a variance is requested and the reason(s) the provider requests the variance. (B) The department may grant variances for specified periods of time to any rule imposed by the department in this chapter if the department has determined that the variance to the rule would not potentially jeopardize the health, safety, or welfare of any children in the PPEC facility. The department shall notify the provider, in writing, of the decision on any request for variance, stating the reason(s) for acceptance or denial, and, if granted, the length of time the variance is to be in effect and any additional corrective factors upon which variance may be conditioned. The determination is subject to review under Chapter 536, RSMo. AUTHORITY: section 192.2554, RSMo Supp. 2024.* Original rule filed Dec. 31, 2024, effective July 30, 2025. *Original authority: 192.2554, RSMo 2024. 19 CSR 30-110.030 Prescribed Pediatric Extended Care Facilities Operations PURPOSE: This rule defines the minimum requirements for the provision of care in licensed Prescribed Pediatric Extended Care (PPEC) facilities. PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Providers must comply with all regulations under this chapter and all relevant regulations under 5 CSR 25-500, 5 CSR 25-600, and all other relevant state and federal laws. (A) Providers shall notify the department of any discipline proposed by Department of Elementary and Secondary Education (DESE) against the provider’s license to operate a child care facility. This notice shall be sent to the department within one (1) business day of receipt of the notice of proposed discipline. (B) The provider must have an active license to operate a child care facility for the same location as the PPEC facility license. (2) Organization and Administration. (A) The facility must immediately notify the department of any personnel changes of the center director or director of nursing. (B) The facility must immediately notify the department of changes in the facility contact information. (C) The director of nursing is responsible for PPEC staff member assignments; coordinating medical care of eligible children; assuring that the needs of eligible children are continually assessed; and assuring the development, implementation, and updates of the individualized plan of care. (D) The center director and director of nursing positions shall not be held by the same individual. (E) When the director of nursing is not available, a qualified designee approved in writing by the department shall assume the same responsibilities and obligations as the director of nursing. (F) The director of nursing or an approved qualified designee shall be available on-site during all operating hours. (3) Policies. (A) Each PPEC facility must develop, implement, and maintain written policies and procedures governing the following at a minimum: 1. Medical, nutritional, and developmental assessments of eligible children; 2. Admission, transfer, and discharge; 3. Multidisciplinary medical staff, direct care staff supervision; 4. Child abuse and neglect; 5. Infection control program; 6. Infection control isolation procedures; 7. Medical equipment; 8. The plan of care; 9. Medication storage and administration; 10. Clinical records; 11. Quality assurance program; 12. Complaints; 13. Emergency preparedness and medical response; and 14. Staff training and competency evaluation. (B) Policies and procedures must be developed, maintained, and implemented by a group of professional PPEC staff members comprised of at least the center director, the director of nursing, and a representative of each multidisciplinary service offered. Policies and procedures shall be developed in conjunction with a physician consultant. (C) The facility policies and procedures must be reviewed yearly during a quality assurance meeting as described in this rule. (4) Medical, Nutritional, and Developmental Assessments. The facility shall conduct the following initial assessments to ensure that the PPEC facility is equipped and staffed to meet the needs of an eligible child prior to admission: (A) Prior to admission to the facility, a registered nurse or physician shall conduct and document an initial assessment to assess the eligible child’s immediate physical and medical equipment needs prior to admission to the facility. The assessment shall be completed as often as required to meet the needs of the eligible child; (B) Prior to admission to the facility, a registered nurse, registered dietician, nutritionist, physician assistant, or physician shall conduct and document an initial nutritional assessment to assess the eligible child’s immediate nutritional and equipment needs prior to admission to the facility. The assessment shall be completed as often as required to meet the needs of the eligible child; (C) Prior to admission to the facility, a registered nurse, physical therapist, occupational therapist, speech therapist, physician assistant, or physician shall conduct and document an initial developmental assessment to assess the eligible child’s immediate developmental needs. Further assessments shall be completed as often as required to meet the needs of the eligible child; and (D) Initial assessments shall be conducted in person and may take place at either the eligible child’s home, the facility, or other medical facility. (5) Admission, Transfer, and Discharge. (A) The admission of each eligible child to a PPEC facility must be under the supervision of the director of nursing in collaboration with the center director and must be in accordance with facility policies and procedures. (B) Each eligible child admitted to a PPEC facility must be admitted upon written orders by a licensed physician and must remain under the care of a physician for the duration of the child’s admittance in the facility. (C) The facility must ensure that all medical equipment and medical staff necessary to meet the needs of the eligible child will be available in the facility before admission of the eligible child. (D) Each eligible child admitted for service to a PPEC facility must meet at least the following criteria: 1. Eligible children considered for admission to the PPEC facility will be those who are medically or technologically dependent and require continuous skilled nursing intervention of at least four (4) hours per day; 2. The eligible children must not, immediately prior to admission, present significant risk of infection to other children or child care staff members. The director of nursing must review, on a case-by-case basis, any eligible child with a suspected infectious disease to determine appropriateness of admission; 3. The eligible child must be medically stabilized, require skilled nursing care or other interventions, and be appropriate for outpatient care; and 4. If the eligible child meets the preceding criteria, the director of nursing must implement a pre-admission plan which delineates services to be provided and appropriate sources for such services. A. If the eligible child is hospitalized at the time of referral, pre-admission planning will include the parents or guardians and relevant hospital medical, nursing, social services, and developmental staff to assure that the hospital discharge plans will be implemented upon admission to the PPEC. B. A consent form outlining the purpose of a PPEC admission, family responsibilities, authorized treatment, liability release, and emergency disposition plans must be signed by the parents or guardians and witnessed prior to admission to the PPEC. The parents or guardians must be provided a copy of the consent form. A copy of the signed consent form must be maintained in the eligible child’s medical record. C. Confidentiality of the PPEC records must be maintained in accordance with facility policies and applicable state and federal laws. (E) If an eligible child requires emergency medical treatment, the facility shall immediately provide the accepting clinician, emergency medical services, or healthcare provider verbally and in writing the necessary medical information regarding immediate medical needs and the eligible child’s relevant history. (F) If an eligible child transfers to another PPEC facility, the facility shall provide to the receiving facility a verbal report and pertinent written information, which shall include at a minimum— 1. Current medication profile; 2. Problems that require intervention or follow-up; and 3. Current plan of care. (G) The name and contact information of the center director and director of nursing, including the telephone numbers, shall be provided to the eligible child’s parent or guardian upon admission and upon any changes to the contact information. The facility shall explain to the child’s parent or guardian when the director of nursing should be contacted for discussion about services provided to the child. (H) A discharge summary must be sent to the primary care practitioner or other healthcare professional who will be responsible for providing care and services to the eligible child after discharge from the facility within five (5) business days of the date of the order for discharge from the responsible physician. (I) Discharge for cause. Notwithstanding other provisions of this rule, a PPEC facility may discharge an eligible child without a discharge order from the responsible physician for cause. 1. Discharge for cause shall only be allowed in situations involving— A. Parent or guardian non-compliance with plan of care; B. Non-payment; or C. Discharge is required to prevent a threat of imminent harm to children in care or child care staff members. 2. The PPEC facility shall provide the eligible child’s parent or guardian with a minimum of fourteen (14) days’ notice except in situations where the director of nursing or center director determines that such discharge is required to prevent a threat of imminent harm to children in care or child care staff members. 3. The PPEC facility shall notify the department in writing within forty-eight (48) hours of the decision to discharge an eligible child for cause. (6) Facility Staffing. (A) Director of nursing. 1. The director of nursing shall have a pre-designated approved qualified individual to act in his/her absence. This individual shall meet the minimum qualifications of the director of nursing. 2. Only individuals approved by the department shall serve as director of nursing or as a qualified individual in the director of nursing’s absence. 3. The director of nursing shall meet the following minimum qualifications: A. Be a registered nurse with an unencumbered license; B. Hold current certifications in basic life support (BLS) appropriate to the ages of eligible children for which the PPEC facility is licensed to provide care; and C. Have a minimum of three (3) years acute pediatric nursing experience. 4. To request approval of a director of nursing or pre-designated qualified individual, the provider shall submit a written request to the department including proof that the individual meets the minimum qualifications listed above. 5. Director of nursing approval shall be on file at the facility for the director of nursing and any pre-designated qualified individuals. 6. The duties and responsibilities of the director of nursing and any pre-designated qualified individual(s) shall be clearly defined in writing. (B) Skilled nursing services. 1. Minimum qualifications for skilled nursing personnel shall be as follows: A. Be a registered nurse or licensed practical nurse with an unencumbered license; B. Hold current certifications in BLS appropriate to the ages of eligible children for which the facility is licensed to provide care; C. Have a minimum of one (1) year of nursing experience; and D. Will be trained by the director of nursing in the care of eligible children per facility policy. The training and competency evaluation must be documented in the employee file. 2. Skilled nursing services shall be provided in accordance with recognized standards of practice. 3. The duties and responsibilities of skilled nursing staff shall be clearly defined in writing. 4. The ongoing assessment, planning, and provision of nursing services shall be the overall responsibility of a registered nurse. 5. When skilled nursing services are delegated to a licensed practical nurse, the licensed practical nurse shall be supervised by a registered nurse present during the hours that the licensed practical nurse is providing services. 6. A registered nurse must provide nursing interventions; educational services to increase the parent’s or guardian’s confidence and competence in caring for the child with special needs; assistance to facilitate coping with the effects of chronic illness on the child and family and support effective relationships among siblings and the ill child; and interventions to foster normal development and psychosocial adaptation. (C) Direct care services. 1. Minimum qualifications for direct care personnel shall be as follows: A. Be a certified nursing assistant or certified medical technician; and B. Hold current certifications in BLS appropriate to the ages of eligible children for which the facility is licensed to provide care. 2. The duties and responsibilities of direct care personnel shall be defined clearly in writing. 3. Direct care personnel must work under the supervision of the registered nurse and be responsible for providing direct care to eligible children. 4. Prior to care responsibilities being assigned to direct care personnel, said personnel must be trained by a facility registered nurse on the specific care, equipment, and medical precautions for care of eligible children. This training shall be documented and recorded in an employee file. (D) Multidisciplinary staffing. 1. The facility may have a written agreement for the provision of multidisciplinary services. The agreement shall include the following: A. Identification of the services to be provided in accordance with the plan of care; B. Delineation of the role(s) of the PPEC facility and the contracted services; C. Assurance that the contracted staff shall be appropriately licensed; and D. Assurance of current certifications in BLS appropriate to the ages of eligible children for which the facility is licensed to provide care by all individuals providing multidisciplinary services. 2. If multidisciplinary services are provided without supervision of PPEC staff members, providers of multidisciplinary services must have evidence of being eligible for employment or presence in a child care facility, as determined by DESE. (E) Employee files. 1. The facility shall maintain employee files for all PPEC staff members, which shall be available to state agencies upon request. The employee files shall contain at a minimum— A. Evidence of the active professional registration, license, or certification; B. Evidence of minimum required experience; C. Evidence of training on medical emergencies and specialized medical equipment; D. Training on PPEC specific policies and procedures; E. A current job description for each PPEC staff member; F. Evidence of initial and annual child abuse and neglect training; and G. Orientation of the PPEC staff member with the philosophy, organization, program, practices, and goals of the PPEC facility. (F) Additional staffing requirements. 1. Nursing services must be provided by direct employees (those employees issued a form W-2) of the licensed provider. 2. All PPEC staff members, including contracted staff, shall be considered child care staff members and must be eligible for employment or presence in a child care facility, as determined by DESE in accordance with 5 CSR 25-600. 3. Nursing services shall be staffed to ensure that the needs of each eligible child are met, including at least the staff members required by this rule and any additional staff necessary to meet the needs of all eligible children in care. 4. The facility shall have staffing which is sufficient to meet the complete needs of all eligible children in care in accordance with the eligible childrens’ respective plans of care. 5. Oversight of all contracted medical staff is the overall responsibility of the director of nursing. 6. A registered nurse shall be on duty at all times when an eligible child is present in the facility. 7. The facility shall have trained PPEC staff members in sufficient numbers to evacuate the children from the facility in case of emergency. 8. The PPEC staffing schedule shall be readily available to inspectors for the previous forty-five- (45-) day period. (7) Eligible Children in Care. (A) The facility shall maintain a daily attendance record, which indicates the names of children currently receiving services at the facility and the times each child arrived at and departed from the facility each day. (B) There shall be no more than thirty-six (36) eligible children in care at any licensed facility. (C) The minimum staffing ratio for the PPEC staff members responsible for care of eligible children shall be as follows: Eligible ChildrenTotal PPEC StaffRNRN or LPNDirect Care Personnel1112-62117-9311110-12411213-15521216-18621319-21722322-24822425-27932428-301032531-331133534-3612336 (8) In-Service Training for Staff, Parents, and Guardians. (A) Each PPEC facility must develop a staff training program. (B) In addition to the training required by 5 CSR 25-500.102, PPEC staff training must include, at a minimum, the following: 1. Staff development programs appropriate to the category of personnel. For the purposes of this rule, staff development programs must consist of a minimum of twelve (12) hours of training per year. Training topics shall include, but need not be limited to, standards of practice, equipment, medication, infection control, and communicating with and educating parents and guardians regarding the eligible child’s plan of care; 2. Documentation of all staff development programs and required participation in an employee file; and 3. Current BLS certification for all PPEC staff. (C) In addition to orientation required by 5 CSR 25-500.102, each new PPEC staff member will participate in orientation to acquaint the PPEC staff member with the philosophy, organization, program, practices, and goals of the PPEC facility. This orientation shall occur prior to providing unsupervised care to eligible children and be documented in an employee file. (D) A comprehensive orientation to acquaint the parent or guardian with the philosophy and services will be provided at the time of the eligible child’s admission to the PPEC facility. (E) In addition to the training requirements set forth in 5 CSR 25-500.102, each PPEC staff member shall be trained on child abuse and neglect recognition, definition, reporting, and the facility policy. The training shall be completed on hire before any unsupervised child contact, and annually. (9) Infection Control. (A) In addition to infection control measures required by 5 CSR 25-500, facilities must maintain infection control requirements that include at least the following: 1. All cribs and beds must be labeled with the individual eligible child’s name. Linens must be removed from the crib for laundering purposes only; 2. Bed linens must be changed when soiled and as necessary, but not less than twice weekly; 3. Laundry facilities shall be so designed, and procedures instituted, to prevent cross-contamination of clean and dirty linens; 4. Adequate space shall be provided in the laundry room for storing, sorting, and processing soiled linen. Space shall be provided for storing clean linen in a separate room from the laundry; 5. Soiled clothes and linens shall be stored in nonabsorbent containers or washable laundry bags and shall be transported for laundering in tightly enclosed bags or containers; 6. Clean clothes and linens shall be stored in a clean place and protected from contamination until used; 7. Handwashing sinks shall be in or immediately adjacent to toilet rooms or vestibules and shall be easily accessible to employees in areas where eligible children may be present; 8. Antimicrobial soap and disposable paper towels must be at each handwashing sink; 9. Sinks used for food preparation or for washing equipment or utensils shall not be used for handwashing; 10. Portable sinks are not permitted; 11. PPEC staff members shall thoroughly wash their hands and exposed portions of their arms with antimicrobial soap and water after direct contact with bodily fluids, before and after performing any type of procedures with a child, before starting work, during work as often as is necessary to keep them clean and after eating, drinking, using the toilet, and between care of eligible children using appropriate handwashing techniques to prevent the spread of infection from one child to another; 12. Alcohol-based hand rub (ABHR) may be used for handwashing in lieu of antimicrobial soap and water except when there has been direct exposure to bodily fluids. ABHR must have a minimum alcohol content of sixty percent (60%); 13. PPEC staff members shall keep their fingernails clean and trimmed; 14. A supply of sanitary towels or a hand-drying device providing heated air shall be conveniently located near each lavatory, except that hand towels for individual use are permitted. Common towels are prohibited. If disposable towels are used, easily cleanable waste receptacles shall be conveniently located near the hand-washing facilities; 15. Lavatories, soap dispensers, hand-drying devices, and all related fixtures shall be kept clean and in good repair; 16. Eligible children suspected of having a communicable disease, which may be transmitted through casual contact, as determined by the facility director of nursing, must be isolated; the parents or guardians must be notified of the condition; and the child must be removed from the PPEC facility as soon as possible. The child may not return to the PPEC facility until deemed non-infectious, as evidenced by a written physician’s statement; 17. The PPEC facility must have an isolation room with the ability to monitor any eligible child requiring isolation under these rules; 18. PPEC staff members suspected of having a communicable disease must leave and may return to work based on the facility’s policy; 19. The facility shall have rigid, leak-proof, and puncture-resistant containers for the safe storage of disposed medical sharps readily available for nursing staff; 20. The facility shall have containers identified for the storage of biohazardous waste; 21. The facility shall dispose of biohazardous waste in a manner consistent with standards of professional practice; 22. The facility shall have an area designated for sterile medical procedures that limits traffic of unnecessary staff and limits the movement of airborne microbes. This area shall not be used to store soiled linens, trash, or any other contaminated materials that may lead to an increased risk of infection; and 23. The facility shall have a potable water management plan. (10) General Sanitation Requirements. (A) There shall be present in the facility only those poisonous or toxic materials necessary for maintaining the establishment, cleaning and sanitizing equipment and utensils, and controlling insects and rodents. (B) Facility ventilation intake and exhaust air ducts shall be maintained to prevent the entrance of dust, dirt, and other contaminating material into the facility. (C) Cleaning of floors and walls, except emergency cleaning of floors, shall be done during periods when the least amount of food is exposed, such as between meals. Mops used for cleaning bathrooms shall be disinfected after use and before using in other areas. (D) Garbage and refuse shall be kept in durable, easily cleanable, insect-proof and rodent-proof containers that do not leak and do not absorb liquids. Plastic bags and wet-strength paper bags may be used to line these containers, and they may be used for storage inside the facility. (E) Garbage or refuse storage rooms, if used, shall be constructed of easily cleanable, nonabsorbent, washable materials, shall be kept clean, shall be insect-proof and rodent-proof, and shall be large enough to store the garbage and refuse containers that accumulate. (F) Effective measures intended to minimize the presence of rodents, flies, cockroaches, and other insects on the premises shall be utilized. The premises shall be kept in such condition as to prevent the harborage or feeding of insects or rodents. (G) Maintenance and cleaning tools such as brooms, mops, vacuum cleaners, and similar equipment shall be maintained and stored in a way that does not contaminate food, utensils, equipment or linens and shall be stored in an orderly manner. (H) Food shall be secured and stored in accordance with 19 CSR 20-1.025. (11) Equipment. (A) The facility shall provide education to PPEC staff members on the safe use of any specialized medical equipment. This education shall be documented in an employee file. (B) The facility shall maintain written evidence that all medical equipment available for use in care of eligible children has been inspected and maintained on an annual basis and in accordance with the manufacturer’s specifications. (C) The facility shall have policies and procedures for cleaning, storing, accessing, and distributing any facility-owned equipment. (D) Oxygen and oxygen safety. 1. The facility shall maintain an alternate emergency oxygen source for oxygen dependent eligible children. 2. There shall be an oxygen storage room that is surrounded by one- (1-) hour fire-rated construction with a powered or gravity vented door. 3. Oxygen storage shall be in accordance with NFPA 99, Health Care Facilities Code (2024), published October 2024, which is incorporated by reference in this rule as published by the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169-7471, and available online at https://www.nfpa.org/product/nfpa-99-code/p0099code#2024-edition-details. This rule does not incorporate any subsequent amendments or additions. The facility shall use permanent racks or fasteners to prevent accidental damage or dislocation of compressed oxygen cylinders. Safety caps remain intact except where a cylinder is in actual use or where the regulator has been attached and the cylinder is ready for use. Individual oxygen cylinders in use or with an attached regulator shall be supported by cylinder collars or by stable cylinder carts. (12) Plan of Care. (A) The facility shall have written policies regarding development and revising the eligible child’s plan of care. The plan of care shall be reviewed and signed every sixty (60) days at a minimum, or as frequently as medically necessary, by a physician. The plan of care shall include, at a minimum, the following: 1. Identification of all allowed practitioners involved in the care of the child; 2. A medication list that includes the medication name, dose, frequency, and route of administration; 3. The medical equipment and emergency equipment necessary to care for the child; 4. The diet, nutrition, and developmental requirements for the child; 5. The frequency of treatment for skilled nursing, speech, physical, and occupational therapy; and 6. Treatments required by the child. (B) The facility must notify the eligible child’s physician when the plan of care cannot be followed or when there is a change in the child’s condition that would indicate a change to the plan of care is necessary. (C) The individualized plan of care must be reviewed and revised by the physician who is responsible for the plan of care as frequently as the eligible child’s condition or needs require, but no less frequently than every sixty (60) days, beginning with the admission date to the facility. (D) The physician who initiated PPEC care is responsible for the ongoing plan of care; however, in order to assure the development and implementation of a coordinated plan of care, the facility shall communicate with all physicians involved in the child’s care as often as medically necessary. (E) The director of nursing is responsible for integrating orders from all relevant physicians involved in the plan of care to ensure the orders are approved by the responsible physician. (13) Medications. (A) The facility shall develop policies and procedures for the safe and effective administration of medications, in accordance with accepted professional standards. (B) The facility shall maintain safe storage and control of medications. (C) Medications shall be administered to eligible children by appropriately trained staff. (D) Multi-use medications must be labeled with the date opened and expiration date. (E) Medications or parenteral fluids that require refrigeration shall be appropriately labeled and stored in a temperature-controlled refrigerator that is tested daily. The refrigerator shall be always maintained between thirty-five to forty-six degrees Fahrenheit (35-46 F°). The daily refrigerator temperature tests shall be documented. (14) Clinical Records. (A) Clinical records and health information must be maintained in accordance with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). (B) The facility shall have written policies for clinical records, including timeliness of data entry. (C) The facility shall establish and maintain a clinical record for every eligible child receiving care and services from admission to discharge. (D) An entry by the licensed nurse shall be documented as often as medically necessary to reflect care and services provided according to the plan of care, at a minimum daily. (E) The record shall be complete, legible, readily accessible, and accurate. (F) Each clinical record shall be a compilation of information for all services provided. (G) Clinical entries shall include time and date of the entry identified by the person providing the services. (H) The clinical record shall include the plan of care, physician orders, medication administration, multidisciplinary assessments, pertinent medical history, precautions, allergies, immunization records, and communication with coordinating healthcare providers. (I) Verbal orders must be authenticated and dated by the physician or allowed practitioner in accordance with the facility policy, no longer than thirty (30) days from the verbal order. (J) Documentation of nutritional management and special diets, as appropriate. (K) The facility shall safeguard the clinical record against loss, destruction, and unauthorized use. (L) A discharge order written by the primary physician will be documented and entered in the eligible child’s record. A discharge summary, which includes the reason for discharge, shall be included. (M) Medical records must be secured after discharge according to applicable state law. (15) Quality Assurance. (A) All PPEC facilities must have a quality assurance program with quarterly meetings that focus on indicators related to improved outcomes, including the use of emergent care services, hospital admissions, and re-admissions; and takes actions that address the facility’s performance across the spectrum of care, including the prevention and reduction of medical errors. The meeting at a minimum shall review staffing, emergency care, medical record audits, complaints, emergency preparedness exercises, and infection control reports. The facility must implement quality improvement projects to correct any issues identified in the program. (B) The quality assurance committee shall conduct quarterly random medical record audits for at least three (3) eligible children, or twenty-five percent (25%) of the daily average census, whichever is greater. (C) The quality assurance committee shall have a minimum of three (3) representatives including the center director, director of nursing, and a professional multidisciplinary team member. (D) The quarterly quality assurance review will be conducted by the quality assurance committee, which shall generate a written report including any recommendations for quality improvement projects. (E) At least yearly, the quality assurance committee will include a physician or allowed practitioner to review care issues and conduct a review of the policies and procedures and provide updates as necessary. (F) The director of nursing maintains overall responsibility to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained. (16) Multidisciplinary Meetings. (A) A multidisciplinary group, representative of the services provided for the eligible child, shall conduct at a minimum a monthly meeting to review each eligible child’s plan of care for appropriateness considering any changes in the child’s condition or needs. (B) The multidisciplinary group shall coordinate immediately for any changes in the eligible child’s immediate medical needs. (C) The team shall notify the eligible child’s physician of any recommendations regarding the eligible child’s plan of care and request physician orders as appropriate. The meeting attendees and any recommendations shall be documented. (D) The director of nursing is responsible for coordination of the multidisciplinary meetings. (E) The director of nursing is responsible to coordinate with and educate the parent or guardian regarding the multidisciplinary plan of care meetings and resulting recommendations. (17) Fire Safety and Emergency Procedures. (A) All PPEC facilities must conform to state standards of the State Fire Marshal. A copy of the current annual fire inspection report must be on file at the PPEC facility. Documentation of a satisfactory fire safety inspection shall be provided annually or when requested by the department. (B) If a facility accepts any eligible child that requires electrical life support equipment, an emergency backup electrical system with an automatic transfer switch shall be installed. The system shall be sized and installed by a qualified installer to provide power for the maximum number of allowed life support systems for a minimum of two (2) hours. The system shall be installed by a qualified installer, tested, and maintained in accordance with manufacturer’s specifications. (C) The provider shall immediately report any fire or facility evacuation to the department. (D) Emergency transportation must be performed by a licensed ambulance service, with PPEC medical staff coordinating the emergent transfer. (E) The PPEC facility must have a child-specific emergency medical kit available for each eligible child in care. (F) PPEC staff shall be trained on the use of emergency medical equipment for eligible children. The training shall be documented in the employee file. (G) The facility shall have an emergency preparedness program that considers the specific needs of eligible children. (H) The facility shall ensure that there is adequate space around eligible children and their life support equipment to allow unencumbered access for evacuation and provision of emergency care. (18) The emergency preparedness program shall include at a minimum— (A) A written communication procedure plan considering special needs of eligible children; (B) A written emergency evacuation plan considering special needs of the eligible children, which must be reviewed and accepted by the department; (C) Annual documented training of PPEC staff on the emergency preparedness program for the PPEC care facility; and (D) Annual simulated exercises to test the emergency plan involving all PPEC staff. The exercise procedure and outcomes shall be documented. Simulations shall include pseudo-patients in lieu of eligible children so as not to risk harm to children during the exercise. (19) Transportation. Child care staff members shall not transport eligible children in their capacity as a child care staff member unless the child care staff member is the eligible child’s parent or guardian. 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