SMALL HOUSE SKILLED NURSING FACILITIES

PILOT PROGRAM STANDARDS

A. INTRODUCTION

I.    The Small House Skilled Nursing Facility Pilot Program

Senate Bill 1228 (Chapter 671, Statutes of 2012) added a new subcategory of skilled nursing facilities in California, the small house skilled nursing facility (SHSNF). See Health and Safety Code (HSC) section 1250(c)(2). 

That same legislation added Article 7.2 to the HSC, commencing with section 1323.5, to establish the Small House Skilled Nursing Facilities Pilot Program (SHSNF PP). The stated purpose of the pilot program is to allow the California Department of Public Health (CDPH or the Department) to authorize the development and operation of up to ten SHSNFs that are licensed to provide skilled nursing care and supportive care to patients in small, homelike, residential settings that incorporate emerging patient-centered health care concepts.

The long-range goal of the pilot program is to evaluate the models developed under the pilot program to determine if each model improves patient satisfaction and clinical outcomes in a cost-effective manner. 

II. Applicability of Existing Law

All of the following shall apply to the SHSNF pilot program:

Federal: All federal statutes and regulations, and the standards and guidance of the Centers for Medicare and Medicaid Services (CMS) pertaining to certification under Title XVIII of the federal Social Security Act (42 U.S.C. § 1395 et seq.) for skilled nursing facilities and/or Title XIX of the federal Social Security Act (42 U.S.C. § 1396 et seq.) for nursing facilities shall be applicable to all pilot facilities.

California: All provisions of the HSC and Title 22 of the California Code of Regulations (CCR) pertaining to skilled nursing facilities (SNFs) shall be applicable to all pilot facilities, except as modified or supplemented by this or any subsequent All Facilities Letter (AFL) pertaining to SHSNFs, or subject to a waiver under HSC section 1323.5(k). All California statutes and regulations, including the California Building Standards Code (CBSC), the Welfare & Institutions Code (WIC), and the California Retail Food Code (CRFC) that pertain to SNFs apply to each pilot facility in the SHSNF PP.

B. DEFINITIONS

The definitions contained in HSC section 1323.5 shall apply to the SHSNF pilot program, and are restated below. The definitions contained in Title 22 of the California Code of Regulations (CCR), Chapter 3, section 72001 et seq., also shall apply, except as modified or supplemented by these SHSNF standards (“standards”). 

“Centralized support area” means administration and public spaces, and areas used for support services as described in the CBSC (CCR Title 24, Part 2) sections 1225.4.3, 1225.4.4, and 1225.4.5. 

“Clinical staff” means professional health care workers (HCWs) and managers in the SHSNF environment including, but not limited to:

• the Nursing Home Administrator (NHA),
• the Director of Nursing (DON),
• the Assistant Director of Nursing (ADON),
• the Medical Director,
• the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) Coordinator,
• the Food Service Operations (FSO) Manager, and
• the Director of Staff Development (DSD).

Clinical staff also includes the dietitian, records administrators, licensed nurses, social workers, speech pathologists, therapists, and pharmaceutical service staff. Clinical staff may be employees of the SHSNF or contractors.

“Companion” means a person who is allowed to stay at the home and share a resident’s bedroom at the request of the resident, but who does not receive any health care from the SHSNF. A companion may be a spouse, domestic partner, family member, or friend of the resident. Companions are not included in any computation relating to occupancy or staffing levels. 

“Continuing care retirement community” (CCRC) means a provider of a continuum of services, including independent living services, assisted living services as defined in paragraph (5) of subdivision (a) of HSC section 1771, and skilled nursing care, on a single campus, that is subject to HSC section 1791, or a provider of such a single campus that has not received a Letter of Exemption pursuant to subdivision (d) of section 1771.3. As used in HSC section 1323.5, subdivision (a)(2), “continuous nursing facilities” means any skilled nursing facility within a “continuing care retirement community.”

“Department” means the California Department of Public Health.

“Health care services” means direct care services, as defined in the NURSING SERVICE STAFFING REQUIREMENTS AND STANDARDS section, provided to SHSNF residents by health care workers (HCW) under appropriate conditions and supervision. The following general activity categories do not constitute health care services: supportive care including homemaker services, and administrative activities involving no resident contact.

“Health care worker” (HCW) means all persons delivering health care services to residents of SHSNFs. HCWs include employees, trainees, clinical staff, contractors, and consultants. Volunteers may be HCWs if they provide, for no compensation, health care services to more than one resident. A resident’s companion, relatives, and visitors are not included in this definition, even though those persons may assist HCWs in providing direct care to a resident. 

“Home” means an apartment, cottage, house, or other residential unit serving 12 or fewer residents. A home may be housed in a variety of structural types and site arrangements, as described in the BUILDING DESIGN STANDARDS section. More than one home may be included in a SHSNF. For purposes of these standards, “home” is synonymous with the term “household unit” as used in the CBSC, CCR, Title 24, Part 2, section 1225.5.2.2.1.

"Homemaker services" means non-direct care that includes food preparation, housekeeping, laundry, maintenance, shopping, and transportation services as specified in the SHSNF’s policies and procedures (P&Ps) and training plan. 

“Initial staff” means the employees and contractors of the SHSNF at the time the facility commences operation.

“Institutional” means a characteristic of an institutional-type health facility such as a hospital, as opposed to something that is residential in appearance. Physical features that are institutional in nature create an industrial or commercial appearance that is generally impersonal, uniform, and not typically found in a private dwelling.

“Licensed nurse” and “licensed nursing staff” mean registered nurses (RNs) and licensed vocational nurses (LVNs) who possess current valid licenses to practice in California. 

“Local permit” means permits, licenses, approvals, authorizations, land use planning entitlements, and clearances granted by local governmental entities having jurisdiction over the proposed site of a pilot facility including, but not limited to:

• a city or county planning department or community development department;
• a county environmental health department; and
• a special purpose district (e.g., fire protection district, utility district, sewer district). 

“Manager” means a health care worker employed at a supervisory level or above and includes, but is not limited to:

• the NHA, 
• the DON,
• the ADON,
• the Medical Director,
• the RAI/MDS Coordinator,
• the FSO Manager, and
• the DSD.

“Non-direct care” means care that does not involve health care services, such as: supportive care, and homemaker services. See the NURSING SERVICE STAFFING REQUIREMENTS AND STANDARDS section for greater detail. 

“Non-health care worker” and “non-HCW” means persons performing services at a SHSNF that do not include health care. Examples of the work that a non-HCW could perform include: food preparation, housekeeping, cleaning, laundry, transportation, clerical work, gardening, and maintenance. Non-HCWs may be SHSNF employees, contractors, or volunteers including residents’ companions, relatives, and visitors.

“Personal care” means assistance provided to a resident regarding dressing, grooming, personal hygiene, and related matters.

"Pilot facility" means one of the SHSNFs participating in the SHSNF PP established by HSC section 1323.5 et seq.

“Policies and procedures” (P&Ps) means written documents prepared by a SHSNF pilot program applicant or licensee pursuant to these standards for use in the pilot facility. All such documents shall be reviewed and approved by the Department prior to implementation and shall be made available to all HCWs, non-HCWs, residents, and designated representatives of residents. 

“Replacement staff” means employees and contractors hired or otherwise retained by the SHSNF to replace initial staff members. 

“Resident,” as used in these standards, means the same as “patient,” as used in State and federal statutes, regulations, and policies, including CCR Title 22, section 72077.1. For purposes of the SHSNF PP, “resident” is the preferred terminology. The term does not include a resident’s live-in companion.

"Small House Skilled Nursing Facility" (SHSNF), means a health facility that provides skilled nursing care and supportive care in a small, homelike, residential setting to patients whose primary need is for the availability of skilled nursing care on an extended basis. A SHSNF may consist of a group or cluster of such residential homes, each home having 12 or fewer beds, or a distinct area within an existing skilled nursing facility that otherwise meets the definition of a SHSNF, is physically separate and distinguishable from the remainder of the skilled nursing facility, and has a distinct entry with no through traffic of staff, residents, or visitors not affiliated with the SHSNF. A SHSNF may also be a distinct part (DP) of a general acute care hospital (GACH) or an acute psychiatric hospital (APH), pursuant to subdivision (c) of HSC section 1418.

“Staff” means the SHSNF’s employees, contractors, trainees, and consultants, other than the facility’s managers. Volunteers and other unpaid individuals at the SHSNF are not staff. 

"Supportive care" means non-direct care that includes the provision of socialization, activity aide services, and homemaker services to residents of SHSNFs. 

“Temporary employee” means a person who either:

• has been hired by the SHSNF or retained by contract, for a limited period of time as defined by the personnel policies of the facility;
• is an employee of the licensee at a health facility other than the SHSNF, and who is loaned to the SHSNF on a limited-term basis; or
• is an employee of an employment agency that has contracted with the SHSNF to provide personnel for a limited period of time, as defined by the facility. 

“Trainee” means a person who has been newly hired by the SHSNF and is being trained in accordance with the requirements of the TRAINING AND ORIENTATION STANDARDS section. It does not include a person training to be a certified nurse assistant (CNA) under the Certified Nurse Assistant Program (CCR Title 22, section 71801 et seq.) because a pilot facility is not a CNA training facility. 

"Versatile worker" (VW) means a HCW who is a CNA providing residents with both direct care and non-direct care, as defined in the NURSING SERVICE STAFFING REQUIREMENTS AND STANDARDS section and in accordance with the P&Ps of the pilot facility. 

“Volunteer” means a person providing, for no compensation, services to more than one resident at a SHSNF. Volunteers may be HCWs if they provide health care services and are under the supervision of SHSNF staff. A resident’s companion, relatives, and visitors are not included in this definition, even though those persons may assist HCWs in the provision of direct care to the resident. 

C. LOCATIONAL STANDARDS

I.     Definitions Specific to the Locational Standards

The definitions given in the DEFINITIONS section apply to this section. Additional definitions specific to the locational standards are:

“Adjacent” means properties or parcels of land that are physically contiguous to each other. Included in this definition are those on the opposite side of a public right-of-way other than a street or highway (e.g., utility rights-of-way, pedestrian rights-of-way including riding and hiking trails, public parks or open space rights-of-way or easements). 

“Close proximity” means nearby, neighboring, or in the immediate vicinity. This term differs from “adjacent” in that properties or land uses in close proximity to the SHSNF site may be separated from it by streets, highways, or intervening parcels of land. 

“Cluster” means a group of two or more homes within the SHSNF, located immediately adjacent to each other.

II.    Model Types Allowed 

(a) Each pilot facility may include one or more homes. 

(b) The physical layout of pilot facilities should be innovative and non-traditional, provided that all applicable codes are followed. The design may include, for example, any of the following types of homes:

(1) freestanding houses or cottages arranged in a group or cluster that meets the standard for “neighborhoods” in the CBSC (CCR Title 24, Part 2) section 1225.5.2.2;

(2) multiple apartments in a larger structure;

(3) more than one home within a larger structure;

(4) whole or partial floors in a multi-story structure;

(5) a distinct area within, or attached to, an existing SNF provided that the home:

(A) otherwise meets the definition of a SHSNF,

(B) is physically separate and distinguishable from the remainder of the SNF, and

(C) has a distinct entry with no through traffic of staff, residents, or visitors who are not affiliated with the SHSNF;

(6) a DP SHSNF of a GACH or an APH, provided that the home:

(A) otherwise meets the definition of a SHSNF,

(B) is physically separate and distinguishable from the acute care facility, and

(C) has a distinct entry with no through traffic of staff, residents, or visitors who are not affiliated with the SHSNF; and

(7) one or more homes integrated into a CCRC. 

III.    Locational Requirements

(a) Because a pilot facility is required to provide a residential environment compatible with surrounding residential development, the location for pilot facilities either shall be:

(1) in, or in close proximity to, a residential area;

(2) in, or in close proximity to, a mixed-use area that is substantially residential in nature; or

(3) on, or adjacent to, the campus of an existing licensed health facility, a residential care facility for the elderly (RCFE), or a CCRC.

(b) The proposed pilot facility shall not be in close proximity to an industrial use or zone, as designated by the local planning jurisdiction. 

(c) If any property adjacent to the proposed pilot facility site is vacant, neither the zoning nor the land use plan designation(s) adopted by the local jurisdiction for the adjacent vacant parcel(s) may be for general commercial or industrial uses. However, the following are permissible:

(1) designations permitting mixed uses in which residential development is combined with commercial or office use, and

(2) designations permitting health facilities, medical offices, clinics, or residential care facilities of any type. 

(d) The property on which the pilot facility is to be located shall be designated on the land use plans of the local jurisdiction for residential use, mixed-uses in which residential development is substantially present, or for healthcare-related uses such as hospitals and long-term care facilities. The property also shall be zoned to permit this type of health facility (a SHSNF), with or without further local permits.

(e) The location and site design of the pilot facility should:

(1) enable residents to interact with, and be a part of, the surrounding community,

(2) allow all necessary access for public safety equipment, including fire protection apparatus and emergency first responders, and

(3) provide residents access to public transportation and other services.

IV.    Site Design

(a) All homes included in the pilot facility shall be located on the same parcel of land or on adjacent parcels. 

(b) The site design for the pilot facility should integrate building and parking locations, access points, and on-site and off-site vehicular and pedestrian patterns, as well as access to public transportation services while maintaining the residential nature of the site. 

(c) The grounds surrounding each home:

(1) shall be fully accessible to disabled persons using all types of mobility devices;

(2) shall include built-in safety features to permit residents access throughout the majority of those areas during both day and night; and

(d) All walkways leading to the pilot facility and within its grounds shall be paved and shall not include steps or any other feature that could adversely affect disability access. 

(e) Emergency medical equipment, services, and staff who may be needed for emergency responses shall be located no farther away from any home than as follows:

(1) for homes located in separate structures, the distance between the entry door of each home sharing a licensed nurse on any shift shall not exceed that which can be traversed in 60 seconds by a pedestrian proceeding at normal walking pace by the most direct path;

(2) for homes located in the same structure (e.g., more than one household unit on the same floor, apartments in the same building, different floors in a multi-floor structure), the distance between the homes shall be no greater than that which can be traversed in 60 seconds by a person proceeding at normal walking pace by the most direct path without relying on the use of elevators. 

(f) A pilot facility may include administrative services or activities that are located in a centralized support area attached to the home(s) or detached in a separate building in close proximity to the home(s), as a part of the SHSNF. Subject to approval by the Department, administrative services and activities in the centralized support area may include but are not limited to:

(1) offices for SHSNF managers (e.g., the NHA, the DON, the ADON, the Medical Director, the RAI/MDS Coordinator, the FSO Manager, and
the DSD) and the dietitian;

(2) public spaces such as a multipurpose room;

(3) administrative services, including medical records administration and storage, shared by all homes in the SHSNF;

(4) storage of equipment shared by SHSNF homes;

(5) storage of long-term supplies not needed for either daily functions of each home or for immediate, emergency response at each home;

(6) facilities for optional service units, such as physical therapy, occupational therapy, speech therapy, speech pathology, audiology, and social services;

(7) optional features such as an on-site laundry and barber/beauty shop; and

(8) a central kitchen facility.

(g) Vehicular access shall be provided by paved roadway to at least one entrance of each home.

V.    Local Permit Requirements

(a) Regardless of the location of the proposed pilot facility, it shall meet all requirements of the local jurisdiction having authority over planning and zoning for the proposed site. 

D. BUILDING DESIGN STANDARDS

I.    Definitions 

The definitions given in the DEFINITIONS section apply to this section. 

II.    Compliance with State Building Regulations 

(a) All portions of each proposed SHSNF pilot facility shall comply with CCR Title 24 including those portions of section 1225.5.2 (CBSC, Household Model for SNFs) in effect at the time that the facility building plans are submitted to the Office of Statewide Health Planning and Development (OSHPD) for review and approval.

III.    Exterior Design for New Construction

(a) Each home in a pilot facility shall have an exterior design similar to housing available within the surrounding community.

(b) All homes, unless designed as multiple household units or apartments in a multi-story structure, shall have the exterior appearance of single-family residences, duplexes, or condominiums. New multi-story structures shall have the exterior appearance of apartment buildings typical in height and design to those in the surrounding area.

(c) Exterior facades shall not include signage or other features that detract from the residential appearance of the facility. Directional signs and those needed to comply with health and safety regulations, building codes, and disability access regulations are exempt from this prohibition. 

(d) The front entrance of each SHSNF shall be designed to have a residential appearance and should include typical residential features such as a doorbell, decorative knocker, porch lighting, and landscape features. 

(e) If the local planning agency has design criteria for this type of development that differ from any of the above, the requirements of the local planning authority shall prevail. 

IV.    Exterior Design for Existing Structures Being Converted/Remodeled 

(a) The exterior facade of an existing care facility that is being converted, all or in part, into a SHSNF need not be redesigned; however, the institutional appearance of the building, if any, should be minimized. 

(b) The exterior entrance to the SHSNF should be redesigned and remodeled if needed to create a homelike appearance.

(c) If the local planning agency has design criteria for this type of development that differ from any of the above, the requirements of the local planning authority shall prevail. 

 V.    Exterior Features for All Homes

(a) Each home shall provide its residents with access to one or more secured outdoor spaces:

(1) permissible designs include, but are not limited to, porches, verandas, balconies, and patios;

(2) these secured outdoor spaces shall be in addition to any exterior spaces shared with other homes;

(3) the outdoor spaces should provide for a variety of resident experiences, both active and passive;

(4) each secured outdoor space should include some form of shade or sun protection for its occupants; and

(5) a secured outdoor space shall be designated as a smoking venue at any home permitting smoking, and should include features that protect occupants from inclement weather. 

(b) All activities conducted in these secured outdoor spaces shall be accessible to disabled persons using all types of mobility assistance devices.

VI.    Interior Design

(a) Each home shall be designed to provide a homelike, residential setting that encourages socialization and personal interaction between the residents, as well as with the staff. 

(b) Homes that permit smoking shall include physical design features to prevent exposure to secondhand smoke.

(c) Each home shall be accessible to disabled persons using all types of mobility assistance devices.

(d) Each home shall include built-in safety features to permit the residents access throughout the majority of the home during most, if not all, of the day and night.

(e) Although the functions of certain interior features are still required, the home shall not, to the extent practicable, contain features having an institutional appearance including, but not limited to:

(1) hospital-like room design;

(2) public address systems and loud-speakers (other than for emergency use);

(3) long central corridors;

(4) nursing stations;

(5) medication carts;

(6) room numbers;

(7) wall-mounted licenses or certificates that could appropriately be accessed through other means; and

(8) drinking fountains. 

(f) Each home shall include areas or rooms for use by residents and their visitors that are commonly shared in a private home or apartment including, but not limited to, a living area where residents and staff may socialize, dine, participate in group activities, and prepare food together.

(g) The shared space within each home shall provide, at a minimum:

(1) one or more rooms that accommodate the functions:

(A) a living room seating area;

(B) a dining area large enough to seat all residents and at least two staff members;

(2) a full kitchen that is open, to the extent permitted by CCR Title 24, to the living room and dining room/area for use by residents, visitors, volunteers, and staff, in which staff and residents may prepare, cook, and serve meals on a daily basis, provided that this part of the home is designed in accordance with Title 24; and

(3) one or more smaller rooms where residents may meet or entertain visitors privately for celebrations, meals, and other social activiti

(h) Homes should provide 50 percent or more of its bedrooms for private, single-occupancy. Single-occupancy bedrooms may be shared only at the request of the resident by a companion, as defined in the DEFINITIONS section. This sharing shall not change the room’s categorization as single-occupancy or affect the facility’s bed count. 

(i) Homes may have double-occupancy rooms that provide bedroom space for two residents if those rooms comply with the following:

(1) the bedroom area for each resident shall be visually separated from the bedroom area of the other resident by a full-height wall or a permanently installed sliding door, folding door, or partition;

(2) walls, doors, or partitions used to separate resident bedroom areas shall provide both visual and acoustic separation; and

(3) a door leading to each resident's bedroom area (in addition to the corridor door) shall not be mandatory unless:

(A) required by applicable fire/safety regulations, or

(B) needed to achieve visual or acoustic separation. 

(j) Each resident’s bedroom area shall have direct access to an exterior window, whether in a single-occupancy room or a double-occupancy room. Ample natural light shall be provided throughout the portions of the facility to be used by residents.

(k) Bathrooms:

(1) all bathrooms, including those for staff and visitors, shall accommodate persons using any type of mobility assistive device;

(2) each single-occupancy bedroom should contain a full private and accessible bathroom with a toilet, lavatory, and a shower or bathtub;

(3) each double-occupancy bedroom shall contain a full private and accessible bathroom with a toilet, lavatory, and a shower or bathtub;

(4) fifty percent of the private resident bathrooms shall be compliant with the accessibility requirements of the CBSC, and the remainder shall be designed to permit toileting assistance and bathing assistance, as recommended by proposed industry guidelines of the American Institute of Architects (White Paper: Proposal of Additions to Accessibility Standards for Nursing Home & Assisted Living Residents in Toileting and Bathing, 8/20/12). 

VII.    Non-Exclusivity of Standards

Nothing in these standards shall be deemed to relieve any pilot program applicant or SHSNF licensee from the obligation to comply with:

(a) All locational, site, and design standards as may be required by the local planning and zoning jurisdiction;

(b) All federal standards and requirements necessary to permit each SHSNF to be eligible for certification as a skilled nursing facility or a nursing facility, or both;

(c) All applicable portions of CCR Title 24; and

(d) All local ordinances or other requirements of the local environmental health agency and any other local governmental agency having jurisdiction over the SHSNF site.

E. NURSING SERVICE STAFFING REQUIREMENTS AND STANDARDS 

For purposes of the SHSNF PP, at all times, each home shall meet the mandatory minimum staffing required by HSC section 1276.5, or HSC 1276.65, as applicable, and CCR Title 22, section 72329. However, based on patient need and acuity, additional staff also may be required. The minimum staffing requirement shall be computed for each home and not for the SHSNF, as a whole.

I.    Definitions Specific to the Nursing Service Staffing Standards

The definitions given in the DEFINITIONS section apply to this section. Additional definitions specific to these nursing service requirements and standards are:

“Actual hours” means the factual, real hours of direct care time, as defined below, provided by direct caregivers, as calculated by:

• punch-in/punch-out times and meal breaks,
• total hours worked, and
• time worked performing direct care duties in a SHSNF.

“Average census” means the average of the census during the patient day. The SHSNF shall record the total in-house census at the beginning of every patient day. The average shall be calculated by dividing the census obtained from the start of the patient day and the end of the patient day. If no census is recorded at the beginning of the patient day, the state, for auditing purposes will use the closest recorded in-house midnight censuses in relation to the patient day start and end times.

“Direct care” and “direct care services” means the types of resident care described in the following sections of CCR Title 22:

• Section 72309 Nursing Service;
• Section 72311 Nursing Service—General; and
• Section 72315 Nursing Service—Patient Care.

• performing gastrointestinal feeds;
• giving medications; and
• performing nursing assessments to:
• admit residents or
• notify physicians about a change in condition.

• a registered nurse (RN),
• a licensed vocational nurse (LVN),
• a licensed psychiatric technician (PT), or
• a certified nurse assistant (CNA) employed as a versatile worker (VW).

• the DON, as defined in CMS 671--Long Term Care Facility Application for Medicare and Medicaid;
• the ADON;
• the DSD performing the duties described in CCR Title 22, section 71829; and
• the licensed nurse serving as the RAI/MDS Coordinator, provided that, for purposes of calculating the minimum NHPPD, data entry of the Resident Assessment Instrument (RAI) is not considered direct care time.

“Delineate and document” means the identification of actual time spent providing direct care services by individuals, other than VWs, who have been hired by the SHSNF to provide both direct care and non-direct care services. Included in this term is the documentation of:

• the direct care assignment,
• the caregiver’s name,
• the actual time that the direct caregiver began and ended his/her shift,
• the actual time that the direct caregiver began and ended meal breaks, and
• the direct caregiver’s signature verifying the truth and accuracy of the information provided. 

“Electronic health record” means a repository of consumer health status information in a digital version of a paper chart used for clinical diagnosis and treatment for a broad array of clinical conditions as that term is used in 42 CFR section 411.351.

“NHPPD” or “nursing hours per patient day” means actual nursing hours performed by direct caregivers per patient day.

“NHPPD calculation” means the calculation of the NHPPD achieved by dividing the actual nursing hours performed by direct caregivers per patient day by the average census.

“Non-direct care activities” and “non-direct care services” mean activities or services that do not involve health care and include, but are not limited to, the following:

• paid or unpaid time spent on meal periods, except when direct care staff is dining with residents or assisting residents with dining which shall be considered direct care services;
• time spent on non-direct care duties and activities that occur away from the resident and are not resident-related, such as:
• administrative duties;
• staff training/orientation;
• medical recordkeeping, financial recordkeeping, and other clerical duties;
• transcribing physicians’ orders;
• performing quality assurance reviews/activities;
• marketing the SHSNF;
• stocking and restocking supplies;
• meal planning and preparation, except when direct care staff are directly interacting with residents in meal planning and preparation
• laundry, maintenance, and other housekeeping services including cleaning linens; supportive care, as defined in the DEFINITIONS section;
• supervision of VWs; and
• work performed by VWs when:
• serving as team leads or coordinators of self-managed work teams or
• coordinating and monitoring the work of other VWs.

“Patient day” means a 24-hour period that is used to determine staffing compliance with HSC section 1276.5.

“Self-managed work team” means a VW pair or group assigned to a home on the same shift and who plan, manage, and carry out the home’s day-to-day supportive care together. 

“Shift” means the working period of a direct or non-direct caregiver
in a SHSNF.

II.    Staffing Requirements

(a) Each home shall:

(1) be staffed with direct caregivers, including licensed nursing staff, whenever residents are housed in the home, with consistent staff assignments over time to allow residents the opportunity to bond with the staff;

(2) adhere to all state and federal laws regarding staffing and the provision of care including Labor Code section 512(a) and CCR Title 22, section 72533;

(3) ensure that at least one licensed nurse is awake and on duty on each shift;

(4) maintain the minimum staffing requirements in effect as indicated in HSC 1276.5 or 1276.65, and provide staffing based on resident need and acuity;

(5) ensure that sufficient VWs are awake and on duty on each shift and in each home to meet the needs of the patients; and

(6) ensure that each employee’s duty statement:

(A) specifies the activities that the employee will be required to perform;

(B) indicates the percent of time to be dedicated to each activity; and

(C) is signed and dated by the employee and the NHA or the DON.

(b) Each pilot facility shall establish, by written P&Ps, the number of hours in each shift and the name of each shift in that facility.

(c) Minimum staffing levels shall be based on the resident census, as specified in 42 CFR section 483.30(e)(1)(iv) Nursing Services.

(d) SHSNFs with contracts with the California Department of Health Care Services (DHCS) to provide Medi-Cal recipients with “subacute” levels of care, as defined in CCR Title 22, section 51124.5, shall maintain a staffing level that complies with DHCS regulations to meet minimum standards of medical necessity for that level of care.

(e) SHSNFs that provide care for “mentally disordered” residents and in which PTs provide patient care, including homes operating a Special Treatment Program (STP) as defined in CCR Title 22, sections 72443 through 72475, shall staff in compliance with CCR Title 22, section 72329(f)(1) in order to meet minimal standards of medical necessity for that level of care. 

(f) Stated staffing requirements are “minimum standards” only. Each SHSNF shall ensure that licensed direct caregivers are employed in accordance with CCR Title 22, sections 72329(a) and 72501(g).

(g) Licensed nursing staff shall supervise all VWs while providing nursing care to residents and while performing any other activities delegated to them under the licensed nurses’ scope of practice.

(h) The appropriate health care professionals shall supervise all activities of self-managed work teams that involve direct care to the residents that falls under the health care professionals’ scope of practice.

(i) The SHSNF shall develop, maintain, and implement written P&Ps for the development of self-managed work team goals and role definitions and responsibilities within the team. 

(j) If the SHSNF allows non-clinical staff to supervise self-managed work teams performing non-direct care duties, the SHSNF shall develop, maintain, and implement written P&Ps that describe the specified duties that are to be assumed by the non-direct care teams. 

(k) Licensed nursing staff may be assigned duties for residents in more than one household unit provided that:

(1) a licensed nurse is able to traverse the distance between the household units:

(A) within five minutes for non-emergency situations, and

(B) within 60 seconds in medical emergency situations;

(2) during the shift in which the residents require the least amount of care (usually the night shift or nocturnal shift), a licensed nurse shall be assigned to not more than three homes at any given time; and

(3) the total number of licensed nurses awake and on duty for each shift shall be based on resident need and acuity and the licensed nursing staff’s ability to traverse the distance between the homes as required by E.II.(k)(1), above. 

(l) Each SHSNF shall designate a licensed nurse as the DSD in accordance with CCR Title 22, section 71829. 

(m) Each SHSNF shall have a RAI/MDS Coordinator. An RN shall conduct or coordinate each resident needs assessment with the participation of appropriate health professionals. 

III.    Staffing Computations

(a) The staffing calculation shall be determined by dividing the total number of actual nursing hours performed by direct caregivers, per patient day, by the average census.

(b) Facilities shall anticipate individual resident needs for each shift and direct caregivers shall be staffed to achieve the minimum staffing requirements in effect as indicated in HSC 1276.5 or 1276.65.

(c) Facilities shall employ and schedule additional staff, as needed to ensure that all residents receive sufficient nursing care, based on their needs and acuity, and in order to meet the minimum staffing requirements.

(d) Any staffing level that falls below the minimum staffing requirements in effect as indicated in HSC 1276.5 or 1276.65, is out of compliance with the minimum standard.

(e) In order to meet the minimum staffing requirements in effect as indicated in HSC 1265.5 or 1265.65 calculation, the SHSNF shall:

(1) keep and maintain documentation of the actual time spent by licensed nursing staff and VWs (i.e., payroll with actual punch detail);

(2) document and delineate the time spent for staff not captured in payroll;

(3) ensure that there are enough VWs awake and on duty in each home during all shifts to comply with the minimum staffing requirement;

(4) keep and maintain documentation of the average census for each patient day;

(5) use actual time, not rounded time; and

(6) not use confidential resident medical records. Medical records are not considered “documentation” for the purposes of establishing nursing hours of a direct caregiver. 

(f) For purposes of calculating the minimum staffing requirement for VWs, 57.16 percent of actual hours worked shall be counted as direct care hours. 

(g) If licensed nursing staff is shared between a SHSNF and a traditional SNF, the time spent in each facility shall be separately documented and delineated. 

IV.    Services

(a) SHSNFs shall assist residents in arranging transportation services as required by federal law including 42 CFR section 483.25(b)(2) [vision and hearing]; 42 CFR section 483.55 [dental services]; 42 CFR section 483.75 and 42 CFR section 483.75(k)(2)(iii) [radiology/diagnostic services]. 

V.    Versatile Workers

(a) VWs shall be assigned duties only within one home, and shall not have duties in any other home. 

(b) If a VW must leave his/her designated home for any reason, a replacement VW shall be available within the SHSNF and shall report to the home before the departing VW leaves, so that the minimum number of VWs does not drop below the number required for that shift in that home.

(c) For other VW staffing requirements, see the DIETETIC SERVICE STANDARDS, Section XVII. 

VI.    Non-HCWs, Trainees, and Volunteers

(a) None of the work performed at a SHSNF by the following individuals shall be used for NHPPD calculations:

(1) non-HCW employees or contractors,

(2) trainees,

(3) volunteers, or

(4) private-duty nursing services performed by staff paid for or supplied by a patient/resident, or patient’s family, guardian, conservator, or other representative. 

(b) The SHSNF shall develop, maintain, and implement written P&Ps that designate:

(1) the types of work that may be performed by:

(A) non-HCW employees;

(B) non-HCW contractors, and

(C) volunteers;

(2) the duties of each such position; and

(3) any conditions under which those duties are to be performed. 

(c) A SHSNF shall not be used as a CNA training facility for the Certified Nurse Assistant Program (CCR, Title 22, section 71801, et seq.). 

F. TRAINING AND ORIENTATION STANDARDS

The following standards shall be followed by all facilities participating in the SHSNF pilot program. These standards supplement the requirements of CCR Title 22, section 71801 et seq. (Chapter 2.5 -- Certified Nurse Assistant Program). 

I.    Definitions Specific to the SHSNF Training and Orientation Standards

The definitions given in the DEFINITIONS section apply to this section. Additional definitions specific to these training and orientation standards are:

“Training” means instruction on the topics included in HSC section 1323.5(g)(2)(A) except site-specific orientation. 

“Orientation” means instruction on site-specific practices, policies, and procedures of the SHSNF, with which all managers, staff, and volunteers must be knowledgeable before being permitted to work in the SHSNF pilot facility.

II.    SHSNF Training and Orientation Requirements

(a) Each pilot facility shall ensure that all managers, staff (including clinical staff), and volunteers involved in the operation of each home are trained in accordance with SHSNF PP standards.

(b) All training and orientation for the managers, initial staff, and volunteers is to be completed prior to commencement of operation of the pilot facility.

(c) Managers who replace the SHSNF’s initial managers shall be fully trained and oriented in accordance with these standards immediately upon employment. Those newly employed individuals shall not be permitted to perform any direct care activities until both the orientation and training have been completed and proficiency has been adequately demonstrated.

(d) Replacement staff shall:

(1) be fully trained in accordance with these standards within two weeks of commencing employment at the SHSNF, and have demonstrated competency in accordance with the facility’s written P&Ps;

(2) receive and complete orientation to the SHSNF immediately upon arrival at the facility; and

(3) have completed both the orientation and the training before being allowed to have any resident contact other than socialization.

(e) Temporary employees:

(1) shall be fully trained in accordance with these standards before being allowed to have any resident contact other than socialization;

(2) may not perform any duty for which they have not been trained; and

(3) shall receive and complete orientation to the SHSNF immediately upon arrival at the facility.

(f) Volunteers:

(1) shall be trained in accordance with the SHSNF’s written P&Ps for each of the duties that the volunteer will be allowed to perform;

(2) shall not perform any duty for which the volunteer has not been trained, other than socialization with the residents; and

(3) shall receive and complete orientation to the SHSNF immediately upon arrival at the facility. 

(g) The training described in these standards shall be in addition to that which each HCW or manager must have in order to obtain and maintain any licensure or certification required of that person in order to be a HCW or manager.

(h) All training shall be provided either directly by the SHSNF or in a manner approved by the Department.

(i) All training programs, whether conducted by the SHSNF or another entity, shall include procedures and methodology for determining the competency of each trainee upon completion of the training program. 

(j) No manager, staff, or volunteer shall be permitted to perform duties in the SHSNF for which they have not completed the SHSNF’s required training and demonstrated competency. 

(k) CCR Title 22, section 72517 relating to staff development in SNFs, shall be applicable to SHSNFs.

(l) If SHSNF personnel are offered continuing education or in-service training programs under CCR Title 22, sections 71805 and 71819, those activities shall not be counted toward the SHSNF training and orientation required by these standards.

III.    SHSNF Training Program

(a) The following topics shall be included, at a minimum, in the training curriculum for all SHSNF managers and HCWs, including clinical staff:

(1) the philosophy and principles of resident-centered care, self-directed-care, and a non-institutional approach to long-term care;

(2) operational differences, generally, between traditional resident care systems and the SHSNF; and

(3) skills sets required to implement:

(A) resident-centered care;

(B) self-directed care;

(C) self-managed work teams; and

(D) non-traditional approaches to long-term care. 

(b) The SHSNF training curriculum for VWs shall also include, at a minimum:

(1) safety skills and procedures;

(2) emergency skills and procedures;

(3) infection control;

(4) food handling, sanitation, and food safety skills and procedures;

(5) housekeeping skills;

(6) culinary skills, including those necessary for the preparation of special meals, unless those duties are to be assumed by non-HCWs;

(7) conflict resolution skills;

(8) personal care assistance skills; and

(9) activity assistance skills.

(c) The SHSNF shall provide its managers with additional training that supplements the professional qualifications of each, in order to assure:

(1) competency in all aspects of the SHSNF’s operations, and

(2) knowledge of all of the duties and responsibilities of the personnel reporting to that manager. 

(d) The SHSNF may modify its training program to vary the range of instruction to tailor it to each type of job classification including: managers, licensed nursing staff, other clinical staff, VWs, volunteers, and other non-HCWs. All such modifications shall be approved in advance by the Department.

(e) The SHSNF shall document, for each person to whom it has provided training, the topics covered, the amount of time spent on each topic, and whether that person has demonstrated satisfactory competency in each. The manner and format for that documentation shall be approved in advance by the Department.

IV.    SHSNF Orientation Program

(a) Each SHSNF shall provide an orientation program that complies with CCR Title 22, section 71833.

(b) Each SHSNF shall supplement its section 71833 orientation program with, at a minimum, orientation for the VWs on the following topics:

(1) specific operational differences between traditional SNFs and the employing SHSNF;

(2) infection control as it relates to all operational aspects of the SHSNF and including, with specificity, the contents of the facility’s Infection Prevention and Control Program (IPCP);

(3) safety and emergency procedures to be followed in each home in the SHSNF, including familiarization with all essential equipment;

(4) food handling, food sanitation, and food safety procedures to be followed in the SHSNF;

(5) laundry and linen practices of the SHSNF, including familiarization with all essential equipment;

(6) housekeeping practices to be used in the SHSNF, including familiarization with all essential equipment;

(7) nature and extent of the maintenance activities that SHSNF staff are expected to undertake, including familiarization with all essential equipment;

(8) facility’s practices and procedures for procuring additional maintenance work not to be performed by SHSNF staff;

(9) facility’s practices and procedures for ordering, delivery, and inventorying of food and supplies;

(10) culinary practices, including familiarization with all essential equipment;

(11) all practices and procedures for the successful and healthful operation of the SHSNF’s dietetic service, including familiarization with menu development, food selection, and food storage;

(12) personal care assistance practices;

(13) all elements of the SHSNF’s activities program; including familiarization with essential supplies and equipment; and

(14) all written policies and procedures of the SHSNF including, but not limited to, those pertaining to the topics enumerated above.

(c) Other orientation topics identified by the SHSNF and/or the Department as being desirable and appropriate for the successful operation of the SHSNF may be added to the above.

(d) The SHSNF shall provide its managers with an orientation that covers:

(1) all aspects of the SHSNF’s operations and

(2) the duties and responsibilities of all of the personnel who will report to that manager. 

(e) The SHSNF may modify its orientation program to vary the range of instruction to tailor it to each type of job classification including: managers, licensed nursing staff, other clinical staff, VWs, volunteers, and other non-HCWs. All such modifications shall be approved in advance by the Department.

(f) The SHSNF shall document, for each person to whom it has provided orientation, the topics covered and the amount of time spent on each topic. The manner and format for that documentation shall be approved in advance by the Department.

V.    Approval of the Training & Orientation Curricula and Instructional Materials

(a) The SHSNF PP applicant shall submit a summary of its proposed training and orientation programs that includes, at a minimum:

(1) a brief description of each proposed training and orientation module

(2) the number of hours to be dedicated to each module;

(3) the methodology to be used to determine each student’s initial and on-going competency/proficiency in a given module;

(4) the identity of the company, organization, or other individuals who will instruct each training module;

(5) the identity of the company, organization, or other individuals who will conduct each of the orientation modules for the SHSNF’s initial managers and those members of the initial staff whose duties will include conducting orientations; and

(6) the identity or position of each person who will be responsible for conducting each orientation module at the SHSNF, after the facility commences operations. 

(b) The applicant shall use, for purposes of providing the information required by the TRAINING AND COMPETENCY STANDARDS section, either the template supplied by the Department or a document of its own design that contains all of the information included in that template. 

VI.    Competency and Proficiency

(a) The following persons shall be required to demonstrate, annually, their continuing proficiency/competency in each of their required training modules, as well as all of the SHSNF’s written P&Ps:

(1) all SHSNF managers,

(2) all HCWs, and

(3) all non-HCWs who interact with residents. 

(b) Non-HCWs whose job description does not include having contact with residents shall be required to demonstrate their proficiency/competency regarding their assigned duties in a manner and frequency set by the written P&Ps of the SHSNF.

(c) The SHSNF’s methodology for conducting this annual competency/proficiency procedure shall be included in its written P&Ps, which shall also include documentation requirements and the steps that shall be taken by the facility in the event that an employee fails any part of the competency/proficiency evaluation. The P&Ps shall be reviewed and approved by the Department prior to being implemented.

VII.    Food Handler’s Card

(a) In addition to the training described above, every manager, staff member, and volunteer having food preparation and serving duties in the dietetic service shall obtain a food handler’s card, as described in the California Retail Food Code (HSC section 113948(d)(4)) prior to assuming duties related to food storage, preparation, or distribution. 

(b) Residents/family/visitors who participate in food preparation activities in the facility shall not be required to have a food handler’s card, but shall be supervised at all such times by a SHSNF employee who has a valid food handler’s card

VIII.    Staffing Requirements for the SHSNF Training and Orientation Programs

(a) Each SHSNF shall employ or contract with, on an on-going basis, at least one person to perform the training and orientation of new managers, staff, and volunteers pursuant to these SHSNF standards.

(b) Each instructor of a nursing-related topic shall have, at a minimum, the qualifications listed in CCR, Title 22, section 71829(d). 

(c) Instructors in non-nursing topics shall possess credentials commonly accepted in their field as evidencing the expertise level required to be an instructor. 

(d) The facility need not use any particular title for its instructor(s), as long as the above qualifications are met. 

G. DIETETIC SERVICE STANDARDS

For purposes of the SHSNF pilot program, the following standards modify and supplement the regulations that apply to dietetic service in SNFs (CCR Title 22, section 72333 through 72351).

I.    Definitions Specific to the Dietetic Service Standards

The definitions given in the DEFINITIONS section apply to this section. Additional definitions specific to the dietetic service standards are:

“Dietetic service” means a service organized, staffed, and equipped to assure that food service to residents is safe, appetizing, and provides for their nutritional needs. 

“Dietetic service area” means all portions of a SHSNF that are used for the preparation and service of food and all areas or rooms in the SHSNF used for the storage of food and other dietary supplies.

“Dietary” and ‘dietetic” are terms that are used interchangeably in these standards and in the CBSC, and are considered to be synonymous for purposes of the SHSNF PP.

“Resident dietary area” means all portions of a home that are used for the preparation and service of food, and has the same meaning as in the CBSC, CCR Title 24, Part 2, section 1225.5.2.5.4. It may also include the nourishment room required by section 1225.5.2.4.9 for provision of snacks and other supplementary nourishment. 

II.    Applicability of Other Requirements

Each SHSNF shall comply with all requirements of:

• Chapter 4 of the CRFC (HSC sections 113996 through 114083, and section 114091);
• all requirements of local environmental health department having jurisdiction over the SHSNF site;
• CCR Title 24, Part 2, section 1225, unless the pilot facility has been granted an AMC from the CBSC by OSHPD; and
• the BUILDING DESIGN STANDARDS section.

III.    Dietetic Service in SHSNFs

(a) The dietetic service should support continued resident involvement in activities of daily living including, at a minimum:

(1) communal dining,

(2) provision of nourishment between meals,

(3) food preparation activities for residents,

(4) food preparation by family members, and

(5) interaction between staff and residents during meal preparation and dining. 

(b) Some dietetic services for the SHSNF may be provided from a central kitchen facility that supports multiple homes. In the alternative, each home may be designed to have its own dietetic service that complies with all applicable requirements of the CRFC and CBSC (CCR Title 24, Part 2). 

IV.    Dietetic Service Area

(a) Each home within a SHSNF shall contain a living area where residents, staff, and visitors may socialize, dine, and prepare food together. 

(b) The home’s dining area shall be large enough to accommodate all residents of the home and at least two staff members. 

(c) The home’s kitchen shall be open to the living and dining rooms, as provided elsewhere in these standards and in accordance with the CBSC (CCR Title 24, Part 2).

(d) The dietetic service space requirements under the CBSC (CCR Title 24, Part 2), section 1225.4.2 may be provided in a central kitchen facility that provides food preparation for more than one home, or for both a SHSNF and another health facility. As an alternative, each home may be designed to have a kitchen equipped in accordance with XVI.(c) in each home. 

(e) The dietetic service shall comply with the following requirements of the CBSC (CCR Title 24, Part 2):

(1) Dietetic Service Space (section 1225.4.2);

(2) Nourishment Room (section 1225.5.2.4.9); and

(3) Resident Dietary Area (section 1225.5.2.5.4). 

(f) Each home shall have:

(1) a resident dietary area that meets the requirements of the CBSC (CCR Title 24, Part 2) section 1225.5.2.5.4, and

(2) a nourishment room that meets the requirements of the CBSC (CCR Title 24, Part 2) section 1225.5.2.4.9. 

(g) The nourishment room required by the CBSC (CCR Title 24, Part 2) section 1225.5.2.4.9 may be combined with a resident dietary area. 

(h) In facilities that allow smoking, it shall not be permitted in:

(1) the dietetic service area, including the kitchen and dining areas, or

(2) any other common room where food consumption may occur. 

V. Facility P&Ps Governing Dietary and Nutritional Services 

(a) Each SHSNF shall develop, maintain, and implement, with the assistance of a dietitian, written P&Ps to govern its dietary and nutritional services.

(b) The written P&Ps shall reflect core resident-centered care concepts regarding food choice and availability, nutrition, meal preparation, and meal service, and shall include, but not be limited to:

(1) resident-assisted food shopping;

(2) food preparation performed by residents, their companions, family, and visitors under the supervision of facility staff;

(3) family-style food service in a communal environment;

(4) acceptance of food gifts received by residents from outside sources; and

(5) the ordering and serving of foods prepared by and bought from commercial vendors (e.g., restaurants, fast food outlets, deli/hot-food counters at grocery stores). 

(c) The P&Ps shall:

(1) include dietetic service processes, tasks, schedules, and staff assignments;

(2) ensure the ongoing maintenance of the dining areas, food preparation areas, appliances, food storage, and storage of food preparation equipment and utensils; and

(3) include infection control practices and measures consistent with the INFECTION CONTROL section that shall be utilized, tracked, and analyzed using specified effectiveness criteria.

(d) The SHSNF shall develop, maintain, and implement written P&Ps for a functional program for the dietetic service that describes the methods of food preparation used throughout the SHSNF. The facilities and equipment in the dietetic service shall be based on the functional program. 

VI.    Availability of Food, Water, and Ice

(a) Each home shall prepare, cook, and serve meals on a daily basis for residents in the homes. 

(b) Each home shall accommodate, to the extent reasonably feasible, each resident’s preference for meal scheduling and eating location, although group dining shall be encouraged unless contraindicated.

(c) The first meal of the day shall be not more than 16 hours after the last meal of the preceding day.

(d) Between-meal nourishment shall be provided:

(1) as required by the diet order for each resident, or

(2) in accordance with requests of the resident or the designated representative for the resident.

(e) Bedtime snacks shall be made available to each resident unless contraindicated.

(f) Drinking water shall be available at all times, in accordance with the CBSC (Title 24 CCR, Part 2) section 1225.5.2.4 and shall be handled and dispensed in a sanitary manner. 

(g) While the inclusion of a drinking fountain in the home is discouraged because of its institutional appearance, if one is provided, it shall be available and accessible to all residents and visitors, including those using mobility devices, as well as to staff.

(h) Ice-making equipment of adequate size to accommodate the needs of all residents, visitors, and staff shall be provided in the dietary service area.

VII.    Resident Participation in Food Selection

(a) The SHSNF shall develop, maintain, and implement written P&Ps that promote and facilitate the ability of residents to participate in:

(1) the preparation of meal menus,

(2) the selection of foods for meals and for snacks, and

(3) meal preparation.

(b) Condiments including salt, pepper, sugar, and others requested by residents shall be made available at each meal to each resident unless contraindicated for a particular resident by diet order.

(c) A profile card shall be maintained and kept current for each resident that includes the resident’s diet order, likes and dislikes, food allergies, diagnosis, and pharmaceutically contraindicated foods. The card shall also contain all instructions and guidelines to be followed in the preparation and serving of food to that resident, and whether any adaptive utensils or other disability accommodations are needed. This information shall be maintained within the home’s dietary services area and shall be readily available to both VWs and clinical staff, but not to other residents or visitors in order to ensure confidentiality of each resident’s medical information.

VIII.    Menus

(a) Menus shall be jointly developed by residents, VWs, and clinical staff of the home. Proposed menus shall be reviewed with all interested residents on an ongoing weekly basis in accordance with the P&Ps required by G.VII.

(b) Cycle menus shall not be used.

(c) Written menus for both the regular and therapeutic diets shall be dated and placed in a standardized location in the home where they can be seen by residents, visitors, and staff. The menus need not be posted in the home.

(d) Standardized recipes for both regular and therapeutic diets, adjusted for appropriate yield, shall be made available to food preparers in all kitchens.

IX.    Meal Service 

(a) Family-style meal service shall be provided, with assistance from the VWs, who also may eat with the residents. 

(b) Opportunities shall be provided for residents to socialize and interact at mealtime, while also maintaining resident independence. 

(c) All residents shall be encouraged to eat each meal in the dining room with other residents and the VWs, and rarely should eat apart from other residents unless health circumstances dictate.

(d) A resident’s occasional request to eat elsewhere, including at a different location than in the home, and/or at a different time than other residents, shall be honored.

(e) The dining area shall have sufficient dining furniture and equipment to accommodate the service of meals to all residents, their companions, and at least two staff members, including:

(1) tables of an appropriate height to accommodate mobility assistive devices including wheelchairs,

(2) chairs,

(3) eating and serving utensils,

(4) tableware, and

(5) napkins. 

(f) Table settings shall be laid out to meet the individualized needs of each resident, and may include adaptive utensils and equipment. 

(g) Single-use tableware including, but not limited to, paper dishware products and plastic utensils, shall not be used for daily meals, except for meals served and consumed outdoors, off-site, or in an emergency situation such as a power failure or similar circumstance beyond the control of the home’s staff.

(h) Bare-hand contact with non-prepackaged, ready-to-eat foods shall be minimized through the use of utensils (e.g., tongs, napkins, paper wrapper).

X.    Dietary Standards

(a) Menus shall be adjusted for each resident’s age and life stage, gender, disability, activity level, medical status, and food preferences.

XI.     Diet Manual 

(a) The diet manual shall include descriptions of the diets that may be ordered, the foods allowed in each, and the nutritional adequacies of each diet. 

XII.    Therapeutic Diets 

(a) Each SHSNF shall develop, maintain, and implement, with the assistance of a dietitian, written P&Ps to minimize dietary restrictions consistent with the resident’s condition, prognosis, and choices. 

(b) The SHSNF’s dietitian shall periodically review each resident’s adjusted needs and make dietary recommendations to the person lawfully authorized to order the resident’s diets. 

(c) The dietitian may receive and record telephonic orders which shall be signed by the prescriber within five calendar days.

XIII.    Food Supplies and Handling 

(a) No food that has been ordered for the SHSNF shall be diverted from it or removed from it except when it is to be consumed by residents, staff, and visitors in an off-site activity of the SHSNF. This prohibition shall be included in the SHSNF’s written P&Ps. 

(b) Food and dietary supplies, other than those obtained by residents or brought by companions or visitors, shall be brought directly from the outside into the receiving/control station in the dietetic service area, and put into the appropriate storage space in a timely manner. The delivery route shall not be through spaces occupied by residents or used for resident activity or care.

XIV.    Kitchen Storage 

(a) Soaps, detergents, and cleaning compounds shall not be stored in bulk in the dietetic service area, nor in any space or room used for food storage, food preparation, or storage of food preparation equipment or utensils. Clearly labeled working containers of these products may be stored in clearly marked, locked kitchen cabinets when not in use. 

(b) Liquid hand soap shall be dispensed using affixed dispensers. 

(c) The SHSNF shall develop, maintain, and implement a written P&P that:

(1) addresses the risk of resident exposure to chemicals in the dietetic service area;

(2) includes procedures to be followed for the approval of cleaning products prior to use; and

(3) requires that manufacturers’ recommendations be followed at all times.

XV.    Dietetic Service Sanitation 

(a) The SHSNF shall have separate “clean” and “soiled” areas in each ware-washing room, separate from the food preparation and serving area, in accordance with the CBSC (CCR, Title 24, Part 2, section 1225). Food shall not be prepared or stored in that area. The clean wares shall be transferred for storage or use in the dining area without passing through food preparation areas. Staff shall be trained regarding infection control measures that include prevention of cross-contamination between the “soiled” and the “clean” wares.

XVI.    Equipment Required for the Dietetic Service Area

(a) Food service facilities and equipment installed in each SHSNF shall be of commercial grade and shall conform with:

(1) the standards of the National Sanitation Foundation (NSF),

(2) the requirements of the local public health agency,

(3) the CBSC (CCR, Title 24, Part 2, section 1225.4.2), and

(4) the CRFC. 

(b) If the dietetic service space in the SHSNF is a central kitchen facility that provides food for more than one household unit, the equipment and facilities in that kitchen shall comply with subdivision (a). 

(c) If the dietetic service space in the SHSNF is located in each home, the following equipment and facilities shall be included, at a minimum:

(1) a cook top with induction heat;

(2) a cooking equipment shut-off switch that shall be activated when a VW is not available to oversee a resident’s use of that equipment;

(3) an oven of adequate size and capacity to accommodate the cooking needs of the home;

(4) a microwave oven that is positioned so that it is readily accessible to residents, including those using a mobility device;

(5) a freezer and a refrigerator meeting temperature requirements for holding cold and frozen food;

(6) ware-washing facilities and equipment that comply with the CSBC (CCR Title 24, Part 2) section 1225.4.2.2.7 and CRFC-designated temperature parameters;

(7) solid, nonporous counter tops of sufficient size, length and height that, would allow residents to sit at them and to participate in food preparation activities;

(8) two-compartment sinks for food preparation, which shall not be also used for hand-washing or ware-washing;

(9) a handwashing station in compliance with the CBSC (CCR Title 24, Part 2) section 1225.4.2.2.4; and

(10) storage areas.

(d) If the dietetic service space is provided in the home, the requirements for facilities and equipment may be combined with those for the resident dietary area, as long as the combined facility is adequate for the type of food preparation provided. 

(e) A resident dietary area shall include the following facilities and equipment, of appropriate size, capacity, and type to meet the functional need:

(1) a stove with an induction-heat cook top surface and an oven;

(2) a cooking equipment shut-off switch that shall be activated when a VW is not available to oversee a resident’s use of that equipment;

(3) a microwave oven that is positioned so that it is readily accessible to residents, including those using mobility devices;

(4) a refrigerator with a freezer meeting temperature requirements for holding cold and frozen food;

(5) self-dispensing ice-making equipment;

(6) ware-washing facilities and equipment that comply with the CSBC (CCR Title 24, Part 2) section 1225.4.2.2.3;

(7) solid, nonporous counter tops of sufficient size, length and height to allow residents to sit at them and to participate in food preparation activities;

(8) a two-compartment sink for food preparation, which shall not also be used for hand-washing or ware-washing;

(9) a handwashing sink and fixture pursuant to the CBSC (CCR Title 24, Part 2) section 1225.5.2.5.4.2; and

(10) storage areas.

(f) If a separate nourishment room is provided, it shall have all of the facilities and equipment described in the CBSC (CCR Title 24, Part 2) section 1225.5.2.4.9, and a microwave oven, toaster oven, or other food-heating device.

XVII.    Dietetic Service Staff

(a) General requirements for all dietary personnel are as follows:

(1) each employee whose duties include food preparation shall possess a valid California food handler’s card that complies with the CRFC (HSC section 113948);

(2) while working in the home’s dietetic service, each employee shall:

(A) wear clean clothing,

(B) wear a cap or a hair net,

(C) cover all beards and mustaches that are not closely cropped and neatly trimmed, and

(D) don an apron upon entering the home’s kitchen area, before starting food service activities;

(3) aprons shall be stored in close proximity to the kitchen’s hand-washing sink near the kitchen’s entrance; and

(4) the personal possessions of all SHSNF staff members, including VWs, shall be stored in the staff support area of each SHSNF, as defined in the CBSC (CCR Title 24, Part 2) section 1225.5.2.6, and not in any portion of the dietetic service area. 

(b) Staffing level for the FSO manager shall be as follows:

(1) if the SHSNF has fewer than 25 proposed beds, total, in all of its homes, the FSO manager may be employed less than full time, but not less than four days per week and not less than six hours per day, subject to the approval of the Department;

(2) if the SHSNF has 25 or more resident beds, total, in all of its homes, the FSO manager shall be employed full time for not fewer than five days per week; and the FSO manager shall be on the premises of the SHSNF. 

(c) If the SHSNF’s FSO manager is a dietary service supervisor (DSS), as defined by CCR Title 22, section 72035, a dietitian also shall be either employed or retained by the SHSNF as a consultant, to:

(1) provide nutrition care for residents,

(2) attend resident care conferences, and

(3) interact, in at least a weekly basis, with physician, nursing, and other healthcare services regarding nutrition and dietetic service issues.

(d) The FSO manager in consultation with the dietitian, if any, each shall observe, monitor, and participate in the home’s complete food service operations, from preparation through clean-up, for one meal. This shall occur, at a minimum, once a month and on separate days for each person. The type of meal (breakfast, lunch, or dinner) selected for observation shall be rotated monthly.

(e) The FSO manager in consultation with the dietitian shall provide the following training for the SHSNF:

(1) initial training in dietary practices designed to supplement the training required to obtain a California food handler’s card and including instruction relating to the facility’s dietary P&Ps, for all new SHSNF employees who will have responsibilities in the facility’s dietetic service; and

(2) periodic in-service training for all SHSNF employees on the topics of nutrition care and food service.

(f) The FSO manager and the dietitian also may cook in the home, provided that sufficient time is available for the completion of all managerial and dietetic supervision responsibilities. 

(g) The FSO manager shall not be assigned to non-dietetic services within the SHSNF.

(h) A written record of the frequency, nature, and duration of the visits of the dietitian shall be maintained by the SHSNF’s administrator, with a copy kept in each home.

(i) Versatile workers.

(1) A sufficient number of VWs shall be scheduled to work in each home at all times necessary to ensure that adequate dietary services are provided to each resident, including provision of snacks and special meals, and in order to maintain the dietetic service areas.

(2) At least two VWs should be assigned to the dietetic service when the residents are present in the dining room for a meal.

(3) VWs shall have the primary responsibilities in each home of:

(A) preparing food for resident meals and snacks, unless non-HCWs are hired by the SHSNF to perform food preparation duties for the SHSNF (see below),

(B) planning menus under the direction and supervision of the dietitian,

(C) acting as liaison between the FSO manager and the dietitian regarding special needs,

(D) facilitating residents’ efforts to participate in food preparation, planning menus, and

(E) assisting residents with their meals, as needed.

(4) The VWs on meal duty may eat with the residents, as permitted by the written P&Ps of the SHSNF.

(5) If the SHSNF intends to designate a VW as a “dietary team leader,” the facility shall prepare written P&Ps describing all of the duties to be delegated by the FSO manager to that VW category, and shall obtain prior approval of those P&Ps from the Department.

(6) Each VW shall receive training in dietary food service topics, as provided in the TRAINING AND ORIENTATION section.

(j) Non-HCW dietary employees.

(1) The SHSNF may employ, in addition to the VWs, individuals who are neither CNAs nor VWs for dietary service activities, provided those non-HCW employees comply with all applicable SHSNF training and orientation requirements pertaining to dietetic service.

(2) If non-HCWs are employed in the dietary service, the SHSNF shall develop, maintain, and implement written P&Ps that describe the specific dietary duties to be assumed by the VWs and by the non-HCWs.

H. INFECTION CONTROL

For purposes of the pilot program, the following sections of CCR Title 22 shall apply regarding infection control at all SHSNFs, except as explicitly modified or supplemented by these standards:

• Section 72321: Nursing Service—Patients with Infectious Diseases;
• Section 72525: Required Committees;
• Section 72535: Employees’ Health Examination and Health Records;
• Section 72537: Reporting of Communicable Diseases;
• Section 72539: Reporting of Outbreaks;
• Section 72541: Unusual Occurrences;
• Section 72621: Housekeeping;
• Section 72623: Laundry;
• Section 72625: Clean Linen;
• Section 72627: Soiled Linen;
• Section 72629: Provisions for Emptying Bedpans;
• Section 72643: Storage and Disposal of Solid Wastes;
• Section 72645: Solid Waste Containers; and
• Section 72647: Infectious Waste. 

I.    Definitions Specific to the Infection Control Standards

The definitions given in the DEFINITIONS section apply to this section. Additional definitions specific to these infection control standards are:

“Cohorting” means the practice of grouping together patients who have been infected or colonized with the same infectious agent in order to:

• confine their care to one physical location, and
• prevent their contact with susceptible patients.

During outbreaks, HCWs may be assigned to a cohort of patients to further limit opportunities for transmission, and are referred to as cohorting staff.

“Education” means formal coursework in a college or university that includes: microbiology, asepsis, disinfection/sterilization, infectious disease communication, epidemiology, and adult education. 

“Infection preventionist” (IP) means a nurse, physician, public health professional, epidemiologist, or medical technologist who:

• collects, analyzes, and interprets health data in order to track infection trends;
• plans appropriate interventions,
• measures results,
• reports relevant data,
• establishes scientifically-based infection prevention practices, and
• collaborates with the health care team to limit the spread of infectious diseases.

“Training” means ongoing post-graduate instruction in the subject matter in which the IP must be proficient in order to competently perform the duties of that position.

II.    Infection Prevention and Control Program

(a) Each SHSNF shall have an infection prevention and control program (IPCP) that incorporates and implements the following:

(1) federal regulations related to infection prevention and control, including those contained in 42 CFR section 483.25(n) and 42 CFR section 483.65;

(2) infection prevention and control guidelines from the Centers for Disease Control and Prevention (CDC); and

(3) guidelines from a nationally-recognized infection prevention and control association such as the Association for Professionals in Infection Control and Epidemiology (APIC) or the Society for Healthcare Epidemiology of America (SHEA).

(b) Each SHSNF shall ensure that all of the following topics are included, at a minimum, in its IPCP:

(1) a Quality Assurance and Improvement Program that includes the following specific infection prevention and control elements:

(A) a risk assessment specific to that individual SHSNF that shall be reviewed and revised at least annually, or more frequently as needed;

(B) focused facility-wide surveillance that includes process and outcome observation, monitoring, data analysis, documentation, and communicable disease reporting;

(C) use of nationally-accepted surveillance criteria specific to long-term care (viz., McGeer’s or Loeb’s Criteria);

(2) identified responsibilities of the IP for both the oversight and the daily activities of the SHSNF’s IPCP including the planning, organizing, implementing, operating, monitoring, and maintaining of all elements of the program;

(3) the requirement that the facility document the education and training of the IP in the following topics:

(A) infection prevention and control, and

(B) IPCP-related standards and best practices;

(4) identified responsibilities of the interdisciplinary committee participating in the facility’s IPCP, which shall be comprised of members from the following disciplines/services: physician, nursing, administration, dietetic, pharmaceutical, activities, social services, rehabilitation services, housekeeping, laundry and maintenance, and other disciplines/services as designated by the SHSNF;

(5) antibiotic review and antimicrobial stewardship; and

(6) the requirement that the facility report, at least quarterly, to the SHSNF’s QAIP regarding infection prevention and control surveillance data and its analysis.

(c) Each SHSNF shall, as an adjunct to its IPCP, adopt written P&Ps and document required practices that address, but are not limited to, the following topics:

(1) cleaning and disinfecting resident care equipment, furniture, and the facility, including equipment storage;

(2) cleaning and disinfecting all areas of the facility, including equipment storage;

(3) use of cleaning chemicals in accordance with manufacturers’ instructions;

(4) procedures to prevent cross-contamination, including but not limited to, the use of personal protective equipment, standard precautions, transmission-based precautions, and hand hygiene;

(5) prevention of the spread of multi-drug resistant organisms, Clostridium difficile, and other infectious diseases;

(6) infection prevention and control in facility areas that include, but not limited to, dietetic services, laundry and linen, activities, and pharmaceutical services;

(7) HCW and patient immunizations;

(8) health screenings that include, but not limited to, tuberculosis (TB) screenings;

(9) prevention of direct contact between an HCW who has a communicable disease and the residents, and the food or drugs of residents;

(10) procedures for handling a resident who has an infectious disease or disease process;

(11) the cohorting of residents and HCWs;

(12) training and education in infection prevention and control for HCWs, residents and visitors;

(13) whether pets are to be allowed in the facility;

(14) recognizing, containing, and reporting outbreaks;

(15) pest control;

(16) waste disposal, including medical waste and hazardous waste, in accordance with state and federal laws; and

(17) such other topics relating to infection prevention and control in SNFs as may be deemed appropriate by the facility’s IP. 

(d) The SHSNF shall review its IPCP P&Ps at least annually, and shall revise them as needed.

(e) The SHSNF shall annually test staff competencies regarding infection prevention and control P&Ps.

III.    Nursing Service–Cleaning and Disinfecting 

(a) Each SHSNF shall adopt written P&Ps on cleaning and disinfecting, which shall include the care of utensils, instruments, solutions, dressings, articles, and surfaces. All cleaning and disinfecting procedures shall be carried out in accordance with those P&Ps on a regular, ongoing basis.

(b) Bedside equipment including, but not limited to, washbasins, emesis basins, bedpans, and urinals shall be sanitized by one of the following methods:

(1) submersion in boiling water for a minimum of 30 minutes; or

(2) application of cleaning chemicals designed for use with bedside equipment, and which are used in accordance with the manufacturer’s directions.

(c) Electronic thermometers shall be cleaned and disinfected between usage by different residents, according to the manufacturer's instructions. Glass thermometers shall be cleaned and disinfected for at least 10 minutes with 70 percent ethyl alcohol or 90 percent isopropyl alcohol with 0.2 percent iodine. Oral and rectal thermometers shall be stored separately in clean, labeled containers with fitted lids.

(d) Point-of-care devices, such as blood glucose meters, if used for multiple residents, shall be cleaned and disinfected after each use according to manufacturer’s instructions with a product effective against blood-borne pathogens.

(e) Fingerstick devices shall never be used for more than one resident.

(f) Individual supply items for resident care that have been designed and identified by the manufacturer as being disposable shall not be reused. 

(g) Individual supply items for resident care that are designed and identified by the manufacturer as being only for single-patient use shall not be used for more than one resident.

IV.    Employees’ Health Examination

In addition to the requirements of CCR Title 22, section 72535, the following shall apply.

(a) All managers, HCWs, and dietary staff shall have, as part of their initial health examination, a tuberculosis (TB) infection test recommended by the federal Centers for Disease Control and Prevention (CDC) and licensed by the federal Food and Drug Administration (FDA). Any of those individuals having a documented history of positive TB testing or a history of active TB disease shall obtain a medical clearance, prior to starting employment at the SHSNF, that shall include a TB symptom screen and a chest X-ray, unless that person has a written report of a negative chest X-ray done in the United States within 90 days preceding hire. A positive TB test result shall be followed by a chest X-ray and medical clearance prior to employment at the SHSNF.

(b) All managers, HCWs, and dietary staff shall have annual TB screenings following employment by the SHSNF, and shall be subject to the following:

(1) previously negative individuals shall have a symptom screen and a test for TB infection that is recommended by the CDC and licensed by the FDA;

(2) previously-positive individuals shall receive a symptom screen and, if he/she has one or more unexplained symptoms, shall be excluded from work in the SHSNF until the HCW provides medical clearance.

V.    Space and Equipment for Sterilizing and Disinfecting

(a) A SHSNF shall:

(1) maintain disposable sterile supplies in an amount necessary to meet the anticipated needs of all residents, or

(2) make contractual arrangements for outside autoclaving and sterilizing services if such services are needed to meet the anticipated needs of the residents. 

(b) The SHSNF shall provide:

(1) effective separation of soiled and contaminated supplies and equipment from clean, disinfected, or sterilized supplies and equipment;

(2) clean cabinets for the storage of clean, disinfected, or sterile supplies and equipment; and

(3) an orderly system of rotation of supplies so that older supplies shall be used first. 

VI.    Housekeeping 

In addition to the requirements of CCR Title 22, section 72621, the following shall apply.

(a) Schedules and procedures for cleaning shall be made available in each home, indicating the frequency with which each area of item shall be cleaned (viz., daily, weekly, bi-weekly, monthly). Each cleaning schedule and P&P shall be implemented on a regular, ongoing basis and documentation shall be kept regarding the frequency and extent of the cleaning, and any special efforts that were required to return the cleaned portion to required condition.

(b) Adequate cleaning supplies and equipment shall be made available to housekeeping personnel, and shall meet the following requirements:

(1) cleaning supplies and equipment shall be stored in housekeeping rooms that comply with the CBSC (CCR Title 24, Part 2) section 1225;

(2) a commercial detergent germicide shall be used according to the manufacturer’s instructions for all cleaning;

(3) a commercial disinfectant shall be used according to the manufacturer’s instructions for all disinfecting; and

(4) mop head detergent germicide shall be used according to the manufacturer’s instructions for all cleaning.

(c) A person qualified by experience and training, as indicated in this subsection, shall monitor the cleanliness of the home, the cleaning processes used by the VWs, and the degree of cleanliness obtained. The qualifications for this position shall include thorough initial and ongoing training, demonstrable by participation in infection control courses or in local/national meetings organized by recognized professional societies, such as APIC and SHEA.

(d) Housekeeping adequacy and procedures shall be in accordance with the facility’s IPCP and shall be overseen by an RN. 

(e) Service and storage areas in each SHSNF shall be maintained in a clean and orderly fashion.

(f) Cleaning and disinfecting materials, and water used for those tasks, shall not be disposed of in any bathtub or lavatory, or in any sink that is used by residents, staff, volunteers, or visitors, or in a sink used for food preparation.

VII.    Laundry

In addition to the requirements of CCR Title 22, section 72623, the following shall apply.

(a) For laundry generated by the SHSNF’s operation, nothing in these standards shall preclude the SHSNF from utilizing the services of a commercial laundry, or from providing an on-site laundry in a separate, centralized support area within the SHSNF.

(b) In addition to a laundry pursuant to subdivision (a), above, a home may also contain a laundry exclusively for the laundering of residents’ personal items. If one is provided, it shall not be used for staff or clinical purposes. It shall be accessible to, and available to, individual residents, family members, companions, volunteers, and anyone assisting the resident. If such a laundry is provided, it shall be:

(1) located and constructed to minimize noise, steam, odors, lint, hazards, and unsightliness in resident-care areas and bedrooms;

(2) adequate in size to meet the needs of the residents;

(3) well-lighted and well-ventilated; and

(4) kept in neat, clean, and sanitary condition, with all equipment kept in good repair.

(c) Laundry areas shall comply with the requirements of the CBSC (CCR Title 24, Part 2) section 1225.

(d) Each home shall provide a methodology for the separation of soiled linen from clean linen, in accordance with federal regulations. This may include the maintenance of separate linen carts labeled “soiled” or “clean” linen.” All equipment used for laundry shall be constructed of washable materials and shall be periodically cleaned and disinfected in a suitable manner to maintain sanitation. 

(e) Each home shall have written P&Ps for the handling, storage, transportation, and processing of linens and other laundry. These P&Ps shall be available for reference in a prominent location in the laundry area and shall be implemented on an ongoing basis.

(f) Reasonable efforts should be made to accommodate a resident’s request regarding the washing/cleaning, drying, and/or storage of that person’s laundry.

(g) Facility-owned linens shall not be comingled with a resident’s personal laundry for washing/cleaning, drying, and/or storage.

VIII.    Clean Linen 

In addition to the requirements of CCR Title 22, section 72625, nothing shall preclude a resident from choosing to utilize his/her own personal linens, including towels, in lieu of those supplied by the SHSNF. ​​