3211.1 Sufficient nursing time shall be given to each resident to ensure that the resident receives the following:

1. (a) Treatments, medications, diet and nutritional supplements and fluids as prescribed, and rehabilitative nursing care as needed;
2. (b) Proper care to minimize pressure ulcers and contractures and to promote the healing of ulcers;
3. (c) Assistance in daily personal grooming so that the resident is comfortable, clean, and neat as evidenced by freedom from body odor, cleaned and trimmed nails, and clean, neat and well-groomed hair;
4. (d) Protection from accident, injury, and infection;
5. (e) Encouragement, assistance, and training in self-care and group activities;
6. (f) Encouragement and assistance to:
7. (1) Get out of bed and dress or be dressed in his or her own clothing, and shoes or slippers, which shall be clean and in good repair;
8. (2) Use the dining room if he or she is able; and
9. (3) Participate in meaningful social and recreational activities;
10. (g) Prompt, unhurried assistance if he or she requires or requests help with eating;
11. (h) Prescribed adaptive self-help devices to assist him or her in eating independently;

12. (i) Assistance, if needed, with daily hygiene, including oral care; and

13. (j) Prompt response to an activated call bell or call for help.3211.2 Each facility shall have at least the following employees:- (a) At least one (1) registered nurse on a twenty-four (24) hour basis, seven (7) days a week;

14. (b) Twenty-four (24) hour licensed nursing staff sufficient to meet nursing needs of all residents;
15. (c) At least one practical or registered nurse, serving as charge nurse, on each unit at all times; and
16. (d) A minimum of two (2) nursing employees per nursing unit, per shift.3211.3 Beginning no later than January 1, 2005, each facility shall employ sufficient nursing staff to provide a minimum daily average of three and half (3.5) nursing hours per resident per day. Nursing staff shall include registered nurses, licensed practical nurses, and certified nurse aides.3211.4 Beginning January 1, 2011, each facility shall have either a physician, physician assistant, or an advanced practice registered nurse, excluding hours per week attributed to medical director duties, available on-site for a minimum of two tenths (0.2) hours per week for each resident at the facility.3211.5 Beginning January 1, 2012, each facility shall provide a minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day, of which at least six tenths (0.6) hours shall be provided by an advanced practice registered nurse or registered nurse, which shall be in addition to any coverage required by subsection 3211.4.3211.6 The Director may adjust the staffing requirements and formulas set forth in subsections 3211.4 and 3211.5 based on the individual needs of a nursing facility; provided, that the staffing requirements of subsection 3211.5 shall not be reduced to less than three and half (3.5) hours of direct nursing care per resident per day.3211.7 The Director may adjust the staffing requirements set out in subsections 3211.4 and 3211.5 to require more than the stated hours of

care per resident if:

(a) Inadequate staffing or inadequate supervision of a resident is cited in four (4) consecutive on-site surveys. For the purposes of this paragraph, a survey shall be an on-site inspection, complaint investigation, or monitoring or compliance visit conducted by the federal government or the District of Columbia; or

(b) It is found that a resident has suffered demonstrable harm because of inadequate staffing or inadequate supervision.

3211.8 In accordance with subsection 3211.6, in order to have staffing requirements adjusted to require less than the stated hours of care per resident as set out in subsections 3211.4 and 3211.5, a nursing facility shall submit to the Director a written request based on the particular needs of the facility.

3211.9 In making a determination on the adjustment of staffing requirements in accordance with subsection 3211.8, the Director's determination shall be based on one (1) or more of the following:

(a) Whether the facility has undergone a system-wide culture change and the impact the facility asserts that such change has had on resident care;

(b) The acuity levels of residents and how stable those levels are based on the case mix of residents; and

(c) Any other justification related to the needs of the facility that warrants revising the staffing pattern or ratio because of:

(1) A change in program or organizational structure; or

(2) An environmental or systemic change.

3211.10 The Department shall publish each request for an adjustment of a staffing ratio in the D.C. Register no later than fifteen (15) days after the written request is received by the Director.

3211.11 The Department shall publish each determination responding to a request for an adjustment in staffing ratios in the D.C. Register no later than sixty (60) days after the written request is received by the Director.

3211.12 Each facility shall maintain an organized process that promotes continuity in assigning the same nursing staff to the same residents as often as practicable in accordance with subsection 3206.1(p). The facility shall demonstrate and allow the Director access to the process upon request.

SOURCE: Notice of Final Rulemaking published at 49 DCR 473 (January 18, 2002); as amended by Notice of Final Rulemaking published at 49 DCR 6824 (July 19, 2002); as amended by Notice of Final Rulemaking published at 52 DCR 3608 (April 8, 2005); as amended by Notice of Final Rulemaking published at 58 DCR 10619, 10621 (December 16, 2011).