1. (1) Nursing homes who accept children with a level of care of Intermediate I or II, skilled or medically fragile must meet the following standards as indicated. Intermediate I and II are defined in Rule 59G-4.180, F.A.C. Children considered skilled have a chronic debilitating disease or condition of one or more physiological or organ systems that generally make the child dependent upon 24 hour per day medical, nursing, or health supervision or intervention. Medically fragile children are medically complex and the medical condition is such that they are technologically dependent upon medical equipment or procedure(s) to sustain life and who can expire, without warning unless continually under observation.
2. (2) Each child must have an assessment upon admission by licensed physical, occupational, and speech therapists experienced in working with children. Therapies must be administered based upon the outcome of these assessments and the orders of the child’s physician.

3. (3) Admission criteria:

   1. (a) The child must require intermediate, skilled or medically fragile nursing care, and be medically stable, as documented by the physician determining level of care.
   2. (b) For nursing home placement a recommendation must be made in the form of a written order by the child’s attending physician in consultation with the parent(s) or legal guardian(s). For Medicaid certified nursing facilities, the recommendations for placement of a Medicaid applicant or recipient in the nursing home must be made by the Department of Health’s Children’s Medical Services Multidisciplinary Assessment Team (CMAT). Consideration must be given to relevant medical, emotional, psychosocial, and environmental factors.

   3. (c) Each child admitted to the nursing home must have a plan of care developed by the interdisciplinary care plan team. The plan of care must consist of those items listed below.

      1. Physician’s orders, diagnosis, medical history, physical examination and rehabilitative or restorative needs.

      2. A preliminary nursing evaluation with physician orders for immediate care, completed on admission.

      3. A comprehensive, accurate, reproducible, and standardized assessment of each child’s functional capability which is completed within 14 days of the child’s admission to the nursing home and every twelve months thereafter. The assessment must be:

      a. Reviewed no less than once every 120 days;

      b. Reviewed promptly after a significant change, which is a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem in the child’s physical or mental condition;

      c. Revised as appropriate to assure the continued usefulness of the assessment.

      4. The plan of care must also include measurable objectives and timetables to meet the child’s medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the child’s highest practicable physical, mental, social and educational well-being. The care plan must be completed within 7 days after completion of the child’s assessments.

      5. The facility must, upon admission and quarterly, conduct and include in the resident’s plan of care a comprehensive assessment of the resident’s functional capacity and a post-discharge plan of care that includes plans, actions and goals to transition the child to a home and community-based, non-institutional setting.

      6. To enhance the quality of life of each child ages 3 years through 15 years, the nursing home must notify by certified mail the school board in the county in which the nursing home is located that there is a school-age child residing in the nursing home. Children ages 16 through 20 years may be enrolled in an education program according to their ability to participate. Program participation for each child regardless of age is predicated on his or her intellectual function, physical limitations, and medical stability. Collaborative planning with the public school system and community at-large is necessary to produce integrated and inclusive settings which meet each child’s needs. The failure or inability on the part of city, county, state, or federal school system to provide an educational program according to the child’s ability to participate shall not obligate the nursing home to supply or furnish an educational program or bring suit against any city, county, state, or federal organizations for their failure or inability to provide an educational program. Nothing contained herein is intended to prohibit, restrict or prevent the parents or legal guardian of the child from providing a private educational program that meets applicable state laws.

      7. At the child’s guardian’s option, every effort must be made to include the child and his or her family or responsible party, including private duty nurse or nursing assistant, in the development, implementation, maintenance and evaluation of the child’s plan of care.

      8. All employees of the nursing home who provide hands-on care, must be knowledgeable of, and have access to, the child’s plan of care.

      9. A summary of the child’s plan of care must accompany each child discharged or transferred to another health care facility or must be forwarded to the facility receiving the child as soon as possible consistent with good medical practice.

4. (4) The child’s attending physician, licensed under Rule Chapter 458 or 459, F.S., must maintain responsibility for the overall medical management and therapeutic plan of care and must be available for face-to-face consultation and collaboration with the nursing home medical and nursing director. The physician or his or her designee must:

   1. (a) Evaluate and document the status of the child’s condition at least monthly;
   2. (b) Review and update the plan of care every 60 days;
   3. (c) Prepare orders as needed and accompany them by a signed progress note in the child’s medical record; and,
   4. (d) Co-sign verbal orders no more than 72 hours after the order is given. Physician orders may be transmitted by facsimile machine. It is not necessary for a physician to re-sign a facsimile order when he or she visits a nursing home. Orders transmitted via computer mail are not acceptable. Verbal orders not co-signed within seventy-two (72) hours shall not be held against the nursing home if it has documented timely, good-faith efforts to obtain said co-signed orders.

5. (5) The following must be completed for each child. A registered nurse must be responsible for ensuring these tasks are accomplished:

   1. (a) Informing the attending physician and medical director of beneficial and untoward effects of the therapeutic interventions;
   2. (b) Maintaining the child’s record in accordance with nursing home policies and procedures; and,
   3. (c) Instructing or arranging for the instruction of the parent(s), legal guardian(s), or other caretakers(s) on how to provide the necessary interventions, how to interpret responses to therapies, and how to manage unexpected responses in order to facilitate a smooth transition from the nursing home to the home or other placement. This instruction must cover care coordination and must gradually pass the role of care coordinator to the parent or legal guardian, as appropriate.

6. (6) In addition to the requirements of Rule 59A-4.133, F.A.C., the nursing home must provide the following:

   1. (a) A minimum of 100 square feet in a single bedroom and 80 square feet per child in multiple bedrooms;

   2. (b) Bathroom and bathing facilities appropriate to the child’s needs to allow for:

      1. Toileting functions with privacy (a door to the bathroom must be provided); and,

      2. Stall showers and tubs.

   3. (c) There must be indoor activities area that:

      1. Encourage exploration and maximize the child’s capabilities;

      2. Accommodate mobile and non-mobile children; and,

      3. Support a range of activities for children and adolescents of varying ages and abilities.

   4. (d) There must be an outdoor activity area that is:

      1. Secure with areas of sun and shade;

      2. Free of safety hazards; and,

      3. Equipped with age appropriate recreational equipment for developmental level of children and has storage space for same.

   5. (e) All furniture and adaptive equipment must be physically appropriate to the developmental and medical needs of the children;
   6. (f) Other equipment and supplies must be made available to meet the needs of the children as prescribed or recommended by the attending physician or medical director and in accordance with professional standards of care.

7. (7) For those nursing homes who admit children age 0 through 15 years of age the following standards apply in addition to those above and throughout Chapter 59A-4, F.A.C.

   1. (a) Each child must have an assessment upon admission by licensed physical, occupational, and speech therapists who are experienced in working with children. Therapies must be administered based upon the outcome of these assessments and the orders of the child’s physician.
   2. (b) The nursing home must have a contract with a board certified pediatrician who serves as a consultant and liaison between the nursing home and the medical community for quality and appropriateness of services to children.
   3. (c) The nursing home must essure that pediatric physicians are available for routine and emergency consultation to meet the children’s needs.
   4. (d) The nursing home must ensure that children reside in distinct and separate units from adults.
   5. (e) The nursing home must provide access to emergency and other forms of transportation for children.
   6. (f) At least one licensed health care staff person with current Pediatric Advanced Life Support (PALS) certification for children must be on the unit where children are residing at all times.
   7. (g) The nursing home must maintain an Emergency Medication Kit of pediatric medications, as well as adult dosages for those children who require adult doses. The contents in the Emergency Medication Kit must be determined by the children’s needs in consultation with the Medical Director, Director of Nursing, a registered nurse who has current experience working with children, and a Pharmacist who has pediatric expertise. The kit must be readily available and must be kept sealed. All items in the kit must be properly labeled. The nursing home must maintain an accurate log of receipt and disposition of each item in the Emergency Medication Kit. An inventory to include expiration dates of the contents of the Emergency Medication Kit must be attached to the outside of the kit. If the seal is broken, the kit must be restocked and resealed the next business day after use.

   8. (h) Each nursing home must develop, implement, and maintain a written staff education plan which ensures a coordinated program for staff education for all nursing home employees who work with children. The plan must:

      1. Be reviewed at least annually by the quality assurance committee and revised as needed.

      2. Include both pre-service and in-service programs. In-service for each department must include pediatric-specific requirements as relevant to its discipline.

      3. Ensure that education is conducted annually for all nursing home employees who work with children in the following areas:

      a. Childhood diseases to include prevention and control of infection;

      b. Childhood accident prevention and safety awareness programs; and,

      4. Ensure that all employees of the nursing home complete an initial educational course on HIV and AIDS, preferably pediatric HIV and AIDS in accordance with Section 381.0035, F.S. If the employee does not have a certificate of completion at the time they are hired, they must have completed the course within six months of employment.

   9. (i) All nursing home staff must receive in-service training in and demonstrate awareness of issues particular to pediatric residents annually.
8. (8) The nursing home must have at least one registered nurse for every 40 children. This registered nurse must be on duty, onsite, 24 hours per day on the unit where the children reside.
9. (9) A qualified dietitian with knowledge, expertise and experience in the nutritional management of medically involved children must evaluate the needs and special diet of each child at least every 60 days.
10. (10) The pharmacist must have access to appropriate knowledge concerning pediatric pharmaceutical procedures, i.e., total parenteral nutrition (TPN) infusion regime and be familiar with pediatric medications and dosages.
11. (11) The nursing home must maintain or contract as needed for pediatric dental services.
12. (12) Safety equipment, such as, child proof safety latches on closets, cabinets, straps on all seating services, locks on specific storage cabinets, bumper pads on cribs and car seats for transporting must be used whenever appropriate to ensure the safety of the child.

13. (13) Pediatric equipment and supplies must be available as follows:

    1. (a) Suction machines, one per child requiring suction, plus one suction machine for emergency use;
    2. (b) Oxygen, in portable tanks with age appropriate supplies;
    3. (c) Thermometers;
    4. (d) Spyhgmomanometers, stethoscopes, otoscopes; and,
    5. (e) Apnea monitor and pulse oximeter.
14. (14) Other equipment and supplies must be made available to meet the needs of the children as prescribed or recommended by the attending physician or medical director and in accordance with professional standards of care.

15. (15) Prior to initiating or expanding services to pediatric residents, the nursing home licensee or applicant must receive written approval from the Agency. In order to convert existing nursing home beds to pediatric beds, nursing home licensees must:

    1. (a) Have a standard license pursuant to Section 400.062, F.S.;
    2. (b) Submit approval from the Office of Plans and Construction based upon submission of plans and specifications of the building for approval as outlined in Rule 59A-4.133, F.A.C.;
    3. (c) Submit a completed Health Care Licensing Application, Nursing Homes, AHCA Form 3110-6001, as incorporated in Rule 59A-4.103, F.A.C., no less than 30 days prior to the anticipated date that services will be provided. The application must include the number and configuration of beds to be used to serve pediatric residents and a listing of services that will be provided.
16. (16) Approval to provide pediatric services shall be based upon demonstration of compliance with this rule and Chapter 400, Part II, F.S.
17. (17) Any changes in pediatric services, including cessation of services, must be reported to the Agency in writing at least 30 days prior to the change.

Rulemaking Authority 400.23(2), 408.819 FS. Law Implemented 400.23(5), 400.071, 408.806 FS. History–New 11-5-96, Amended 9-7-97, 12-4-16.