Authority: IC 16-28-1-7

Affected: IC 12-10-5.5; IC 16-28-5-1; IC 25-19-1-5

Sec. 13. (a) The licensee:

1. (1) is responsible for compliance with all applicable laws and rules; and

2. (2) has full authority and responsibility for the:

   1. (A) organization;
   2. (B) management;
   3. (C) operation; and
   4. (D) control;
3. of the licensed facility.

The delegation of any authority by the licensee does not diminish the responsibilities of the licensee.

(b) The licensee shall provide the number of staff as required to carry out all the functions of the facility, including the following:

1. (1) Initial orientation of all employees.
2. (2) A continuing in-service education and training program for all employees.
3. (3) Provision of supervision for all employees.

(c) If a facility offers services in addition to those provided to its long-term care residents, the administrator is responsible for assuring that the additional services do not adversely affect the care provided to its residents.

(d) The licensee shall notify the:

1. (1) department within three (3) working days of a vacancy in the administrator's position; and
2. (2) director of the name and license number of the replacement administrator.

(e) An administrator shall be employed to work in each licensed health facility. For purposes of this subsection, an individual can only be employed as an administrator in one (1):

1. (1) health facility; or
2. (2) hospital-based long-term care unit;

at a time.

(f) In the administrator's absence, an individual shall be authorized, in writing, to act on the administrator's behalf.

(g) The administrator is responsible for the overall management of the facility but shall not function as a departmental supervisor, for example, director of nursing or food service supervisor, during the same hours. The responsibilities of the administrator shall include, but are not limited to, the following:

1. (1) Immediately informing the division by telephone, followed by written notice within twenty-four (24) hours, of unusual occurrences that directly threaten the welfare, safety, or health of the resident or residents, including, but not limited to, any:

   1. (A) epidemic outbreaks;
   2. (B) poisonings;
   3. (C) fires; or
   4. (D) major accidents.
2. If the department cannot be reached, such as on holidays or weekends, a call shall be made to the emergency telephone number ((317) 383-6144) of the division.

3. (2) Promptly arranging for:

   1. (A) medical;
   2. (B) dental;
   3. (C) podiatry; or
   4. (D) nursing;
4. care or other health care services as prescribed by the attending physician.
5. (3) Obtaining director approval prior to the admission of an individual under eighteen (18) years of age to an adult facility.

6. (4) Ensuring that the facility maintains, on the premises, time schedules and an accurate record of actual time worked that indicates the:

   1. (A) employees' full names; and
   2. (B) dates and hours worked during the past twelve (12) months.
7. This information shall be furnished to the division staff upon request.
8. (5) Maintaining a copy of this article and making it available to all personnel and the residents.
9. (6) Maintaining reports of surveys conducted by the division in each facility for a period of two (2) years and making the reports available for inspection to any member of the public upon request.

(h) Each facility, except:

1. (1) a facility that cares for children; or
2. (2) an intermediate care facility for the mentally retarded;

shall encourage all employees serving residents or the public to wear name and title identification.

(i) Each facility shall establish and implement a written policy manual to ensure that resident care and facility objectives are attained, to include the following:

1. (1) The range of services offered.
2. (2) Residents' rights.
3. (3) Personnel administration.
4. (4) Facility operations.

(j) The licensee shall approve the policy manual, and subsequent revisions, in writing. The policy manual shall be reviewed and dated at least annually. The resident care policies shall be:

1. (1) developed by a group of professional personnel; and
2. (2) approved by the medical director.

(k) The policies shall be maintained in a manual or manuals accessible to employees and made available upon request to the following:

1. (1) Residents.
2. (2) The department.
3. (3) The sponsor or surrogate of a resident.
4. (4) The public.

Management/ownership confidential directives are not required to be included in the policy manual; however, the policy manual must include all of the facility's operational policies.

(l) To assure continuity of care of residents in cases of emergency, the facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents and including situations that may require emergency relocation of residents. Facilities caring for children shall have a written plan outlining the staff procedures, including isolation and evacuation, in case of an outbreak of childhood diseases.

(m) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under a written agreement. Such agreements pertaining to services furnished by outside resources must specify, in writing, that the facility assumes responsibility for the following:

1. (1) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility.
2. (2) The timeliness of the services.
3. (3) Orientation to pertinent facility policies and residents to whom they are responsible.

(n) Each facility shall conspicuously post the license or a true copy thereof within the facility in a location accessible to public view.

(o) Each facility shall submit an annual statistical report to the department.

(p) The facility must have in effect a written transfer agreement with one (1) or more hospitals that reasonably assures the following:

1. (1) Residents will be transferred from the facility to the hospital and ensured of timely admission to the hospital when transfer is medically appropriate as determined by the attending physician.
2. (2) Medical and other information needed for care and treatment of residents and, when the transferring facility deems it appropriate, for determining whether the residents can be adequately cared for in a less expensive setting than either the facility or the hospital will be exchanged between the institutions.

3. (3) Specification of the responsibilities assumed by both the discharging and receiving institutions for prompt notification of the impending transfer of the resident for the following:

   1. (A) Agreement by the receiving institution to admit the resident.
   2. (B) Arranging appropriate transportation and care of the resident during transfer.
   3. (C) The transfer of personal effects, particularly money and valuables, and of information related to the items.
4. (4) Specification of the restrictions with respect to the types of services available or the types of residents or health conditions that will not be accepted by the hospital or the facility, or both, including any other criteria relating to the transfer of residents.

The facility is considered to have a transfer agreement in effect if the facility has attempted in good faith to enter into an agreement with a hospital sufficiently close to the facility to make transfer feasible.

(q) A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

(r) The facility must operate and provide services in compliance with:

1. (1) all applicable federal, state, and local laws, regulations, and codes; and
2. (2) accepted professional standards and principles that apply to professionals providing services in such a facility.

(s) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility.

(t) The governing body shall appoint the administrator who is:

1. (1) licensed as a comprehensive care facility administrator as required by IC 25-19-1-5(c); and
2. (2) responsible for the management of the facility.

(u) The facility must designate a physician to serve as medical director.

(v) The medical director shall be responsible for the following:

1. (1) Acting as a liaison between the administrator and the attending physicians to encourage physicians to:

   1. (A) write orders promptly; and
   2. (B) make resident visits in a timely manner.
2. (2) Reviewing, evaluating, and implementing resident care policies and procedures and to guide the director of nursing services in matters related to resident care policies and services.

3. (3) Reviewing the following:

   1. (A) Incidents and accidents that occur on the premises to identify hazards to health and safety.
   2. (B) Employees preemployment physicals and health reports and monitoring employees health status.
4. (4) The coordination of medical care in the facility.

(w) In facilities that are required under IC 12-10-5.5 to submit an Alzheimer's and dementia special care unit disclosure form, the facility must designate a director for the Alzheimer's and dementia special care unit. The director shall have an earned degree from an educational institution in a health care, mental health, or social service profession or be a licensed health facility administrator. The director shall have a minimum of one (1) year work experience with dementia or Alzheimer's residents, or both, within the past five (5) years. Persons serving as a director for an existing Alzheimer's and dementia special care unit at the time of adoption of this rule are exempt from the degree and experience requirements. The director shall have a minimum of twelve (12) hours of dementia-specific training within three (3) months of initial employment as the director of the Alzheimer's and dementia special care unit and six (6) hours annually thereafter to:

1. (1) meet the needs or preferences, or both, of cognitively impaired residents; and
2. (2) gain understanding of the current standards of care for residents with dementia.

(x) The director of the Alzheimer's and dementia special care unit shall do the following:

1. (1) Oversee the operation of the unit.

2. (2) Ensure that:

   1. (A) personnel assigned to the unit receive required in-service training; and

   2. (B) care provided to Alzheimer's and dementia care unit residents is consistent with:

      1. (i) in-service training;
      2. (ii) current Alzheimer's and dementia care practices; and
      3. (iii) regulatory standards.

(y) For purposes of IC 16-28-5-1, a breach of:

1. (1) subsection (a), (c), (g), (r), (t), (u), (v), or (x) is a deficiency;
2. (2) subsection (b), (d), (e), (f), (i), (l), (p), (q), (s), or (w) is a noncompliance; and
3. (3) subsection (h), (j), (k), (m), (n), or (o) is a nonconformance.

(Indiana Department of Health; 410 IAC 16.2-3.1-13; filed Jan 10, 1997, 4:00 p.m.: 20 IR 1535, eff Apr 1, 1997; errata filed Apr 10, 1997, 12:15 p.m.: 20 IR 2414; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; filed Jul 22, 2004, 10:05 a.m.: 27 IR 3990; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; filed Jul 31, 2008, 4:24 p.m.: 20080827-IR-410070657FRA; readopted filed Sep 11, 2013, 3:19 p.m.: 20131009-IR-410130346RFA; readopted filed Nov 13, 2019, 3:14 p.m.: 20191211-IR-410190391RFA; readopted filed Nov 14, 2025, 11:18 a.m.: 20251210-IR-410240588RFA)