Ind. Admin. Code tit. 410, r. 16.2-5-1.3 – Administration and management

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

Sec. 1.3. (a) The licensee:

(1) is responsible for compliance with all applicable laws; and
(2) has full authority and responsibility for the:
1. (A) organization;
2. (B) management;
3. (C) operation; and
4. (D) control;
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) Initial orientation of all employees.
(2) A continuing in-service education and training program for all employees.
(3) Provision of supervision for all employees.

(1) appoint an administrator with either a:
1. (A) comprehensive care facility administrator license as required by IC 25-19-1-5(c); or
2. (B) residential care facility administrator license as required by IC 25-19-1-5(d); and
(2) delegate to that administrator the authority to organize and implement the day-to-day operations of the facility.

(d) The licensee shall notify the director:

(1) within three (3) working days of a vacancy in the administrator's position; and
(2) 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) health facility; or
(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. The responsibilities of the administrator shall include, but are not limited to, the following:

(1) Informing the division within twenty-four (24) hours of becoming aware of an unusual occurrence that directly threatens the welfare, safety, or health of a resident. Notice of unusual occurrence may be made by telephone, followed by a written report, or by a written report only that is faxed or sent by electronic mail to the division within the twenty-four (24) hour time period. Unusual occurrences include, but are not limited to:
1. (A) epidemic outbreaks;
2. (B) poisonings;
3. (C) fires; or
4. (D) major accidents.
If the division cannot be reached, a call shall be made to the emergency telephone number published by the division.
(2) Promptly arranging for or assisting with the provision of medical, dental, podiatry, or nursing care or other health care services as requested by the resident or resident's legal representative.
(3) Obtaining director approval prior to the admission of an individual under eighteen (18) years of age to an adult facility.
(4) Ensuring the facility maintains, on the premises, an accurate record of actual time worked that indicates the:
1. (A) employee's full name; and
2. (B) dates and hours worked during the past twelve (12) months.
(5) Posting the results of the most recent annual survey of the facility conducted by state surveyors, any plan of correction in effect with respect to the facility, and any subsequent surveys. The results must be available for examination in the facility in a place readily accessible to residents and a notice posted of their availability.
(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) The facility shall establish and implement a written policy manual to ensure that resident care and facility objectives are attained, to include the following:

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

The policies shall be made available to residents upon request.

(i) The facility must maintain a written fire and disaster preparedness plan to assure continuity of care of residents in cases of emergency as follows:

(1) Fire exit drills in facilities shall include the transmission of a fire alarm signal and simulation of emergency fire conditions, except that the movement of nonambulatory residents to safe areas or to the exterior of the building is not required. Drills shall be conducted quarterly on each shift to familiarize all facility personnel with signals and emergency action required under varied conditions. At least twelve (12) drills shall be held every year. When drills are conducted between 9 p.m. and 6 a.m., a coded announcement may be used instead of audible alarms.
(2) At least every six (6) months, a facility shall attempt to hold the fire and disaster drill in conjunction with the local fire department. A record of all training and drills shall be documented with the names and signatures of the personnel present.

(j) If professional or diagnostic services are to be provided to the facility by an outside resource, either individual or institutional, an arrangement shall be developed between the licensee and the outside resource for the provision of the services. If a written agreement is used, it shall specify the following:

(1) The responsibilities of both the facility and the outside resource.
(2) The qualifications of the outside resource staff.
(3) A description of the type of services to be provided, including action taken and reports of findings.
(4) The duration of the agreement.

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

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

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

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

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

(1) subsection (a), (g), or (m) is a deficiency;
(2) subsection (b), (c), (d), (e), (f), (h), (i), (j), or (l) is a noncompliance; and
(3) subsection (k) is a nonconformance.

(Indiana Department of Health; 410 IAC 16.2-5-1.3; filed Jan 10, 1997, 4:00 p.m.: 20 IR 1565, eff Apr 1, 1997; errata filed Jan 10, 1997, 4:00 p.m.: 20 IR 1593; errata filed Apr 10, 1997, 12:15 p.m.: 20 IR 2415; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; filed Jan 21, 2003, 8:34 a.m.: 26 IR 1919, eff Mar 1, 2003; filed Jul 22, 2004, 10:05 a.m.: 27 IR 4002; 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)