1. (A) All facilities shall provide appropriate, adequate and sufficient nursing services to meet the needs of residents and to ensure preventive measures, treatments, medications, diets, restorative nursing care, activities and related services are carried out, recorded and reviewed.

   1. (1) Facilities providing Level I, II or III care shall provide a 24-hour nursing service with an adequate number of trained and experienced nursing personnel on duty 24 hours per day, seven days a week, including vacation and other relief periods.
   2. (2) Nursing services in facilities providing Level I, II or III care shall be in accordance with written policies and procedures.
   3. (3) Community Support Facilities and Resident Care Facilities with Community Support Residents shall provide organized, routine nursing services in order to monitor resident medications, potential medication side effects, and general resident physical and psychosocial well-being. Nursing services shall be provided at a minimum of at least 15 hours per 30 residents per month and more if needed, and shall be scheduled so as to assure at least one visit per week. Such services shall be equally distributed across the month.
   4. (4) Facilities providing only Level IV care are not required to provide organized, routine nursing services. However, nursing services shall be provided as needed to residents in the case of minor illness of a temporary nature.

2. (B) Minimum Nursing Personnel Requirement.

   1. (1) General.

      1. (a) Nursing personnel shall not serve on active duty more than 12 hours per day, or more than 48 hours per week, on a regular basis.
      2. (b) One director of nurses may cover multiple units of the same or different levels of care within a single facility. One supervisor of nurses may cover up to two units of the same or different levels of care within a single facility. Where a SNCFC unit or units is in combination with an adult nursing program, there shall be a day supervisor whose sole responsibility is to the pediatric nursing program.
      3. (c) Full-time shall mean 40 hours per week, five days per week.
      4. (d) The amount of nursing care time per resident shall be exclusive of non-nursing duties.
      5. (e) The minimum staffing patterns and nursing care hours as contained in 105 CMR 150.007(B) shall mean minimum, basic requirements.
      6. (f) The supervisor of nurses and the nurse as required by 150.007(C)(3), but not the director of nurses, may be counted in the calculation of licensed nursing personnel.

   2. (2) Facilities providing Level I care shall provide:

      1. (a) A full-time director of nurses during the day shift.
      2. (b) A full-time supervisor of nurses during the day shift, five days per week for facilities with more than one unit. In facilities with a single unit, the director of nurses may function as supervisor.
      3. (c) A nurse as required by 105 CMR 150.007(C)(3), 24 hours per day, seven days per week for each unit.
      4. (d) Sufficient nursing personnel to meet resident nursing care needs, based on acuity, resident assessments, care plans, census and other relevant factors as determined by the facility. On and after April 1, 2021, sufficient staffing must include a minimum number of hours of care per resident per day of 3.580 hours, of which at least 0.508 hours must be care provided to each resident by a registered nurse. The facility must provide adequate nursing care to meet the needs of each resident, which may necessitate staffing that exceeds the minimum required PPD.

   3. (3) Facilities providing Level II care shall provide:

      1. (a) A full-time director of nurses.
      2. (b) A full-time supervisor of nurses during the day shift, five days per week for facilities with more than one unit. In facilities with only a single unit, the director of nurses may function as supervisor. A SNCFC shall provide a full-time supervisor of nursing during the day and evening shifts seven days a week, who shall be a registered nurse and shall have had at least one year of nursing experience in pediatrics, preferably with the developmentally disabled population.
      3. (c) A charge nurse as required by 105 CMR 150.007(C)(3), 24 hours per day, seven days per week for each unit.
      4. (d) Sufficient nursing personnel to meet resident nursing care needs based on acuity, resident assessments, care plans, census and other relevant factors as determined by the facility. On and after April 1, 2021, sufficient staffing must include a minimum number of hours of care per resident per day (PPD) of 3.580 hours, of which at least 0.508 hours must be care provided to each resident by a registered nurse. The facility must provide adequate nursing care to meet the needs of each resident, which may necessitate staffing that exceeds the minimum required PPD. A SNCFC shall provide a staff nurse, 24 hours per day, seven days per week for each unit.

   4. (4) Facilities providing Level III care shall provide:

      1. (a) A full-time supervisor of nurses during the day shift, five days per week, in facilities with more than one unit.
      2. (b) A nurse as required by 105 CMR 150.007(C)(3) during the day and evening shifts, seven days per week, for each unit.
      3. (c) A nurse aide who is a responsible person, on duty during the night shift.
      4. (d) Sufficient nursing personnel to meet resident nursing care needs based on acuity, resident assessments, care plans, census and other relevant factors as determined by the facility. On and after April 1, 2021, sufficient staffing must include a minimum number of hours of care per resident per day (PPD) of 3.580 hours, of which 0.508 hours must be care provided to each resident by a registered nurse. The facility must provide adequate nursing care to meet the needs of each resident, which may necessitate staffing that exceeds the minimum required PPD.
      5. (e) The facility shall provide additional nursing services, sufficient to meet the needs, in the event a resident has a minor illness and is not transferred to a higher level facility or unit.

   5. (5) Facilities providing Level IV care shall provide:

      1. (a) A responsible person on the premises at all times.
      2. (b) In facilities with less than 20 beds, at least one responsible person on active duty during the waking hours in the ratio of one per ten residents.
      3. (c) In facilities with more than 20 beds, at least one responsible person on active duty at all times per unit.

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1. (d) If none of the responsible persons on duty are licensed nurses, then the facility shall provide a licensed consultant nurse, four hours per month per unit. (In multiple level facilities the director or supervisor of nurses may function in this capacity.)
2. (e) In all facilities with more than ten Community Support Residents, at least one responsible person awake and on duty at all times on the night shift.

3. (C) Qualifications and Duties.

   1. (1) Director of Nurses. The Director of Nurses shall be a registered nurse with at least two years of nursing experience, at least one of which has been in an administrative or supervisory capacity. The director of nurses shall be responsible for development of the objectives and standards of nursing practice and procedures, overall management of nursing personnel, coordination of nursing services, development of staff training programs, and the evaluation and review of resident care and nursing care practices. The Director of Nursing of a free-standing SNCFC must have at least one year of nursing experience in pediatrics, preferably with the developmentally disabled population.
   2. (2) Supervisor of Nurses. The supervisor of nurses shall be a registered nurse with at least two years of nursing experience, one of which has been in the capacity of a nurse as required by 105 CMR 150.007(C)(3). The supervisor of nurses shall be responsible for the supervision of nursing care and nursing personnel, the supervision and evaluation of staff assignments and performance, the supervision of resident care, the application and evaluation of resident care plans and the integration of nursing care with other professional services. In cases where a supervisor of nursing is responsible for a SNCFC unit or units, that individual must have a minimum of one year training or experience in pediatrics, preferably with the developmentally disabled population.

   3. (3) One registered nurse or one licensed practical nurse shall be responsible for the performance of total nursing care of the residents in his or her unit during his or her shift with the assistance of ancillary nursing personnel.

      1. (a) In a SNCFC, such nurse shall be a registered nurse or a licensed practical nurse, with training and/or experience in pediatric nursing.
      2. (b) In a SNCFC, the staff nurse shall be a registered nurse or licensed practical nurse, with training and/or experience in pediatric nursing.
   4. (4) The nurse aide or the responsible person on duty in facilities providing Level III or IV care shall be readily accessible so residents can easily report injuries, symptoms, or emergencies. Such person shall be responsible for ensuring appropriate action is taken promptly, and facilities shall be responsible for establishing mechanisms and procedures for the nurse aide or responsible person to obtain assistance in the case of an emergency.
   5. (5) Licensed practical nurses and nurse aides shall be assigned duties consistent with their training and experience. A SNCFC shall provide nurse aides who have training or experience in caring for children. Assignments shall be made so each resident is cared for by at least one aide who is assigned to care for him or her on a continuing basis.
   6. (6) At no time shall direct resident care be provided by individuals younger than 16 years old, housekeeping staff, or kitchen workers.
   7. (7) Nursing personnel shall not perform housekeeping, laundry, cooking or other such tasks normally performed by maintenance or other personnel.

4. (D) Nursing Care. In facilities providing Level I, II or III care, the resident’s care plan shall include a comprehensive, nursing care plan for each resident developed by the nursing staff in relation to the resident’s total health needs.

   1. (1) The nursing care plan shall be an organized, written daily plan of care for each resident. It shall include diagnoses, significant conditions or impairments, medication, treatments, special orders, diet, safety measure, mental condition, bathing and grooming schedules, activities of daily living, the kind and amount of assistance needed, long-term and short-term goals, planned resident teaching programs, encouragement of resident’s interests and desirable activities. It shall indicate what nursing care is needed, how it can best be accomplished, and what methods and approaches are most successful. This information shall be readily available for use by all personnel involved in resident care. In a SNCFC, the nursing care plan shall also include consideration of the resident’s physical and mental status with respect to his need for recreational and educational stimulation and growth; consideration of the resident’s familial situation, and of his or her behavior with other residents, staff, family and visitors.
   2. (2) The nursing care plan shall be initiated on admission and shall be based on the primary care provider’s medical care plan and the nursing assessment of the resident’s needs.
   3. (3) The plan shall be the responsibility of the director or supervisor of nurses and shall be developed in conjunction with the nursing staff, resident or resident’s guardian and representatives of other health disciplines where appropriate.
   4. (4) All personnel who provide care to a resident shall have a thorough knowledge of the resident’s condition and the nursing care plan.
   5. (5) The plan shall specify priorities of nursing need, which shall be determined through communication with the resident or resident’s guardian, the resident’s primary care provider, and other staff.
   6. (6) The plan shall reflect the resident’s psycho-social needs and ethnic, religious, social, cultural or other preferences.
   7. (7) Nursing care plans shall be reviewed, revised and kept current so resident care constantly meets resident needs. Plans shall show written evidence of review and revision at least every 30 days in facilities providing Level I or II care, and every 90 days in facilities that provide Level III care. Reviews of nursing care plans shall be performed in conjunction with reviews of other aspects of the resident’s total health care.
   8. (8) For residents in certified facilities with DD/ORC nursing care plans shall include the carry-over services that integrate all relevant specialized services contained in the resident’s DDS Rolland Integrated Services Plan and Specialized Services Provider plan. The plan shall be developed in conjunction with the resident, and/or guardian, representatives of DDS or a case manager designated by DDS and the specialized service providers, reviewed not less frequently than every three months, annually and at the time of significant change.
   9. (9) Relevant information from the nursing care plan shall be included with other health information when a resident is transferred or discharged.

5. (E) Restorative Nursing Care.

   1. (1) All facilities providing Level I, II or III care shall provide a program of restorative nursing care as an integral part of overall nursing care. Restorative nursing care shall be designed to assist each resident to achieve or maintain the highest possible degree of function, self-care and independence.
   2. (2) Nursing personnel shall provide restorative nursing care in their daily care of residents.

   3. (3) Restorative nursing care shall include such procedures as:

      1. (a) Maintaining good body alignment, keeping range of motion of weak or paralyzed limbs, proper positioning and support with appropriate equipment, particularly of bedfast or wheel chair residents.
      2. (b) Encouraging and assisting bedfast residents to change positions at least every two hours during waking hours (7:00 A.M. to 10:00 P.M.) in order to stimulate circulation, and prevent decubiti and contractures.
      3. (c) Maintaining a program of preventive skin care.
      4. (d) Assisting residents to keep active and out of bed for reasonable periods of time except when contraindicated the primary care provider’s orders or the resident’s condition.
      5. (e) Maintaining a bowel and bladder training program.
      6. (f) Assisting residents to adjust to any disabilities and to redirect their interests if necessary.
      7. (g) Assisting residents to carry out prescribed physical therapy, occupational therapy and speech, hearing and language therapy exercises between visits by the therapist.
      8. (h) Assisting residents to maintain or restore function and activity through proper general exercises and activities appropriate to their condition.
      9. (i) Assisting and teaching the activities of daily living (such as feeding, dressing, grooming and toilet activities).
      10. (j) Coordinating restorative nursing care with rehabilitation services, activity programs and other resident care services.

6. (F) Dietary Supervision.

   1. (1) Nursing personnel shall have knowledge of the dietary needs, food and fluid intake and special dietary restrictions of residents and shall see residents are served diets as prescribed. Residents’ acceptance of food shall be observed, and any significant deviation from normal food or fluid intake or refusal of food shall be reported to the nurse in charge and the food service supervisor or dietitian.
   2. (2) Residents requiring assistance in eating shall receive adequate assistance. Help shall be assigned promptly upon receipt of meals, and adaptive self-help devices shall be provided when necessary.

7. (G) Nursing and Supportive Routines and Practices.

   1. (1) All facilities shall provide sufficient nursing care and supportive care so each resident:

      1. (a) Receives treatments, medications, diet and other services as prescribed and planned in his or her medical, nursing, restorative nursing, dietary, social and other care plans. In certified facilities this shall include carry over services for residents with DD/ORC.
      2. (b) Receives proper care to prevent decubiti, contractures and immobility.
      3. (c) Is kept comfortable, clean and well groomed.
      4. (d) Is protected from accident and injury through safety plans and measures.
      5. (e) Is treated with kindness and respect.
   2. (2) No medication, treatment or therapeutic diet shall be administered to a resident except on written or oral order of a primary care provider.
   3. (3) Nursing personnel and responsible persons shall constantly be alert to the condition and health needs of residents and shall promptly report to the nurse or person in charge aresident’s condition or symptomatology such as dehydration, fever, drug reaction or unresponsiveness.
   4. (4) Nursing personnel and responsible persons shall assist residents to dress and prepare for appointments, medical or other examinations, diagnostic tests, special activities and other events outside the facility.

   5. (5) The following personal care routines shall be provided by all facilities as a part of the resident’s general care and well-being.

      1. (a) A tub bath, shower or full-bed bath as desired or required, but at least weekly. In a SNCFC, a bath or shower daily.
      2. (b) Bed linen changed as required, but at least weekly.
      3. (c) Procedures to keep incontinent resident clean and dry.
      4. (d) Frequent observation of bedfast resident for skin lesions and special care for all pressure areas.
      5. (e) Daily ambulation or such movement as condition permits (as ordered by the primary care provider).
      6. (f) A range of recreational activities.
      7. (g) Provision for daily shaving of men, based on resident preference.
      8. (h) Provision for haircuts for men at least monthly, based on resident preference.
      9. (i) Hair shampoos at least once every two weeks. In a SNCFC, hair shampoos twice a week.
      10. (j) Daily oral hygiene and dentures or teeth cleaned morning and night.
      11. (k) Foot care sufficient to keep feet clean and nails trimmed.
      12. (l) Appropriate, clean clothing properly mended, appropriate for the time of day and season, whether indoors or outdoors. No clothing of highly flammable fabrics shall be permitted.
      13. (m) Appropriate staff for walks and other such activities, when necessary, to safeguard ambulatory residents.

8. (H) Nursing Review and Notes. Each resident’s condition shall be reviewed to note change in condition, nursing or other services provided and the resident’s response or progress.

   1. (1) In facilities providing Level II care each resident shall be reviewed by the nursing personnel going off duty with the nursing personnel coming on duty at each change of shift. At minimum a weekly progress note shall be recorded in each resident’s record unless the resident’s condition warrants more frequent notations; the weekly progress note documentation shall be performed by a licensed nurse.
   2. (2) In facilities that provide Level III care, each resident’s general condition shall be reviewed each morning. Significant changes of findings shall be noted in the clinical record and the primary care provider notified with a written notation or the time and date of notification. A note summarizing the resident’s condition shall be written monthly in the clinical record, unless the resident’s condition warrants more frequent notations.
9. (I) Educational Programs. Facilities providing Level I, II or III care shall provide a continuing in-service educational program appropriate to the level of care provided in the facility for all nursing personnel. Such a program shall be in addition to a thorough job orientation for new personnel. In addition, facilities admitting residents with DD/ORC shall include, as part of the new personnel job orientation and continuing in-service education, content addressing the theory, skills and techniques required to provide care and services to such residents.