Chapter 249

2005 -- H 6550 SUBSTITUTE A

Enacted 07/08/05








     Introduced By: Representatives McNamara, Kennedy, Faria, Church, and Rice

     Date Introduced: May 26, 2005


It is enacted by the General Assembly as follows:


SECTION 1.   Legislative purpose and intent. The legislature is committed to ensuring the

highest quality of long-term care for the state's most vulnerable and frail populations: or elderly

and persons with disabilities. The recent closure of Hillside Health Center, a nursing facility

located in Providence, was precipitated not only by a history of problems in meeting federal and

state nursing facility licensing standards but also financial instability which led to eventual

insolvency. Two recently released reports, one by the state Long-Term Care Coordinating

Council's Task Force on Nursing Facility Closures, entitled "Hillside Health Center: Doors

Closed, Lessons Learned" and one prepared for the Governor by the state Office of Health and

Human Services, entitled "Review of Department of Health's Response to the Quality of Care at

Hillside Health Center," showed critical deficiencies in the care provided to a number of residents

at Hillside Health Center, specifically including resident Germaine Morsilli (referred to as

resident number "1" in certain state department of health survey reports). These reports also

pointed to serious gaps and weaknesses in state oversight of nursing facilities and the state's

ability to safeguard the health and well-being of nursing facility residents. The purpose of this act

is to adopt further requirements to strengthen state oversight of nursing facilities, to improve

quality of care of nursing facility residents, to prevent future residents from suffering serious

harm such as that experienced by Germaine Morsilli, and prevent the trauma faced by other

residents and families when Hillside Health Center was forced to close.


     SECTION 2. This act shall be known as the "Germaine Morsilli Nursing Facility Quality

Improvement and Reform Act."


     SECTION 3. Sections 5-45-3 and 5-45-12 of the General Laws in Chapter 5-45 entitled

"Nursing Home Administrators" are hereby amended to read as follows:


     5-45-3. Board of examiners -- Functions. -- (a) It is the function of the board to:

      (1) Conduct examinations as required by the department and to act in an advisory

capacity to the department in all matters pertaining to the licensing of nursing home


      (2) Develop and apply appropriate techniques, including examinations and

investigations, for determining whether an individual meets those standards, subject to the

approval of the director;

      (3) Recommend to the department the issuance of licenses and registrations to

individuals determined, after application of those techniques, to meet those standards; and to

recommend to the director the revocation or suspension of licenses or registrations previously

issued; and to recommend disciplinary action to be taken against a nursing home administrator,

including placing a licensee on probation, and ordering continuing education or professional

mentoring by nursing facility professionals in any case where the individual holding that license

or registration is determined substantially to have failed to conform to the requirements of those

standards or when a nursing facility under the administrator's control has been found on its

survey to have continued poor performance or is repeatedly unable to remain in compliance with

standards; and

      (4) Adopt, on or before January 1, 1995, with the approval of the director of the

department of health, rules and regulations governing a mandatory program of continuing

education for nursing home administrators.

      (b) Programs for continuing education for nursing facility administrators may be

presented by:

      (1) The Rhode Island Health Care Association;

      (2) The Rhode Island Association of Facilities for the Aging;

      (3) The American College of Health Care Administrators;

      (4) The Alliance for Better Nursing Home Care;

      (5) Nationally recognized associations of the groups listed in subdivisions (1) -- (4) of

this subsection;

      (6) Any accredited college or university; or

      (7) Any organizations authorized and approved by the department.


     5-45-12. Disciplinary proceedings -- Grounds for discipline. (a) The department may

suspend, or revoke or refuse to renew any license issued under this chapter, or may reprimand,

censure, or discipline a licensee or may require participation in continuing education, or

professional mentoring or may place an administrator on probation in accordance with the

provisions of this section, upon decision and after a hearing as provided by chapter 35 of title 42,

upon proof that the licensee engaged in unprofessional conduct. Unprofessional conduct includes,

but is not limited to, any of the following:

      (1) Being unfit or incompetent by reason of negligence, habits, or other causes;

      (2) Violating any of the provisions of this chapter or the rules enacted in accordance with

it; or acting in a manner inconsistent with the health and safety of the patients of the home

nursing facility in which he or she is the administrator;

      (3) Engaging in fraud or deceit in the practice of nursing home administration, or in his

or her admission to this practice;

      (4) Being convicted in a court of competent jurisdiction, either within or without this

state, of a felony.

      (5) Failing to conform to minimal standards of acceptable and prevailing practice of

nursing home administration.

     (b) If a nursing home administrator is placed on probation, the department may require

the licensee to:

     (1) Report regularly to the department on matters that are the basis of the probation;

     (2) Limit practice to the areas prescribed by the department; or

     (3) Complete a prescribed program of continuing professional education until the licensee

attains a degree of skill satisfactory to the department in those areas that are the basis of the



     SECTION 4. Section 23-17-10.5 of the General Laws in Chapter 23-17 entitled

"Licensing of Health Care Facilities" is hereby amended to read as follows:


     23-17-10.5. Medical director and attending physician file. -- Each nursing facility

licensed under this chapter shall designate a physician to serve as medical director. The medical

director shall be responsible for implementation of resident care policies and for the coordination

of medical care in the facility. Such responsibilities shall include, but not be limited to: the

implementation of facility policies and procedures related to the medical care delivered in the

facility; physician and advanced practice practitioner credentialing; practitioner performance

reviews; employee health including infection control measures; evaluation of health care delivery,

including oversight of medical records and participation in quality improvement; provision of

staff education on medical issues; participation in state survey process, including the resolution of

deficiencies as needed; and such other duties and responsibilities as may be stipulated in

regulations promulgated by the department of health.

     The medical director, charged with the aforementioned duties and responsibilities for the

delivery of medical care in the nursing facility, shall be immune from civil or criminal

prosecution for reporting to the board of medical licensure and discipline the unprofessional

conduct, incompetence or negligence of a nursing facility physician or limited registrant;

provided, that the report, testimony or other communication was made in good faith and while

acting within the scope of authority conferred by this section. Each nursing facility shall maintain

an active file of all current attending physicians including their phone number and address, an

emergency phone number, their current medical license number, and their preferred hospital

admitting privileges. The director of the department of health is hereby authorized to promulgate

rules and regulations to implement the provisions of this section.


     SECTION 5. Chapter 23-17 of the General Laws entitled "Licensing of Health Care

Facilities" is hereby amended by adding thereto the following sections:


     23-17-12.8. Posting of nursing staff levels in nursing facilities. The department is

authorized to adopt federal Medicare nurse staff posting requirements by regulation. In addition

to any federal requirements for posting of nursing staff levels, the nursing facility shall post the

nurse staff levels for the facility in a public place within the facility. The posting information

shall be maintained on file by the nursing facility and shall be made available to the public upon

request. The nursing facility shall prepare an annual report showing the average daily direct care

nurse staffing level for the facility by shift and by category of nurse to include registered nurses,

licensed practical nurses, nursing assistants and medication technicians; the use of nurse and

nursing assistant staff from temporary placement agencies; and the nurse and nurse assistant

turnover rates. The information on nurse staffing shall be reviewed as part of the nursing

facility's annual licensing survey and shall be available to the public, both in printed form and on

the departments website, by facility.


     23-17-12.9. Resident and family notification. The director shall establish regulations

which: (1) notify the resident, or his or her legal representative, the resident's family

representative, the resident's attending physicians of record and the nursing facility's medical

director, if that resident has been found to be in immediate jeopardy to health and safety; (2)

notify all facility residents, or their legal representatives, their family representatives, their

attending physicians and the nursing facility's medical director, whenever a nursing facility is

cited for substandard quality of care as defined in 42 CFR 488.301 or successor regulation; and

(3) provide for notification of changes regarding resident condition as provided in federal

regulation 42 CFR 483.10 or successor regulation. A facility citation for substandard quality of

care shall be considered to be a public record ten (10) days following the citation, or upon

departmental approval of the corresponding plan of correction, whichever is sooner.

     For purposes of this section, "immediate jeopardy to health and safety" means a situation

which the institution's noncompliance with one or more state or federal requirements or

conditions has caused, or is likely to cause, serious injury, harm, impairment or death to a resident

receiving care in the institution.


     23-17-12.10. Quality predictive modeling -- Established. The department of health

shall develop a data modeling or other capacity to use quality data already collected from nursing

facilities to detect patterns of high performance and/or potential deficiency(ies) affecting resident



     23-17-12.11. Nursing facility quality improvement program. (a) Established. Each

licensed nursing facility shall develop and implement a quality improvement program and

establish a quality improvement committee.

     (b) Each licensed nursing facility shall designate a qualified individual, who shall be

determined by the facility's administrator, to coordinate and manage the nursing facility's quality

improvement program.

     (1) The nursing facility's quality improvement committee shall include at least the

following members:

     (i) The nursing facility administrator;

     (ii) The director of nursing;

     (iii) The medical director;

     (iv) A social worker; and

     (v) A representative of dietary services.

     (2) The quality improvement committee shall:

     (i) Meet at least quarterly;

     (ii) Maintain records of all quality improvement activities; and

     (iii) Keep records of committee meetings that shall be available to the department during

any on-site visit.

     (3) The quality improvement committee for a nursing facility shall annually review and

approve the quality improvement plan for the nursing facility. Said plan shall be available to the

public upon request.

     (c) Each nursing facility shall establish a written quality improvement plan that shall be

reviewed by the department during the facility's annual survey and that:

     (1) Provides criteria to monitor nursing care, including medication administration,

prevention and treatment of decubitus ulcers, dehydration and nutritional status and weight loss or

gain, accidents and injuries, unexpected deaths, changes in mental or psychological status, and

any other data necessary to monitor quality of care; and

     (2) Includes methods to identify, evaluate and correct problems.

     (d) The nursing facility administrator shall take appropriate remedial actions based on the

recommendations of the nursing facility's quality improvement committee.

     (e) The director may not require the quality improvement committee to disclose the

records and the reports prepared by the committee except as necessary to assure compliance with

the requirements of this section.

     (f) Good faith attempts by the quality improvement committee to identify and correct

quality deficiencies will not be used as a basis for sanctions.

     (g) If the department determines that a nursing facility is not implementing its quality

improvement program effectively and that quality improvement activities are inadequate, the

department may impose sanctions on the nursing facility to improve quality of resident care

including mandated hiring of, directly or by contract, an independent quality consultant.


     SECTION 6. Chapter 23-17.5 of the General Laws entitled "Rights of Nursing Home

Patients" is hereby amended by adding thereto the following section:


     23-17.5-30. Family councils. (a) For the purposes of this section "family council"

means an organized group of the family members, friends or representatives of facility residents

who may meet in private without the presence of facility staff.

     (b) The role of the family council shall be to address issues affecting residents generally

at the facility, not to pursue individual grievances. The family council shall not be entitled to

obtain information about individual residents or staff members, or any other information deemed

confidential under state or federal law.

     (c) No licensed nursing facility may prohibit the formation of a family council. When

requested by a member of a resident's family or a resident's representative, a family council shall

be allowed to meet in a common meeting room of the nursing facility at least once a month

during mutually agreed upon hours.

     (d) Upon the admission of a resident, the nursing facility shall inform the resident and the

resident's family members, in writing, of their right to form a family council, or if a family

council already exists, of the date, time and location of scheduled meetings.

     (e) The nursing facility administration shall notify the state long-term care ombudsman of

the existence or planned formation of a family council at that facility.

     (f) The family council may exclude members only for good cause, subject to appeal by

the excluded party to the state long-term care ombudsman. No member shall be excluded on the

basis of race or color, religion, gender, sexual orientation, disability, age or country of ancestral


     (g) A facility shall provide its family council with adequate space in a prominent posting

area for the display of information pertaining to the family council.

     (h) Staff or visitors may attend family council meetings at the council's invitation.

     (i) The nursing facility shall provide a designated staff person who, at the request of the

council, shall be responsible for providing assistance to the family council and for responding to

recommendations and requests made by the family council.

     (j) The nursing facility shall consider the recommendations of the family council

concerning issues and policies affecting resident care and life at the nursing facility.

     (k) A violation of the provisions of this section will constitute a violation of the rights of

nursing home residents.


     SECTION 7. This act shall take effect upon passage.     


LC03356/SUB A