2005 -- H 6550 SUBSTITUTE A
A N A C T
RELATING TO HEALTH AND SAFETY -- THE LONG-TERM CARE REFORM ACT OF
2005 -- NURSING FACILITY QUALITY IMPROVEMENT
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
(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
(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
(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
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
acting in a manner inconsistent with the health and safety of the patients of
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 department’s 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
(1) The nursing facility's quality improvement committee shall include at least the
(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.