· web viewlicensure procedure and suitability requirements for long-term care facilities

Representing Massachusetts’s nursing facilities and other organizations that provide health care and community for older adults and people with disabilities.

December 21, 2016Commissioner Monica Bharel, MD, MPHMassachusetts Department of Public Health250 Washington StreetBoston, MA 02108

Dear Commissioner Bharel: On behalf of the Massachusetts Senior Care Association (MSCA), which represents approximately 400 nursing homes, we thank the Department of Public Health (Department) for the opportunity to present testimony and comments in response to the Department’s proposed amendments to the following regulations: 105 CMR 150.000, Licensing of Long-Term Care Facilities and 105 CMR 153.000, Licensure Procedure and Suitability Requirements for Long-Term Care Facilities. Our comments also concern the proposed rescission of 105 CMR 151.000, General Standards of Construction for Long-Term Care Facilities in Massachusetts.

These regulations are being proposed as part of Governor Baker’s Executive Order #562 to reduce unnecessary regulatory burden. Mass Senior Care applauded Governor Baker in announcing this Order and met the challenge of identifying opportunities to reduce unnecessary and outdated state regulations that are not required by state or federal law and regulation. We respectfully note our disappointment that few of our recommendations were incorporated in the Department’s proposed regulations, including our request for the removal of obsolete care and practice language within the existing regulations. For example, references made to autoclaving and sterilization of equipment and supplies, bed pan washers and sanitizers, training toilets which are no longer current practice.Herewith, we again submit, as an attachment for the Department’s consideration, our recommendations, which are the result of the active engagement and participation from nursing facility clinicians and administrators from across the Commonwealth. We welcome the opportunity to work with the Department on the Association’s proposed recommendations.

800 South Street, Suite 280, Waltham, MA 02453 Tel: 617.558.0202 Fax: 617.558.3546 www.maseniorcare.org


In addition, Mass Senior Care has identified a number of issues of concern to the nursing home provider community, including: (1) the proposed repeal of the regulatory provision that allow facilities built prior to 1968 to meet construction standards in effect at the time of construction, (2) continued prohibition on facilities providing outpatient services, (3) potential elimination of the numerically-based licensure staffing requirements, and (4) decreasing the number of beds permitted in bedrooms in nursing units from no more than four to no more than two beds.

1) CMR 151.000, General Standards of Construction for Long-Term Care Facilities in Massachusetts and deletion of 150.017 regulatory language – the Department has proposed rescission of CMR 151.000 and incorporation of relevant sections into 105 CMR 150.000. DPH's proposed amendment would eliminate the current 'grandfathering' provision contained in 105 CMR 150.017, which requires facilities constructed prior to March 19, 1968 to only meet the standards in effect at the time of construction. We strongly oppose the deletion of the “grandfathering” provision contained in 105 CMR 150.017. The potential deletion of the grandfathering provision would have a significant financial and operational impact, including the possibility of unplanned forced closures, on a potentially large number of our members who currently are in compliance with Life Safety Code regulations and have been providing quality nursing facility services to frail elders and disabled individuals in their communities for over 48 years but have facilities that were originally constructed prior to 1968. First, the intent of this deletion is not clear from the language of the proposed regulations itself. From the Department’s presentation to the Public Health Council, however, it appears that the deletion of the grandfathering provision is an attempt to require all facilities to meet current construction standards immediately. If that is the Department’s intent, we would assume, but wish to confirm, that all facilities that were constructed prior to 1968 which currently have waivers in place, will continue to hold these waivers and will not be impacted by removal of the grandfathering provision. We also want to 800 South Street, Suite 280, Waltham, MA 02453 Tel: 617.558.0202 Fax: 617.558.3546

www.maseniorcare.org


confirm that for facilities which were constructed prior to 1968 and which do not have waivers but were grandfathered, that the Department will issue the appropriate waivers to ensure that there is no interruption in the provision of services and resident care in these facilities. In the absence of the Department affirmatively stating that it will continue to grandfather in NFs with existing waivers and authorize waivers for those facilities who would need them under the proposed regulation, the Department’s proposal is potentially a death knell for these nursing facilities. Second, although it may appear to DPH, as stated in its presentation at the Public Health Council on November 9, 2016 on the proposed regulations, that deleting the grandfather provision would impact only a few facilities, based on a survey of Mass Senior Care members it is not clear that is the case. Mass Senior Care has reviewed cost reports for calendar year 2014 which lists the date the facility was originally constructed (Schedule 1, General Information, Question 9). We have totaled over 130 facilities as self-identifying an original construction date prior to 1968. In short, it would

appear that removing the grandfathering provision has the potential to affect about one-third of facilities in the Commonwealth.

Third, Mass Senior Care believes that the basis for any proposed Department action should be to promote quality. It is also unclear to us whether the Department has conducted an analysis to determine whether facilities built prior to 1968 score differently on quality measures than facilities built after 1968.

Fourth, it is not clear to us that the Department has considered the potential financial implications on nursing facilities that could result from this change. Mass Senior Care believes that the proposed regulatory change could trigger violations of financing covenants between facilities and lenders as facilities need to be in compliance with state regulations. And, as the Department knows, due primarily to longstanding inadequate Medicaid reimbursement, facilities are currently operating at razor thin margins, with nearly half experiencing a loss. The proposed change if enacted could result in certain facilities 800 South Street, Suite 280, Waltham, MA 02453 Tel: 617.558.0202 Fax: 617.558.3546



needing to undertake substantial capital expenditures subject to Determination of Need to achieve compliance. There is no guarantee that facilities, in the current reimbursement climate, would be able to secure financing to do the renovation to come into compliance. As such, the proposed regulation could ultimately force a facility to close, requiring such facilities to go through the Department’s voluntary closure process which involves advance notice to the Department and other key stakeholders, a closure plan and a public hearing process. Finally, it is not clear to us how the proposed regulation addresses facilities that may have only a portion of their building built before 1968. It is worth noting that the proposed regulations appear to be inconsistent with common practices with respect to building standards. As a general matter in all sectors where facilities are regulated, compliance with new standards is only required for new construction, alterations or additions. Deleting the grandfathering provision could potentially render some facilities immediately non-compliant and in turn raise a number of operational issues.

We, again, respectfully and strongly urge the Department to reject the proposed regulation.

2) The Department moved 105 CMR 153.030 (Suitability) Restrictions to 105 CMR (Standards) 150.160 Restrictions. Mass Senior Care urges the Department to remove this outdated prohibition that restricts facilities from offering a variety of outpatient

services. We believe maintenance of this prohibition is inconsistent with the state’s ongoing efforts to ensure Massachusetts consumers have access to high quality integrated care in their communities. Each year, nursing facilities discharge nearly 70,000 residents to the community after receiving high quality rehabilitation services. These patients often require additional outpatient medical and social services. For many patients, the nursing facility has become a part of their health care community. We believe that allowing facilities to utilize excess capacity by offering ambulatory, outpatient services will ensure enhanced patient care and reduce health care costs.



3) 105 CMR 150.007 Nursing Services (B) Minimal Nursing Requirements – the Department’s proposed amendments would revise existing nurse staffing requirements from numerically ratio-based to a more subjective standard is individually determined by surveyors in the field, based on acuity and census. Mass Senior Care has many questions related to this proposal and concerns about the lack of clarity and uniformity that would result from this potential change. While we strongly support efforts to ensure facilities have the resources to hire and retain staff to ensure quality resident care, we believe that potential changes to staffing requirements require careful thought and consultation with stakeholders, to ensure consistency. We believe any potential change from numerical ratios to acuity based standards require accompanying clear interpretive guidelines from the Department in order to precisely define the level of staffing that is required for each clinical condition. In the event that the facilities need to increase staffing to achieve newly defined standards by the Department, it is incumbent on the agency to support higher funding to achieve this goal. As you know, Medicaid is the primary payer of nursing home long term care services, covering over 2/3 of residents. Over the last 8 years, Medicaid has provided funding rate increases in only two years. Inadequate Medicaid reimbursement makes it increasingly challenging for facilities to meet existing standards of care. Imposing new, higher standards on nursing facilities must be accompanied by an investment of resources by Medicaid.

4) 105 CMR 150.032 (B) Bedrooms – Nursing Care Units - the Department decreased the number of beds permitted in bedrooms in nursing units from no more than four to no more than two beds. Mass Senior Care requests the Department retain the language contained in the current regulation 105 CMR 151.320 (B) (B) No patient bedroom shall contain more than four beds. Multi-bed rooms shall be designed to permit no more than three beds side by side parallel to the window wall. This requirement is consistent with the Federal Requirements of Participation under §483.90 (d) (1) Bedrooms must- §483.90(d) (1) (i) Accommodate no more than four residents. For facilities that receive



approval of construction or reconstruction plans by State and local authorities or are newly certified after November 28, 2016, bedrooms must accommodate no more than two residents.

In addition to the four concerns detailed above, we have also attached for staff’s consideration additional recommendations for modernizing and streamlining regulations consistent with Governor Baker’s order. As always, MSCA welcomes the opportunity to work with the Department in amending licensure regulations consistent with Governor Baker’s Executive Order 562 to streamline regulatory burdens. However, as noted above, we strongly oppose the Department’s proposed action to delete the regulatory provision that allows facilities built prior to 1968 to meet construction standards in effect at the time of construction. We believe a change of this potential magnitude requires more careful review by the Department and impacted stakeholders.

Sincerely,

Tara GregorioSenior Vice President



Comments from Massachusetts Senior Care Association on Proposed Revisions to 105 CMR 150.000 Standards for Long-Term Care Facilities

General Recommendations related to105 CMR 150.000 Standards for Long-Term Care Facilities:

Reference to Levels of Long-Term Care Facilities or Units (I, II, III & IV) should be deleted from the regulations as they no longer apply. Mass Senior Care recommends using Skilled Nursing Facilities, Skilled Nursing Facilities for Children (SNCFC), Nursing Facilities and Rest Homes as the distinction between the levels of care provided.

The use of the word “Restorative” should be changed to “Rehabilitation” throughout the regulations. The term “Rehabilitation” is used throughout the federal Requirements of Participation.

Regulations do not reflect the care that is provided in long-term care facilities. Long-term care facilities provide care for both short and long-term residents and these regulations reflect care provided to long-term care residents only.

The regulations should be thoroughly reviewed to remove outdated care and practice language. For example, references to autoclaving and sterilization of equipment and supplies, bed pan washers and sanitizers, and training toilets.

The regulations should be reviewed in conjunction with the federal Requirements of Participation and all duplication between state and federal requirements should be deleted.

The regulations should be consistent in the use of the term “primary care provider”. There are references throughout the regulations to “primary care provider” and “physician, physician assistants or nurse practitioner. The definition of primary care provider in 105 CMR 150.001 includes a physician, physician assistants or nurse practitioner.

The definition of a “legally authorized representative” should be included in 105 CMR 150.001 Definitions. In addition, the regulations should be consistent in the use of the term “legally authorized representative” as there are references throughout to “legally authorized representative” and “legal representative”.800 South Street, Suite 280, Waltham, MA 02453 Tel: 617.558.0202 Fax: 617.558.3546



The regulations do not separate out those regulations that are requirements for long-term care facilities and those that are requirements for rest homes leading to significant confusion for rest home providers. Mass Senior Care recommends developing a separate set of regulations for rest homes.

Specific Recommendations related to105 CMR 150.000 Licensure of Long-Term Care Facilities:

150.001: DefinitionsAdvisory Physician shall mean a physician who advises on the conduct of medical and medically related services in a facility.

Mass Senior Care recommends revising this title to Medical Director. Advisory Physician is rarely referenced in the regulations. The term Medical Director or primary care provider is used throughout.

Advisory Physician in a SNCFC shall mean a pediatrician who advises on the conduct of medical and medically related services in a facility.

Mass Senior Care recommends revising this title to Medical Director. (See above).

Individual Service Plan (ISP) shall mean a multidisciplinary plan of care setting forth measurable goals and objectives and prescribing an integrated program of individually designed treatments and therapies, activities and experiences necessary to achieve such goals and objectives. The overall objective of the plan shall be to attain or maintain the optimal physical, social and developmental functioning of which the resident is currently or potentially capable.

Mass Senior Care recommends deleting this definition as all sectio0ns related to an Individual Service Plan (ISP) have been deleted from the proposed revisions.



Organized Medical Staff shall mean an organized group of physicians as defined by the Joint Commission on Accreditation of Hospitals.

Mass Senior Care recommends deleting this definition as nowhere is an “Organized Medical Staff” referenced in the regulations and it is unclear why long-term care facilities are required to meet the standards defined by the Joint Commission on Accreditation of Hospitals.

Restorative Therapy Assistant shall mean a physical therapist assistant.Mass Senior Care recommends deleting this definition as it is the same as a Physical Therapist Assistant which is already defined under 150.001 Definitions.

Utilization Review Committee shall mean a multi-disciplinary committee consisting of at least two physicians, a registered nurse, and, where feasible, other appropriate health professionals with responsibility to review the patient care provided in a facility or group of related facilities. No member shall have a proprietary interest in the facility.

Mass Senior Care recommends deletion of definition and references furtherer in the regulations as this is no longer current practice in long-term care facilities. Long-term care facilities have other mechanisms to review the resident care provided, i.e. Quality Assurance and Performance Improvement Committees (QAPI) which is outlined in the federal Requirements of Participation §483.75 .150.002: Administration (D) (1) At all times, every facility shall provide a sufficient number of trained, experienced and competent personnel to provide appropriate care and supervision for all patients and residents and to ensure that their personal needs are met. Accurate time records shall be kept on all personnel. Personnel time records shall be posted and maintained on a weekly basis.

Mass Senior Care recommends deleting the statement “Personnel time records shall be posted and maintained on a weekly basis.” The federal Requirements of Participation §483.35(g) Nurse Staffing Information requires facilities to post nurse staffing information on a daily basis.



150.002: Administration(5) Completed and signed application forms and employee records shall be maintained. They shall be accurate, current and available on the premises. Such records shall include the following:

(a) Pertinent information regarding identification (including maiden name).

Mass Senior Care recommends removing the language “including maiden name” and revising it to state “including any other names previously used.”

150.002: Administration (D)(6) Employee records shall contain evidence of adequate health supervision.

(a) A pre-employment physical examination, including a chest x-ray or an intradermal skin test for tuberculosis, and periodic physical examinations at least every two years shall be performed and recorded.

Mass Senior Care recommends revising (a) ….and periodic physical examinations according to recommendations from the Centers for Disease Control (CDC).” Requiring employees to have a physical every two years places an undue financial burden on employees who may be required

to pay co-pays for physician visits. In addition, according to a Special Article Guideline for Infection Control in Health Care Personnel 1998, “A physical examination, another component of the medical evaluation, can be used to screen personnel for conditions that might increase the risk of transmitting or acquiring work-related diseases and can serve as a baseline for determining whether future diseases are work related. However, the cost-effectiveness of routine physical examinations, including laboratory testing (such as complete blood cell counts, serologic tests for syphilis, urinalysis, and chest radiographs) and screening for enteric or other pathogens for infection control purposes, has not been demonstrated.” http://www.cdc.gov/hicpac/pdf/infectControl98.pdf

150.002: Administration (D)(6)(b) Food personnel shall have routine health examinations in conformance with state and local sanitary codes. Food handler's permits, where required, shall be current.


http://www.cdc.gov/hicpac/pdf/infectControl98.pdf


Mass Senior Care recommends deleting “Food personnel shall have routine health examinations in conformance with state and local sanitary codes” as this requirement is no different for food handlers than any other employee of the long-term care facility.

150.002: Administration (D) (8) (a) through (i) Requirement that Personnel be Vaccinated Against Influenza Virus.

Mass Senior Care strongly recommends making these regulations a separate and distinct section within the regulations.

150.002: Administration(D) (8) (a) Definitions.

1. For purposes of 105 CMR 250.002(D) (8), personnel means an individual or individuals employed by or affiliated with the facility, whether directly, by contract with another entity, or as an independent contractor, paid or unpaid, including but not limited to employees, members of the medical staff, contract employees or staff, students, and volunteers who either work at or come to the licensed facility site, whether or not such individual(s) provide direct care.

Mass Senior Care recommends revising the definition of “personnel” to mean “an individual or individuals employed by the facility, paid or unpaid, including employees and volunteers who work at the licensed facility site, whether of not such individual(s) provide direct care.”

150.002: Administration(9) A facility may not hire any individual who cannot perform the duties of his or her job or whose employment could pose a threat to the health, safety or welfare of the residents.

Mass Senior Care recommends revising this to “A facility may not knowingly hire any individual who cannot perform the duties of his or her job or whose employment could pose a threat to the health, safety or welfare of the residents.



150.002: Administration(11) The Department shall be notified as specified in the guidelines of the Department of the resignation or dismissal of the administrator, the director of nurses and the name and qualifications of the new employee. In the case of dismissal, notice to the Department shall state the reasons.

Mass Senior Care recommends deleting “In the case of dismissal, notice to the Department shall state the reasons”.

150.002: Administration (E) (4) A statement of all funds, valuables and possessions shall be prepared on admission, transfer or discharge and shall be verified, dated and signed by the resident, or the resident’s legal representative and by a witness. A copy of the list shall be given to the resident, or his or her legal representative.

Mass Senior Care recommends further revision of this regulation to “A statement of all funds, valuables, and possessions shall be prepared on admission, discharge, and transfer (other than transfer for medical or personal leave of absence with return anticipated) and shall be verified, dated, and signed by the resident or the resident's legal representative and by a witness.”

150.003: (B) Admissions, Transfers and Discharges(2) No facility shall admit a patient or resident without written consent of the individual or his or her legal representative except in emergencies.

Mass Senior Care recommends revising “(2) No facility shall admit a patient or resident without written consent of the individual or his or her authorized legal representative except in emergencies.”

150.003: Admissions, Transfers and Discharges(G) Transfer and Discharge.



(6) No resident shall be transferred or discharged without the attending physician, nurse practitioner or physician assistant’s order and notification to the emergency contact.

The reason for transfer or discharge shall be noted on the patient’s or resident’s clinical record.

Mass Senior Care recommends adding language to promote and enhance resident safety, “No resident shall be transferred or discharged without the attending physician, nurse practitioner or physician assistant’s order and notification to the emergency contact “except in circumstances where the assessing clinician determines that the resident's condition is such that any delay associated with awaiting physician, nurse practitioner, or physician assistant’s response would increase risk for an adverse outcome for the resident. In such case, the physician, nurse practitioner, or physician's assistant, and the emergency contact, would be informed that the resident had been emergently transported based on the assessing clinician's judgment of the resident's condition.”

150.004 Resident Care Policies(D) In facilities providing Level I, II or III care, each resident shall have a care plan that shall include the medical, nursing, social service, dietary, rehabilitation, activity and other such plans and services as may be required to provide for the individual’s total care. The care plan shall be coordinated by the nursing staff and shall be reviewed in consultation with all relevant disciplines.

Mass Senior Care recommends deleting this regulation as it is duplicative to 150.007 Nursing Services (D) (2) (a) Nursing Care.

150.005: Physician Services (C) (1) (1) A schedule listing the names and telephone numbers of "emergency" physicians and the specific days each is on call shall be posted at each nurses’ or attendants’ station.

Mass Senior Care recommends deleting this regulation as this is no longer the current practice. When a physician needs to contacted, the physician’s office number is used. If the physician is not on duty, in most cases an answering service directs the call to the covering physician.



150.005: Physician Services (D) (2) If medical orders for the immediate care of a patient or resident are not available at the time of admission, the emergency or advisory physician shall be contacted to provide temporary orders until the attending physician assumes responsibility.

Mass Senior Care recommends revising this regulation by changing “advisory physician” to “Medical Director”.

150.006: Other Professional Services and Diagnostic Services(F) Diagnostic Services. (4) No clinical laboratory tests shall be routinely performed in facilities providing Level I, II, III or IV care except simple urine tests customarily performed by nursing personnel for diabetic patients, and tuberculin skin tests.

Mass Senior Care recommends revising this regulation as it is outdated. All long-term care facilities are required to have a Clinical Laboratory Improvement Act (CLIA) waiver and produce a current waiver during annual health inspections. The waiver requires facilities to list all waived testing provided at the facility. http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/labs/public-health-clinical-lab-clia-info.html

150.007: Nursing Services(B) Minimum Nursing Personnel Requirement. (1) General.

(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.

Mass Senior Care recommends revising the regulations to “Nursing personnel shall not serve on active duty more than 12 hours per day, or more than 48 hours per week, on a scheduled basis.”

150.007: Nursing Services (C) Qualifications and Duties.


http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/labs/public-health-clinical-lab-clia-info.html

http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/labs/public-health-clinical-lab-clia-info.html


(3) Charge Nurse: The charge nurse shall be a registered nurse or a licensed practical nurse. The charge nurse shall be responsible for the performance of total nursing care of the residents in his/her unit during his/her shift with the assistance of ancillary nursing personnel.

Mass Senior Care recommends revising this regulation as the “Charge Nurse” position is no longer a common position to: “A registered nurse or a 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.”

150.007: Nursing Services (C) Qualifications and Duties.

(7) Nursing personnel shall not perform housekeeping, laundry, cooking or other such tasks normally performed by maintenance or other personnel.

Mass Senior Care recommends revising this regulation as it does not support culture change. In neighborhood and small house models, nursing personnel may indeed perform housekeeping, laundry, cooking or other such tasks.

150.007: Nursing Services (D) Nursing Care(2) Nursing Care Plan: 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.

(a) 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. 800 South Street, Suite 280, Waltham, MA 02453 Tel: 617.558.0202 Fax: 617.558.3546



Mass Senior Care recommends deleting this regulation as it is duplicative to §483.21 (b) Comprehensive Care Plans contained in the revised Requirements of Participation. If not deleted than Mass Senior Care recommends revising this regulation by changing a “Nursing Care Plan” to an “Interdisciplinary Care Plan.” The federal Requirements of Participation under §483.21 (b) (2) (ii) Comprehensive Care Plans requires the comprehensive care plan to be prepared by an interdisciplinary team. 150.007: Nursing Services (E) Restorative Nursing Care.

Mass Senior Care recommends deleting this regulation as it is duplicative to §482.24 (a) (1) (2) and (b) Activities of Daily Living in the federal Requirements of Participation. 150.007: Nursing Services (G) Nursing and Supportive Routines and Practices (1 through 5)

Mass Senior Care recommends deleting this regulation as it is duplicative to §482.24 (a) (1) (2) and (b) Activities of Daily Living in the federal Requirements of Participation. 150.007: Nursing Services (H) Nursing Review and Notes. (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 weekly in the clinical record.

Mass Senior Care recommends deleting the following statement from the regulation, “A note summarizing the resident’s condition shall be written weekly in the clinical record” and revising the requirement to “A note summarizing the resident’s condition shall be written monthly in the clinical record unless the resident’s condition warrants more frequent notations.” These residents are stable residents and the need to document weekly is



overly burdensome and takes time away from resident care. In addition, there is other documentation available including the Medication Administration Record (MAR) and Treatment Administration Record (TAR) in the resident’s clinical record.

150.008: Pharmaceutical Services and Medications(B) (1) Verbal or telephone orders shall be given only to a licensed nurse (or responsible person in facilities that provide only Level IV care), shall be immediately recorded in writing and signed by the same nurse or responsible person. All verbal or telephone orders shall be countersigned by an authorized prescriber within 48 hours.

Mass Senior Care recommends revising the time frame for countersigned verbal and telephone orders from 48 hours to a more realistic time frame. Mass Senior Care recommends “When orders are not maintained electronically, all verbal and telephone orders shall be countersigned by an authorized prescriber within 48 hours.

150.008: Pharmaceutical Services and Medications(B) (3)(c) Medications not specifically limited to time or number of doses by the physician, nurse practitioner, or physician assistant shall automatically be stopped in accordance with the

facility's stop order policies or, in the absence of such policies, at the end of 30 days. The physician, physician assistant, or nurse practitioner shall be contacted for renewal of orders or other instructions.

Mass Senior Care recommends revising this regulation to align with 105 CMR 150.008 (B) (2) which outlines the review time frame of resident’s medications between the licensed nurse and the primary care provider.

150.008: Pharmaceutical Services and Medications(B) (4) Medication may be released to patients or residents or their legally authorized guardian on discharge. If the medication is abandoned by the resident or legally authorized guardian, the facility shall dispose of the medication in accordance with Department guidelines.

Mass Senior Care recommends revising the language “legally authorized guardian” to “legally authorized representative”. Nowhere in this regulation



does it indicate that this requirement only applies to residents deemed incompetent and who have a court appointed guardian.

150.009: Dietary Service (E) Quality of Food (1 through 3).

(1) At least three meals that are nutritious and suited to special needs of patients and residents shall be served daily. (2) Meals shall be served at regular times, with not more than a 15-hour span between a substantial evening meal and breakfast. Breakfast shall not be served before 7:00 a.m.; the evening meal shall not be served before 5:00 P.M. When a five-meal plan is in effect, the main evening meal shall not be served before 4:00 P.M. (3) Appropriate between-meals snacks and bedtime nourishment shall be offered to each patient or resident.

Mass Senior Care recommends deleting these regulations as it is duplicative to the federal Requirements of Participation §483.60(f) Frequency of Meals.

150.009: Dietary Service (G) Preparation and Serving of Food. (9) (g) There shall be a tray tag in a holder on each tray.

Mass Senior Care recommends revising this regulation as “a tray tag in a holder” is outdated. Long-term care facilities should have flexibility in determining what they will use as a “resident identifier” on food trays.

150.013: Clinical and Related Records (A) Each facility shall develop, through an interdisciplinary team, and adopt written policies and procedures to ensure complete and accurate clinical records are maintained for each resident and readily available as needed, including to the resident and his or her legally authorized representative and other providers as permitted by law or authorized by the resident or his or her legally authorized representative prior to submitting an application for a license. Each facility shall implement, review and revise, through an interdisciplinary team as needed, but not less than once a year, its written policies and procedures. A facility shall ensure all staff, including temporary staff and volunteers, are trained and determined to be competent as needed for their duties on the policies and procedures developed.



Mass Senior Care requests clarification of the statement “A facility shall ensure all staff, including temporary staff and volunteers, are trained and determined to be competent as needed for their duties on the policies and procedures developed.” Is this in relation to Clinical Record policies and procedures?

150.013: Clinical and Related Records (B)(5) In a SNCFC an Individual Service Plan (ISP) shall be developed for each resident.

Mass Senior Care recommends deleting this regulation as all regulations related to Individual Service Plans has been deleted in the proposed revisions. (See (B) Individual Service Plan (ISP) in a SNCFC).

150.013: Clinical and Related Records (C) All facilities shall maintain a separate, complete, accurate and current clinical record in the facility for each resident from the time of admission to the time of discharge. This record shall contain all medical, nursing and other related data. All entries shall be dated and signed. This record shall be kept in an individual folder at the nurses' or attendants' station. The clinical record shall include:

Mass Senior Care recommends revising this regulation by deleting the following statement, “This record shall be kept in an individual folder at the nurses' or attendants' station”. Mass Senior Care also recommends revising this regulation to reflect the use of Electronic Health Records (EHR).

150.013: Clinical and Related Records (C)(8) A Record of all fires and all incidents involving patients or residents and personnel while on duty.

Mass Senior Care recommends revising this regulation by moving it to the 105 CMR 150.002 Administration as it does not belong in the section. This section refers to the content of the clinical record for individual residents.

150.013: Clinical and Related Records (C) (15) Utilization Review Plan, Minutes, Reports and Special Studies



Mass Senior Care recommends deleting this section as there are no regulations listed in this section.

150.014: Utilization Review (A through H)

Mass Senior Care recommends deleting this regulation in its entirety as this is not current practice in long-term care facilities. Long-term care facilities have other mechanisms to review the resident care provided, i.e. Quality Assurance and Performance Improvement Committees (QAPI) which is outlined in the federal Requirements of Participation §483.75 .150.015: Resident Comfort, Safety, Accommodations and Equipment (C) Safety and Personal Protection. (12) All hospital beds shall have brakes set and all wheelchairs shall be equipped with brakes.

Mass Senior Care recommends revising this regulation by deleting “hospital beds” and adding “beds for patient use”. The use of this type of language continues to portray long-term care facilities as institutions and does not reflect the progress made in making long-term care facilities more home-like.

150.015: Resident Comfort, Safety, Accommodations and Equipment(D) Fire Protection. (3) At least once a year, employees of the home shall be instructed by the head of the local fire department or his representative on their duties in case of fire and this noted in the facility's record.

Mass Senior Care recommends revising this regulation by changing the word “home” to “long-term care facility”.

150.015: Resident Comfort, Safety, Accommodations and Equipment(F) Residents' Accommodations. (3) Every bedroom and every bed location shall be permanently, clearly and distinctively identified by a number or letter in addition to the resident's name.

Mass Senior Care recommends revising this regulation from “in addition to the resident’s name” to “a patient identifier.”

150.015: Resident Comfort, Safety, Accommodations and Equipment



(G) Residents' Equipment and Supplies. (3) All facilities shall use techniques approved by the Department to autoclave, sterilize, disinfect or dispose of equipment and supplies.

Mass Senior Care recommends revising this regulation by deleting autoclave, sterilize. This practice is outdated and is no longer current practice.

150.015: Resident Comfort, Safety, Accommodations and Equipment(G) Residents' Equipment and Supplies. (4) Every patient or resident shall be provided with the following basic equipment and supplies:

(a) A comfortable bed. In facilities that provide Level I or II care, each patient or resident shall have a hospital-type bed which shall not be less than 76 inches long and 36 inches wide and shall be equipped with a headboard and swivel lock casters. In facilities that provide Level III and IV care, beds of household size or hospital beds may be used. Cots and folding beds are prohibited.

Mass Senior Care recommends revising this regulation to “A comfortable bed. Each patient or resident shall have an appropriate bed to accommodate resident’s needs and/or choices.” Or align with the federal Requirements of Participation §483.90 (d)(2) which states, “The facility must provide each resident with – (i) A separate bed of proper size and height for the safety and convenience for that resident.”Mass Senior Care recommends revising this regulation to address those patients and residents who choose not to sleep in a bed but prefer to sleep in a chair.

150.015: Resident Comfort, Safety, Accommodations and Equipment(G) Residents' Equipment and Supplies. (4) (f) A bedside cabinet with a hard-surfaced, washable top, a drawer and a cabinet section is adequate for resident needs. In facilities providing Level I or II care, hospital-type bedside cabinets shall be provided and shall contain a towel and wash cloth, a wash basin, an emesis basin and the equipment.



Mass Senior Care recommends revising this regulation to change from “A bedside cabinet with a hard-surfaced, washable top, a drawer and a cabinet section with a towel rack that is

adequate for resident needs.” to “A bedside cabinet to accommodate the needs of the resident.” Or, align with the federal Requirements of Participation §483.90 (d) (2) (iv) Functional furniture appropriate to the resident’s needs…….”150.016: Environmental Health and Housekeeping(C) Housekeeping and Maintenance

(2) Nursing, dietary, and other personnel providing resident care shall not be assigned housekeeping duties.

Mass Senior Care recommends deleting this regulation as it does not acknowledge the use of a “universal worker” as it relates to culture change and the existence of small houses designs.

150.016: Environmental Health and Housekeeping(D) Laundry and Linen Sanitation. (3) Handling of Clean Linen.

(a) Clean linen shall be sorted, dried, ironed and folded in a specified area separate from soiled linen and in a sanitary manner.

Mass Senior Care recommends updating this practice to the current practice in place in long-term care facilities. Most facilities outsource the laundering of linens. In addition linens are made of material that no longer requires ironing.

150.016: Environmental Health and Housekeeping(E) Housekeeping and Maintenance. (12) Windows and doors shall be properly screened during the insect breeding season, and harborages and entrances for insects shall be eliminated.

Mass Senior Care recommends revising this regulation by deleting “during insect breeding season”. The windows should always have screens.



150.024 Staff Qualifications and Training(B) (2) Notwithstanding 105 CMR 150.024, each facility with one or more DSCUs shall ensure that all relevant staff members that were providing care in a DSCU prior to the promulgation of 105 CMR 150.022 through 150.029 have been trained by May 29, 2014. (3) Notwithstanding 105 CMR 150.024, each facility that does not operate a DSCU shall ensure that all relevant staff members that were providing care in the unit prior to the promulgation of 105 CMR 150.022 through 150.029 have been trained by August 27, 2014.

Mass Senior Care recommends deleting these regulations as they are no longer relevant. These regulations were included as part of the implementation of the training requirements. The regulations in (1), (4) and (5) cover the current training requirements for DSCU direct care staff.

150.026: Therapeutic Activity Directors in Dementia Special Care Units(A) A facility that operates one or more DSCUs shall have a therapeutic activity director for the DSCU(s) who is a qualified therapeutic recreation specialist or an activities professional who: (1) Is certified as a therapeutic recreation specialist or as an activities professional by an accrediting body recognized by the Department; or

Mass Senior Care requests clarification from the Department as to which accrediting bodies are recognized by the Department.

150.029: Physical Environment for Dementia Special Care Units (A through J)

Mass Senior Care requests the Department review the Physical Environment requirements for Dementia Special Care Units as it relates to waivers received from long-term care facilities since the promulgation of the regulations. Mass Senior Care believes the physical environment regulations far exceed what was required in SECTION 1 Chapter 111 of the General Laws. SECTION 1 Chapter 111 of the General Laws Section 71C states “3. Guidelines for dementia special care unit physical design including, but not limited to, anti-wandering methods and promoting a therapeutic environment.”



Mass Senior Care believes the intent of the statute was not to decrease the number of Dementia Special Care Units in the Commonwealth but to ensure that long-term care facilities meet specific standards in caring for residents with dementia. Since the promulgation of these regulations, the number of long-term care facilities that have submitted annual Disclosure Forms to the DPH for Dementia Special Care Units has decreased from over 100 long-term care facilities to approximately 78 long-term care facilities. Providers find the physical environment requirements difficult to meet without additional funding to make the physical space come into compliance with the requirements. General Recommendations related to105 CMR 150.000 Standards for Long-Term Care Sections 150.100 through 150.1000

If changes are made to the regulations, any previously constructed buildings or renovations should not be required to meet new or revised regulations.

Recommend the Department review all waivers submitted over the last three to five years for construction related regulations to identify areas that are the most problematic for long-term care facilities.

The use of terminology “Nursing Care Units” versus “Resident Care Units” is unclear. In the current regulations the units are defined as Nursing Care Units Level I, II, III and Resident Care Units Level IV. In the definition section of the proposed revisions 150.001 Level IV is defined as Resident Care Facilities (Level IV) or Rest Home. Mass Senior Care requests clarification as to which Level of Care Nursing Care Units and Resident Care Units refer to in the proposed revisions.

If Resident Care Units does not refer to Level IV or Rest Home then Mass Senior Care recommends combining the requirements in those sections into one section and differentiates those requirements that are different.

150.300: Maximum Number of Beds -- Nursing Care Units (A) Level I and II nursing units shall consist of not more than 41 beds. (B) Level III nursing units shall consist of not more than 60 beds. (C) A nursing unit shall not encompass beds on more than one floor. (D) An HB/LTCF shall consist of at least 20 but not more than 41 beds.



Mass Senior Care recommends a differentiation in the regulations between new construction and renovations. 150.300 (C) for example, may be problematic for some of the older (smaller) facilities in the Commonwealth who have nursing units on more than one floor to comply with these regulations for a renovation project or to bring current buildings into compliance.

150.310: Required Supporting Elements -- Nursing Care Units A unit shall have, centrally located within its area, a special care room, a nurse's station, a nurse's toilet, a walk-in medicine room, a clean utility room, a soiled utility room, a linen storage closet, a drinking fountain or water dispenser, a janitor's closet and a room for the storage of supplies and equipment.

Mass Senior Care recommends changing “nurse’s station, a nurse’s toilet” to a “staff workstation” and a “staff toilet” to bring the regulations up to date with current language and practice.

150.320 Bedrooms – Nursing Care Units(A) Floor Area.

(1) The floor area of resident bedrooms, excluding closet, vestibule and toilet room areas shall not be less than 125 square feet for single occupancy rooms and 90 square feet per bed for multiple occupancy rooms.

Mass Senior Care recommends deleting this regulation as it is duplicative to the federal Requirements of Participation §483.90(d)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms.150.320 Bedrooms – Nursing Care Units(D) Resident bedrooms shall have a floor level or above the grade level adjacent to the building.(E) All resident bedrooms shall be along exterior walls with window access to the exterior.



(F) All resident bedrooms shall open directly to a main corridor and shall be permanently and clearly identified by number on or beside each entrance door. (G) Each room with more than one bed shall have cubicle curtains or equivalent built-in devices for privacy for each resident.(H) Each resident bedroom shall contain closet interior space of not less than two feet by two feet per resident with at least five feet clear hanging space for the storage of personal belongings. In addition, either a built-in or free-standing multiple-drawer bureau not less than two feet wide with a minimum of one drawer per resident shall be provided. (I) Each resident bedroom shall be sized and dimensioned to accommodate hospital-type beds of not less than 76 inches long and 36 inches wide, a hospital-type bedside cabinet and an easy chair or comfortable straight-back arm chair.

Mass Senior Care recommends deleting this regulation as it is duplicative to the federal Requirements of Participation under:

§483.90(d)(1)(vii) Have a floor at or above grade level; §483.90(d)(1)(vi) Have at least one window to the outside; §483.90 (d)(1)(iii) Have direct access to an exit corridor; §483.90(d)(1)(iv) Be designed or equipped to assure full visual privacy

for each resident; §483.90(d)(1)(v) In facilities initially certified after March 31, 1992,

except in private rooms, each bed must have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains.§483.10(i) (4) Private closet space in each resident room, as specified in §483.90 (d) (2) (iv);

§483.90(d)(2) -The facility must provide each resident with-(i) A separate bed of proper size and height for the safety and convenience of the resident;

(ii) A clean, comfortable mattress; (iii) Bedding, appropriate to the weather and climate; and (iv) Functional furniture appropriate to the resident’s needs, and individual closet space in the resident’s bedroom with clothes racks and shelves accessible to the resident.

150.320: Patient Bedrooms -- Nursing Care Units 800 South Street, Suite 280, Waltham, MA 02453 Tel: 617.558.0202 Fax: 617.558.3546



(J) A nursing unit shall not encompass beds on more than one floor.

Mass Senior Care recommends deleting this regulation as it is duplicative to 150.300: Maximum Number of Beds – Nursing Care Unit (D). Please see previous comments under 150.300 (D).

150.330: Special Care Room -- Nursing Care Unit (A) In each unit, one single bedroom shall be provided for occupancy by a patient requiring isolation or intensive care. This room shall be located in close proximity to the nurse's stationand shall not have direct access with any other patient room. The room shall be included in the quota and may be generally used until such time as it is used for isolation or intensive care. (B) The special care room shall be provided with a separate toilet, lavatory and bathing fixture.

Mass Senior Care recommends deleting this regulation as it is outdated and no longer applies to current practice.

150.340: Nurses Station (A) A nurse's station shall be conveniently located within each nursing unit and shall be located not more than 100 feet from the entrance to any patient room. (B) Each nurse's station shall have a minimum area of 81 square feet with no dimension less than six feet, except that smaller dimensions may be approved for an HB/LTCF. (D) Each nurse's station shall be provided with a desk or counter. The maximum height of counter shall not exceed 42 inches. (E) A nurse's toilet room shall be located convenient to the nurse's station.

Mass Senior Care recommends revising this regulation. We agree there needs to be a designated area for documentation, private conversations and secure medical records. However, dictating through regulation the size, type of furniture and maximum feet located from a patient room is a limiting factor for culture change and innovation. It is not efficient and is more hospital-like than home-like.



150.350: Medicine Room -- Nursing Care Units (A) A separate, locked medicine room at least 30 square feet with no dimension less than five feet shall be provided directly off or immediately adjacent to each nurse's station, except that smaller dimensions may be approved for an HB/LTCF. (B) Each medicine room shall contain a top and base cabinet. The base cabinet shall be equipped with a counter top and a sink with hot and cold running water. (C) A separate locked compartment shall be provided for the storage of narcotics and other dangerous drugs. (D) Each medicine room shall contain a refrigerator for medication which requires refrigeration.

Mass Senior Care recommends revising Medicine Room – Nursing Care Units to the following:

Medication Storage Area(s):Each unit will have a medication storage area which allows for security of medication, privacy, refrigeration and access to hot and cold running water.

150.360: Activity Area -- Nursing Care Units One day room solarium, sitting room or equivalent area with direct outside exposure shall be provided in each unit. Each such room or area shall have a minimum area of nine square feet for each bed authorized in the corresponding nursing unit.

Mass Senior Care recommends revising this regulation and changing it from an “Activity Area” to a “Multi-purpose Room” or “Common Area” as more recent regulations for Dementia Special Care Units recognize that a “common area” can be used for different purposes. In addition, under the Requirements of Participation §483.5 Definitions define Common Areas as “Common areas are areas in the facility where residents may gather together with other residents, visitors, and staff or engage in individual pursuits, apart from their residential rooms. This includes but is not limited to living rooms, dining rooms, activity rooms, outdoor areas, and meeting rooms where residents are located on a regular basis.”

150.370: Patient Bathrooms and Washrooms (C) Toilets and Handwashing Facilities.



(3) One fixed or portable training toilet per nursing unit shall be provided for the training of incontinent patients.

Mass Senior Care recommends deleting this regulation as the use of a “training toilet” is outdated and is no longer current practice.

150.370: Patient Bathrooms and Washrooms (D) Grab Bars Required for Tubs, Showers, and Toilets. All tubs, showers and toilet enclosures shall be equipped with grab bars. Grab bars, accessories and anchorage shall have sufficient strength to sustain a dead weight of 250 pounds for five minutes.

Mass Senior Care recommends the Department reference 521 CMR 5.00 Definitions which addresses Structural Strength of Grab Bars.

In addition, Mass Senior Care recommends an addition to the regulation which addresses that “any towel bar” needs to be equal to the requirements of the grab bar.

150.380: Storage Areas -- Nursing Care Units (A) Linen Closet. A linen storage closet shall be provided in each unit for the storage of daily linen needs. Each such closet shall be at least 20 square feet and shall contain non-combustible shelving to a maximum height of six feet.

Mass Senior Care recommends revising the regulation from requiring a linen storage closet with specific dimensions and size to requiring a “dedicated space for storing daily linen”.

150.390: Utility Rooms -- Nursing Care Units (B) Clean Utility Room. The clean utility room shall be provided with an instrument sterilizer and contain wall hung and base cabinets. The base cabinet shall be equipped with a counter top and sink with hot and cold running water and a gooseneck spout. The minimum area shall be 70 square feet with no dimension less than six feet.

Mass Senior Care recommends revising this regulation and deleting instrument sterilizer as this is outdated and no longer current practice.

150.390: Utility Rooms -- Nursing Care Units 800 South Street, Suite 280, Waltham, MA 02453 Tel: 617.558.0202 Fax: 617.558.3546



(C) Soiled Utility Room. The soiled utility room shall contain a service sink with gooseneck faucet and hot and cold running water; either a clinical service sink or a bedpan washer and sanitizer; and a work counter at least 24 inches wide and 36 inches high by four feet long. Hand washing facilities shall be provided. The minimum area shall be 70 square feet with no dimension less than six feet.

Mass Senior Care recommends revising the regulation and deleting bedpan washer and sanitizer as this is outdated and is no longer current practice.

150.410: Required Supporting Elements -- Resident Care Units All units shall have, centrally located within its area, an attendant's station, a special care room, an attendant's toilet, a medicine closet, a linen storage closet, a drinking fountain, a janitor's closet and a room for the storage of supplies and equipment.

Mass Senior Care recommends changing “attendant’s station”, “attendant’s toilet” to a “staff workstation” and a “staff toilet” to bring the regulations up to date with current language and practice.

150.420 Bedrooms – Resident Care Units(A) The floor area of resident bedrooms, excluding closet, vestibule and toilet room areas shall not be less than 125 square feet for single occupancy rooms and 90 square feet per bed for multiple occupancy rooms.

Mass Senior Care recommends deleting this regulation as it is duplicative to the federal Requirements of Participation §483.90(d)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms;150.420: Patient Bedrooms -- Resident Care Units (C) The ceiling height in areas used by patients shall be a minimum of eight feet.

Mass Senior Care recommends deleting this regulation as it is has been deleted under Nursing Care Units.



150.420: Patient Bedrooms -- Resident Care Units (D) Rooms shall be shaped and sized so that each bed can be placed at least three feet from any lateral wall. Beds shall be spaced at least three feet from any other bed and an unobstructed passageway of at least four feet shall be maintained at the foot of each bed. Variations in bed placement and dimensions shall be permitted only with the approval of the Department.

Mass Senior Care recommends this regulation be revised to allow long-term care facilities to set-up rooms based on the needs of the residents and not to meet specific measurements. This would eliminate the need for waivers for room set-ups.

150.420 Bedrooms – Resident Care Units(E) Resident bedrooms shall have a floor level or above the grade level adjacent to the building.(F) All resident bedrooms shall be along exterior walls with window access to the exterior(G) All resident bedrooms shall open directly to a main corridor and shall be permanently and clearly identified by number on or beside each entrance door.

(H) Each room with more than one bed shall have cubicle curtains or equivalent built-in devices for privacy for each resident.(I) Each resident bedroom shall contain closet interior space of not less than two feet by two feet per resident with at least five feet clear hanging space for the storage of personal belongings. In addition, either a built-in or free-standing multiple-drawer bureau not less than two feet wide with a minimum of one drawer per resident shall be provided. (J) Each resident bedroom shall be sized and dimensioned to accommodate hospital-type beds of not less than 76 inches long and 36 inches wide, a hospital-type bedside cabinet and an easy chair or comfortable straight-back arm chair.

Mass Senior Care recommends deleting this regulation as it is duplicative to the federal Requirements of Participation under:

§483.90(d)(1)(vii) Have a floor at or above grade level; §483.90(d)(1)(vi) Have at least one window to the outside; §483.90 (d)(1)(iii) Have direct access to an exit corridor;



§483.90(d)(1)(iv) Be designed or equipped to assure full visual privacy for each resident; §483.90(d)(1)(v) In facilities initially certified after March 31, 1992, except in private rooms, each bed must have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains. §483.10(i) (4) Private closet space in each resident room, as specified in §483.90 (d) (2) (iv);

§483.90(d)(2) -The facility must provide each resident with-(i) A separate bed of proper size and height for the safety and convenience of the resident; (ii) A clean, comfortable mattress; (iii) Bedding, appropriate to the weather and climate; and (iv) Functional furniture appropriate to the resident’s needs, and individual closet space in the resident’s bedroom with clothes racks and shelves accessible to the resident.

150.430: Special Care Room -- Resident Care Units (A) In each unit, one single bedroom shall be available for occupancy by a patient requiring isolation. This room shall be located in close proximity to the attendant's station and shall not have direct access with any other patient room. The room shall be included in the quota and may be generally used until such time as it is used for isolation. (B) This room shall be provided with a separate toilet, lavatory and bathing fixture.

Mass Senior Care recommends deleting this regulation as it is outdated and no longer applies to current practice.

150.440: Attendant's Station (A) An attendant's station shall be conveniently located within each nursing unit and shall be located not more than 100 feet from the entrance to any patient room. (B) Each attendant's station shall have a minimum area of 81 square feet with no dimension less than six feet. (D) Each attendant's station shall be provided with a desk or counter. The maximum height of counter shall not exceed 42 inches. (E) An attendant's toilet room shall be provided convenient to the attendant's station.



Mass Senior Care recommends revising this regulation. We agree there needs to be a designated area for documentation, private conversations and secure medical records. However, dictating through regulation the size, type of furniture and maximum feet located from a patient room is a limiting factor for culture change and innovation. It is not efficient and is more hospital-like than home-like.

150.450: Medicine Closet -- Resident Care Units (A) A medicine closet is required within Level IV directly off or immediately adjacent to the attendant's station. (B) A separate locked compartment shall be provided for the storage of narcotics and other dangerous drugs. (C) Each medicine closet shall contain a refrigerator for medication which requires refrigeration. (D) Each medicine closet shall contain a top and base cabinet. The base cabinet shall be equipped with a counter top and a sink with hot and cold running water.

Mass Senior Care recommends revising Medicine Closet – Resident Care Units to the following:

Medication Storage Area(s):Each unit will have a medication storage area which allows for security of medication, privacy, refrigeration and access to hot and cold running water.

150.460: Activity Areas -- Resident Care Units One day room, solarium, sitting room or equivalent space with direct outside exposure shall be provided in each unit. Each such room or area shall have a minimum area of nine square feet for each bed authorized in the corresponding nursing unit.

Mass Senior Care recommends revising this regulation and changing it from an “Activity Area” to a “Multi-purpose Room” or “Common Area” as more recent regulations for Dementia Special Care Units recognize that a “common area” can be used for different purposes. In addition, under the



federal Requirements of Participation §483.5 Definitions define Common Areas as “Common areas are areas in the facility where residents may gather together with other residents, visitors, and staff or engage in individual pursuits, apart from their residential rooms. This includes but is not limited to living rooms, dining rooms, activity rooms, outdoor areas, and meeting rooms where residents are located on a regular basis.”150.470: Patient Bathrooms and Washrooms -- Resident Care Units (C) Toilet and Handwashing Facilities

(3) One fixed or portable training toilet per nursing unit shall be provided for the training of incontinent patients. The facilities provided under 105 CMR 151.470(C) (2) may serve this purpose.

Mass Senior Care recommends deleting this regulation as the use of a “training toilet” as this is outdated and is no longer current practice.

150.470: Patient Bathrooms and Washrooms -- Resident Care Units (D) Grab Bar Required for Tubs, Showers, and Toilets. All tub, shower and toilet enclosures shall be equipped with grab bars. Grab bars, accessories and anchorage shall have sufficient strength to sustain a dead weight of 250 pounds for five minutes.

Mass Senior Care recommends the Department reference 521 CMR 5.00 Definitions which discuss Structural Strength of Grab Bars. In addition, Mass Senior Care recommends an addition to the regulations which addresses that “any towel bar” needs to be equal to the requirements of the grab bar.

150.480: Storage Areas -- Resident Care Units (A) Linen Closet. A linen closet shall be provided in each unit for the storage of daily linen needs. Each such closet shall be at least 20 square feet and shall contain non-combustible shelving to a maximum height of six feet.

Mass Senior Care recommends revising the regulation from requiring a linen storage closet with specific dimensions and size to requiring a “dedicated space for storing daily linen”.

150.500: Storage Areas (B) Linen Storage.



(1) A central linen room shall be provided within each facility with a clear area of at least six feet by nine feet. Shelving of at least 18 inches in depths shall be provided. (2) A central soiled linen room shall be provided within each facility with a clear area of at least six feet by nine feet and shall be equipped with handwashing facilities. (3) Laundry chutes, when provided, shall terminate in the soiled linen room. Sufficient space shall be provided to accommodate a laundry hamper.

Mass Senior Care recommends an explanatory statement for this regulation. This statement should include “If a facility does not have a central laundry, then these minimal requirements must be met. If a facility does have a central laundry, then these regulations are ancillary to the central laundry regulations.”

150.510: General and Special Activity Areas (A) General Activity Room.

(1) A general activities room shall be provided for the use of all patients. The area of this room shall be at least eight square feet per bed for 100% of the total beds authorized.

Mass Senior Care recommends revising this regulation and changing it from an “Activity Area” to a “Multi-purpose Room” or “Common Area” as more recent regulations for Dementia Special Care Units recognize that a “Common Area” can be used for different purposes. In addition, under the federal Requirements of Participation §483.5 Definitions define Common Areas as “Common areas are areas in the facility where residents may gather together with other residents, visitors, and staff or engage in individual pursuits, apart from their residential rooms. This includes but is not limited to living rooms, dining rooms, activity rooms, outdoor areas, and meeting rooms where residents are located on a regular basis.”150.510: General and Special Activity Areas (B) Beauty Parlor and Barber Shop. A room may be provided for the beauty parlor and barber shop only with written approval of the Department. If provided, such a room shall have a minimum floor area of not lessthan120 square feet. Each such room shall contain cabinet and counter space and a shampoo basin sink with a mixing faucet and attached spray.



Mass Senior Care recommends deleting the statement “only with written approval of the Department.”150.510: General and Special Activity Areas (C) Snack Shop. Facilities may provide a snack shop commensurate with the size of the facility only with written approval of the Department.

Mass Senior Care recommends deleting the statement “only with written approval of the Department.”150.510: General and Special Activity Areas (D) Gift Shop. Facilities may provide a gift shop commensurate with the size of the facility only with written approval of the Department.

Mass Senior Care recommends deleting the statement “only with written approval of the Department.”

150.520: Examination and Treatment Room (A) A treatment room shall be available in each facility providing Levels I, II or III care. This room may also be used by physicians as an examination room. Use for any other purpose shall be approved in writing by the Department. (B) The treatment room shall have a minimum area of 125 square feet with no dimension less than ten feet. (C) The treatment room shall include handwashing facilities with hot and cold running water and be sized and dimensioned to accommodate a treatment table, instrument table, instrument sterilizer and locked storage cabinet.

Mass Senior Care recommends deleting this regulation and at a minimum delete “instrument sterilizer” as this is outdated and no longer current practice.

150.530: Office Space (A) Administrative Offices.

(a) Appropriate space and equipment shall be provided for administrative activities and for the storage of medical records. (b) Separate offices of not less than 80 square feet each shall be provided for the use of the Administrator and the Director of Nurses.



An office for the Director of Nurses is not required within a free-standing Level IV facility.

Mass Senior Care recommends deleting this regulation.

150.530: Office Space (B) Consultant Offices.

(1) Consideration shall be given to provide separate rooms in Level I & II facilities for the use of full-time consultants, such as a medical director, dietitian, social worker and others. (2) Consultant's offices, if provided, shall be not less than 100 square

feet each.

(3) A room shall be provided for a dietary consultant; it shall be located convenient to the kitchen area.


150.540: Restorative Service Units (1) The following restorative service areas shall be permitted only in facilities providing Levels I or II Care. (2) Restorative service areas shall be sized and arranged to the extent consistent with the program of treatment within the particular facility; however, in each case, the following are the minimums that must be provided for the types of therapy programmed. (3) Physical environment for restorative service programs also providing services to outpatients shall include:

(a) direct entrance from the outside or direct access from the main lobby that is accessible to persons with disabilities; (b) parking convenient to the entrance to the restorative program

area; (c) resident and staff toilet rooms conveniently located near the restorative service program areas; these toilet rooms must be separate from those serving nursing units; (d) adequate waiting and reception areas; (e) record storage; and(f) office space.

(4) The following equipment shall be provided in restorative areas: (a) treatment table, footstool and chairs; (b) adequate linen supply; 800 South Street, Suite 280, Waltham, MA 02453 Tel: 617.558.0202 Fax: 617.558.3546



(c) sanitary waste containers; (d) hamper for soiled linen; (e) curtains or cubicles to assure privacy; and, (f) desk or table and chair for clerical use.

(B) Physical Therapy Room. (1) Physical therapy rooms shall have a minimum floor area of 200 square feet with a minimum dimension of not less than ten feet. (2) Physical therapy rooms shall be provided with a closet for the storage of supplies and equipment and a handwashing sink with hot and cold running water. (3) Additional space may be required to accommodate the outpatient restorative services. The physical therapy room shall include provisions for privacy. Dressing facilities and lockers shall be provided for outpatient use.

Mass Senior Care recommends that these regulations be revised and separate regulations be written to address in-patient restorative services and out-patient restorative services. In addition, the name of these regulations should be changed to Rehabilitation Services which is a more accurate definition of what these services are.

Mass Senior Care requests clarification as to why the following was deleted from the requirements as this addresses Occupational Therapy. Mass Senior Care previously recommended that these regulations be revised to allow for physical and occupational therapy to be provided in the same area and share storage space.

C) Workshop Room. (1) If a workshop room for occupational therapy and patient activities is provided, it shall have a minimum floor area of 300 square feet with a minimum dimension of not less than ten feet. (2) Within such room there shall be provided a closet for the storage of supplies and equipment and a service sink with hot and cold running water and a plaster trap.

150.550: Staff and Public Toilets and Washrooms



(B) Visitor's toilets shall be conveniently located and accessible to the normal visitors’ entrance and lobby. A separate toilet room shall be provided for each sex with a water closet and lavatory.


150.550: Staff and Public Toilets and Washrooms (C) Staff toilets shall be located in close proximity to the kitchens and employees' locker rooms. Kitchen toilets shall not open directly into food preparation areas.

Mass Senior Care recommends deleting the statement “Staff toilets shall be located in close proximity to the kitchens and employees' locker rooms.” Mass Senior Care recommends adding: Staff and visitor toilets can be combined on the units or in common areas.

150.560: Central Kitchen (A) The kitchen floor area shall be not less than five square feet per bed for 100% of the total authorized beds, exclusive of food storage areas, dishwashing area, janitor's closet, refrigeration space, delivery and receiving areas, and administration space. (B) A handwashing sink with hot and cold running water shall be provided together with disposable towels and towel dispenser and a soap dispenser.

(C) A double-compartment sink with hot and cold running water and an attached 30 inch drain board and backsplash for the preparation and cleaning of fresh vegetables shall be provided. (D) A triple-compartment sink with hot and cold running water and an attached 30 inch drain board on each side, with backsplash, shall be provided for the washing of pots and pans. (E) The kitchen floor shall have a floor drain equipped with a grease trap and a backup flow check valve. (F) A separate dishwashing area containing a commercial dishwasher with attached dirty and clean work counters shall be provided. Access of food carts containing soiled dishware shall not be through the food preparation area. The dishwasher shall be equipped with a grease trap. A separate entrance to the dishwashing area shall be provided. (G) Dumbwaiters, when provided, shall open into nourishment kitchens or dining rooms and shall be used exclusively for food transportation.



(H) The rear of all equipment not flush and sealed to the wall shall be at least eight inches from the wall. Not less than eight inches of clear space shall be provided between separately installed units. If units are to be joined, a filler strip must be used. The minimum aisle width shallbe42 inches; except when mobile equipment is used, where minimum aisle width shall be 60 inches. (I) The kitchen shall be located to avoid through traffic. Traffic through the food service department shall be limited to authorized personnel. Food receiving shall be in a separate area with space for scales and counters. (J) A separate and defined area shall be provided for food cart washing and can washing. (K) An office for the use of the dietitian and food service manager shall be provided as set for under 105 CMR 151.530(B) (3). (L) Enclosed cabinets shall be provided for the storage of dishes, silverware and other eating utensils. (M) A separate janitor's closet shall be provided specifically for the kitchen use. (N) In the case of HB/LTCFs, if the hospital and the long-term care facility share dietary services, a separate central kitchen is not required.

Mass Senior Care recommends changing this regulation to:

Food Preparation/Dishwasher Area(s):Each facility must designate a kitchen that meets the following requirements and does not cause duplication on the nursing units:

(A) A handwashing sink with hot and cold running water shall be provided together with disposable towels and towel dispenser and a soap dispenser. (B) A double-compartment sink with hot and cold running water and an attached 30 inch drain board and backsplash for the preparation and cleaning of fresh vegetables shall be provided.

(C) A triple-compartment sink with hot and cold running water and an attached 30 inch drain board on each side, with backsplash, shall be provided for the washing of pots and pans. (D) The kitchen floor shall have a floor drain equipped with a grease trap and a backup flow check valve. (E) A separate dishwashing area containing a commercial dishwasher with attached dirty and clean work counters shall be provided. Access for food carts containing soiled dishware shall not be through the food preparation



area. The dishwasher shall be equipped with a grease trap. A separate entrance to the dishwashing area shall be provided. (F) Dumbwaiters, when provided, shall open into nourishment kitchens or dining rooms and shall be used exclusively for food transportation. (G) The rear of all equipment not flush and sealed to the wall shall be at least eight inches from the wall. Not less than eight inches of clear space shall be provided between separately installed units. If units are to be joined, a filler strip must be used. The minimum aisle width shall be42 inches; except when mobile equipment is used, where minimum aisle width shall be 60 inches. (H) Traffic through the food service department shall be limited to authorized personnel. Food receiving shall be in a separate area with space for scales and counters. (I) A separate and defined area shall be provided for food cart washing and can washing. (J) A separate janitor's closet shall be provided specifically for the kitchen use. (K) In the case of HB/LTCFs, if the hospital and the long-term care facility share dietary services, a separate central kitchen is not required.

In addition, Mass Senior Care recommends that the size of the Food Preparation/Dishwasher Area(s) be scaled by the number of beds in the facility and the number of meals served.

150.590: Central Laundry (A) When total laundry service is to be performed on the premises, sufficient space and equipment for such service shall be provided. (B) When total laundry service is not to be performed on the premises, a laundry room of not less than 70 square feet shall be provided. Each such room shall contain a washer, a dryer, a double-compartment tub and shelving for the storage of soaps, bleaches and other laundry supplies. (C) In the case of HB/LTCFs, if the hospital and the long-term care facility share laundry services, a separate central laundry is not required.

Mass Senior Care recommends deleting this regulation and combining it with 150.500: Storage Areas (B) Linen Storage.

150.600: Corridors (A) Corridors



(1) Corridors in areas used primarily by patients shall not be less than eight feet wide. All other corridors shall be not less than five feet wide.

Mass Senior Care recommends deleting the “not less than five feet wide” and adding “in accordance with local building codes and 2012 NFPA 101 Life Safety Code.

151.630: Doors and Doorways (A) All doors used by patients shall be swing-type at least 41 inches wide except toilet room doors which shall be at least 32 inches wide and, if in-swinging, have pivots and manually operated emergency release.

Mass Senior Care recommends this regulation be revised to state: “All doors used by patients for bed transport shall be swing-type at least 41 inches wide except toilet room doors which shall be at least a 32 inch wide clear opening and have pivots and manually operated emergency release. Patient toilet doors shall be allowed to be sliding in operation.

150.660: Room Surface Finishes(B) Interior wall surfaces of all areas assigned for patient housing, care, and recreation, exclusive of shower enclosures, kitchen, food preparation areas, dishwashing areas, bathrooms, toilets, utility rooms, and nourishment kitchens, shall be finished with a smooth, non-absorbent, washable surface. Walls of kitchens, food preparation areas, bathrooms, toilets utility rooms, nourishment kitchen and dishwashing areas shall be finished to a height of at least 72 inches from the finished floor with an impervious material.

Mass Senior Care recommends revising this regulation from “…a height of at least 72 inches from the finished floor with an impervious material.” to “….an appropriate height from the finished floor with an impervious material.”

150.660: Room Surface Finishes(E) All trim shall be simple in profile to prevent pockets where dust might accumulate and to afford surfaces which are easily kept clean.


150.820: Reading Lamps A reading lamp shall be provided for each patient. If wall-mounted bed lamps are provided they shall be not less than 64 inches from the finished floor and



be mounted directly over each bed. A reading light shall be provided for each resident. If wall-mounted reading lights are provided they shall be not less than 64 inches from the finished floor and be mounted directly over each

bed. If a reading lamp located on the bedside cabinet is provided, it shall be bolted to the bedside cabinet. The light switch for the reading light shall be located for easy operation by a resident lying in bed.

Mass Senior Care recommends deleting this regulation or at a minimum delete “it shall be bolted to the bedside cabinet.”

150.850: Call Systems (A) A nurse's and attendant's calling station shall be installed at each resident bedside, in each resident's toilet, bath and shower room, and in the following additional areas: resident dining room, treatment room, workshop and physical therapy rooms, special care room, activity rooms, television rooms, and sitting rooms, consultation rooms and beauty parlor and barber shop.

Mass Senior Care recommends removing the word “workshop” as it is no longer in the requirements.


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