902 KAR 20:280. Prescribed pediatric extended care centers.


      RELATES TO: KRS 198B.260, 216.875, 216.880, 216.885, 311.571, 314.041, 319.010(3), 327.010(2), 334A.020, 335.090, 620.030

      STATUTORY AUTHORITY: KRS 216B.042(1), 216.890

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 216B.042(1) requires the Cabinet for Health and Family Services to promulgate administrative regulations necessary for the proper administration of the licensure function, which includes establishing licensure standards and procedures to ensure safe, adequate, and efficient health facilities and health services. KRS 216.890 requires the Cabinet for Health and Family Services to promulgate administrative regulations to implement the provisions of KRS 216.875 to 216.890, which include standards related to the operation of prescribed pediatric extended care (PPEC) centers. This administrative regulation establishes the requirements for prescribed pediatric extended care centers.


      Section 1. Definitions. (1) "Child life specialist" means an individual who has:

      (a) A minimum bachelor's degree with an educational emphasis on:

      1. Human growth and development;

      2. Education, which may include early childhood education;

      3. Psychology; or

      4. A related field of study; and

      (b) Current experience in planning and implementing developmental stimulation programs for children.

      (2) "Developmentalist" means a master's prepared individual with current experience in:

      (a) Transdisciplinary evaluation; and

      (b) Treatment planning for children who are at risk for or experiencing developmental delay.

      (3) "Medical director" means a board certified pediatrician who:

      (a) Serves as the liaison between the PPEC center and the medical community;

      (b) Reviews the quality and appropriateness of PPEC center services; and

      (c) Is available for consultation to PPEC center staff.

      (4) "Medically dependent or technologically dependent child" is defined by KRS 216.875(6).

      (5) "Nursing director" means a registered nurse who:

      (a) Is licensed pursuant to KRS 314.041;

      (b) Is responsible for providing continuous supervision of PPEC center services; and

      (c) Manages the daily operations of the facility.

      (6) "Occupational therapist" is defined by KRS 319A.010(3).

      (7) "Physical therapist" is defined by KRS 327.010(2).

      (8) "Prescribed pediatric extended care center" or "PPEC center" is defined by KRS 216.875(1).

      (9) "Prescribing physician" means a physician who:

      (a) Is licensed in Kentucky to practice medicine or osteopathy in accordance with KRS 311.571; and

      (b) Signs the order admitting a child to the PPEC center.

      (10) "Primary care provider" means a health care practitioner who:

      (a) Is licensed to practice in Kentucky;

      (b) Maintains overall responsibility for a child's medical management; and

      (c) Is available for consultation and collaboration with PPEC center staff.

      (11) "Protocol of care" means a comprehensive plan for implementation of the following services:

      (a) Medical;

      (b) Nursing;

      (c) Psychosocial;

      (d) Developmental; and

      (e) Educational therapies.

      (12) "Social worker" means an individual who is:

      (a) Licensed pursuant to KRS 335.090; and

      (b) A graduate of a school of social work accredited by the Council on Social Worker Education.

      (13) "Speech-language pathologist" is defined by KRS 334A.020(3).


      Section 2. Scope of Operation and Services. A PPEC center shall be a nonresidential health care service that provides:

      (1) A link in the continuum of care for medically dependent or technologically dependent children; and

      (2) The following triad of services for children and their parents:

      (a) Day health care;

      (b) Developmental interventions; and

      (c) Parent training programs.


      Section 3. Applicability. Each PPEC center shall:

      (1) Be equipped and staffed to accommodate no fewer than three (3) medically dependent or technologically dependent children;

      (2) Be in compliance with this administrative regulation and federal, state, and local laws and regulations pertaining to the operation of PPEC centers;

      (3) Have a minimum full-time equivalent staff of two (2) registered nurses and one (1) nursing assistant; and

      (4) Meet the following ratios:

3-12 children

2 RNs plus 2 others

13-18 children

2 RNs, 1 LPN, plus 3 others

19-24 children

2 RNs, 2 LPNs, plus 4 others

If the PPEC center has a census of more than twenty-four (24) children, the number of registered nurses and other staff shall increase by one (1) each for up to six (6) additional children enrolled.


      Section 4. Criteria for Admission. Each child admitted to a PPEC center shall meet at least the following criteria:

      (1) An infant or child considered for admission to the PPEC center shall be medically dependent or technologically dependent with a complex condition requiring continual care, which may include:

      (a) Supplemental oxygen;

      (b) Ventilator dependence;

      (c) Cystic fibrosis;

      (d) Apnea;

      (e) Spinal cord injury; or

      (f) Malignancy;

      (2) An infant or child shall not, prior to admission, present significant risk of infection to other children or personnel. The medical and nursing director may review, on a case-by-case basis, any child with a suspected infectious disease to determine appropriateness of admission;

      (3) The child shall be medically stabilized, require skilled nursing care or other interventions, and be appropriate for outpatient care; and

      (4) The primary care provider, in consultation with the parent or legal guardian, shall be responsible for recommending placement in a PPEC center upon consideration of medical, emotional, psychosocial, and environmental factors.


      Section 5. Preadmission Conference. (1) If a child meets the admission criteria established in Section 4 of this administrative regulation, the primary care provider or designee shall contact the medical or nursing director of the PPEC center to schedule a preadmission conference.

      (2) If a child is hospitalized at the time of referral, preadmission planning shall include:

      (a) The parent or legal guardian; and

      (b) Relevant hospital medical, nursing, social services, and developmental staff to assure that the discharge plans shall be implemented upon admission to the PPEC center.

      (3) If a child is not hospitalized at the time of referral, preadmission planning shall be conducted with the:

      (a) Primary care provider;

      (b) Parent or legal guardian;

      (c) PPEC center representatives; and

      (d) Representatives of other relevant agencies as determined by the primary care provider and nursing director.

      (4) A preadmission planning conference shall:

      (a) Be scheduled at least seventy-two (72) hours prior to placement; and

      (b) Allow sufficient time to assure that the therapeutic plan can be implemented upon placement in the PPEC center.

      (5) The protocol of care shall:

      (a) Be developed under the direction of the PPEC center's nursing director during the preadmission planning conference;

      (b) Specify the treatment plan needed to accommodate the medical, nursing, psychosocial, and educational needs of the child and family;

      (c) Identify specific goals for care, including plans for achieving those goals;

      (d) Include a schedule for evaluation of progress;

      (e) Include procedures to follow in an emergency situation;

      (f) Include criteria for discharge from the PPEC center; and

      (g) Be signed by the:

      1. Physician;

      2. Authorized representative of the PPEC center; and

      3. Parent or legal guardian.

      (6) A consent form outlining the purpose of the PPEC center, family responsibilities, authorized treatment, appropriate liability release, and emergency disposition plans shall be:

      (a) Signed by the parent or legal guardian; and

      (b) Witnessed prior to admission to the PPEC center.

      (7) A copy of the consent form shall be:

      (a) Provided to the parent or legal guardian; and

      (b) Maintained in the child's medical record.


      Section 6. Admission Procedure. (1) In consultation with the parent or legal guardian, a child may be referred to the PPEC center medical or nursing director for determination of placement.

      (2)(a) Each child admitted to a PPEC center shall be admitted in accordance with a physician's written order placed in the child's medical record.

      (b) A copy of the order shall be provided to the child's parent or legal guardian.


      Section 7. Provision of Services. (1) Medical staff services.

      (a) Each child admitted to a PPEC center shall be admitted upon prescription by the:

      1. Child's prescribing physician; or

      2. Medical director.

      (b) The child's primary care provider shall maintain responsibility for the overall medical therapeutic plan.

      (c) The medical director shall participate in review of the protocol of care. Prescribed therapies shall be adjusted in consultation with the primary care provider to accommodate the child's condition.

      (d) The PPEC center shall coordinate the prescribed therapies for the child.

      (2) Nursing staff services.

      (a) A PPEC center nursing staff member shall participate in preadmission planning.

      (b) Nursing personnel, under the direction of the nursing director, shall be responsible for implementing the nursing care.

      (c) Nursing personnel shall be responsible for monitoring and documenting the effects of prescribed therapies.

      (d) Nursing personnel shall inform the primary care provider and medical director of the results of therapeutic interventions.

      (e) Nursing personnel shall participate in interdisciplinary staff meetings regarding the child's progress.

      (f) Nursing personnel shall assure that the PPEC center provides an environment conducive to the:

      1. Stabilization of the child's medical condition; and

      2. Promotion of the child's development.

      (g) Nursing personnel shall be responsible for maintaining the child's record in accordance with facility policies and procedures.

      (h) Nursing personnel shall instruct the parent or legal guardian in how to provide the necessary therapies in the home.

      (3) Developmental services.

      (a)1. Each child shall have a functional assessment and an individualized program plan to accommodate the child's developmental needs.

      2. The following functional areas shall be included as appropriate:

      a. Self-care;

      b. Communication skills;

      c. Social skills;

      d. Motor skills;

      e. Cognitive areas;

      f. Play; and

      g. Growth and development appropriate for age.

      (b) The child's program plan shall:

      1. Include specific programs and action steps to facilitate developmental progress;

      2. Be reviewed at least quarterly;

      3. Include measurable goals in need areas, or goals to enhance and normalize independent functioning in daily activities;

      4. Describe the child's strengths and present performance level with respect to each goal;

      5. Document skill areas in priority order; and

      6. Include anticipatory planning for specific areas identified as at-risk for future problems.

      (c) The child life specialist shall participate in interdisciplinary staff meetings.

      (d) Each PPEC center shall:

      1. Include the parent or legal guardian in care-related conferences; and

      2. Train the parent or legal guardian on how to:

      a. Perform necessary therapies; and

      b. Meet the developmental and psychosocial needs of their child at home.

      (e) PPEC center staff shall:

      1. Make referrals to appropriate resources;

      2. Refer to community, social, educational, and financial services; and

      3. Refer or provide counseling to enhance coping skills, interpersonal relationships, and family functioning.

      (4) Nutritional services.

      (a) Therapeutic diets shall be maintained in the child's file.

      (b) A registered dietician shall be available to provide assistance with:

      1. Nutritional needs;

      2. Special diets of individual children; and

      3. The development of policies and procedures for the handling, serving, and storage of food.

      (c) All food and formula, except for specialized formula, shall be provided by PPEC center staff under the supervision of the nursing director.

      (d) Prepared foods shall be:

      1. Kept under refrigeration with identifying dates; and

      2. Labeled with the child's name.


      Section 8. Quality Assurance. (1) Each PPEC center shall have a quality assurance program to evaluate the provision of patient care.

      (2) The quality assurance program shall:

      (a) Be ongoing; and

      (b) Have a written plan of implementation.

      (3)(a) All organized services related to patient care, including services furnished by a contractor, shall be evaluated at least every six (6) months.

      (b) Nosocomial infections and medication therapy shall be evaluated.

      (c) Evidence of involvement by the parent or legal guardian shall be evaluated at least every six (6) months.


      Section 9. Administration. (1) Each PPEC center shall develop, implement, and maintain written policies and procedures governing all child care and related medical or other services provided.

      (2) Personnel policies and procedures shall specify qualifications and required ratios for staff employed by the PPEC center.

      (3) Each PPEC center shall:

      (a) Maintain a personnel record for each employee;

      (b) Develop and maintain a current job description for each employee;

      (c) Provide each employee with access to written personnel policies governing conditions of employment; and

      (d) Provide an orientation and development program for all PPEC center employees.

      (4) Policies and procedures pertaining to PPEC center services shall:

      (a) Be available to the public; and

      (b) Include a procedure manual with specifications for each therapeutic intervention. The manual shall be:

      1. Available for use by all staff involved in the care of the children; and

      2. Reviewed every six (6) months to assure that procedures conform to prevailing and acceptable treatment modalities.

      (5) Each PPEC center shall maintain an admission and discharge register that:

      (a) Lists children admitted by name with identifying information about each and the source from which the child was admitted;

      (b) Identifies the reason for disposition; and

      (c) Identifies the place to which the child is to be discharged.

      (6) Each PPEC center shall maintain;

      (a) A daily census record;

      (b) An accident and incident record; and

      (c) A complete medical and nursing history for each child.

      (7) Each PPEC center shall:

      (a) Conduct a review of each child's protocol of care quarterly and revise upon a change in the child's condition; and

      (b) Include any recommendations or revisions to the protocol based on consultation with other professionals involved in the child's care.

      (8) Any changes in the orders shall be documented and signed by the primary care provider.

      (9) Prior to a discharge, a conference involving PPEC center staff, the primary care provider, the parent or legal guardian, and staff of other agencies involved in the patient's care shall be held to discuss postdischarge care and follow-up.

      (10) A discharge order written by the primary care provider shall be documented and entered in the child's record.

      (11) A discharge summary, including the reason for discharge, shall also be included in the child's record.

      (12) Except in an emergency situation, other agencies involved in the care of the child shall be notified prior to the discharge date.

      (13) Each PPEC center shall have linkage agreements through written agreements with providers of other levels of care that may be medically needed to supplement the services available at the center.

      (14) Each PPEC center shall have written policies to ensure the reporting of cases of abuse, neglect, or exploitation of children to the Cabinet for Health and Family Services pursuant to KRS 620.030.


      Section 10. Personnel. (1) A board certified pediatrician shall serve as the medical director for the PPEC center. Responsibilities of the medical director shall include:

      (a) Participation in preadmission planning to establish a protocol of care as described in Section 5(5) of this administrative regulation;

      (b) Review of services to assure acceptable levels of quality of care;

      (c) Maintenance of a liaison role with the medical community;

      (d) Advisement on the development of new programs and modifications of existing programs; and

      (e) Assurance that medical consultation shall be available if the medical director is absent.

      (2) A nursing director shall be employed to provide continuous supervision of PPEC center services. The nursing director shall be responsible for:

      (a) Daily operations of the PPEC center;

      (b) All services rendered at the center;

      (c) Personnel management;

      (d) Organization and implementation of in-service education programs for staff;

      (e) Assistance to the medical director in determining patient eligibility for admission to PPEC center;

      (f) Assurance of adequate nursing representation at preadmission conference;

      (g) Supervision of all patient records; and

      (h) Documentation of the PPEC center's activities to assure compliance with rules and administrative regulations.

      (3) Nursing services shall be provided within the nurse's scope of practice pursuant to KRS Chapter 314 and any administrative regulations promulgated thereunder.

      (4) The nursing director shall have at least two (2) years nursing experience of which at least six (6) months shall have been spent in a pediatric intensive care, neonatal intensive care setting, PPEC center, or similar care setting in which the nurse provided care to medically fragile children.

      (5) Staffing.

      (a) The PPEC center shall employ nursing and ancillary staff that are necessary to:

      1. Provide the services essential to the center's operation; and

      2. Meet the level of care needs of the children enrolled.

      (b) There shall be an individual personnel record for each person employed by the center, which includes the following:

      1. Resume with employee's training and experience;

      2. Evidence of current licensure or registration;

      3. Reports of all accidents occurring on duty; and

      4. Current certification in basic life support.

      (c) The following categories of personnel shall be available to the PPEC center on an in-house or consultant basis:

      1. Developmentalist;

      2. Child life specialist;

      3. Occupational therapist;

      4. Physical therapist;

      5. Speech-language pathologist; and

      6. Social worker.


      Section 11. In-service Training for Staff, Parents, and Legal Guardians. (1) Monthly staff development programs appropriate to the category of personnel shall be conducted to maintain quality patient care.

      (2) All staff development programs shall be documented.

      (3) All personnel shall maintain current certification in basic life support.

      (4) Each new employee shall participate in orientation to acquaint the employee with the philosophy, organization, program, practices, and goals of the PPEC center.

      (5) A comprehensive orientation to acquaint the parent or legal guardian with the philosophy and services shall be provided at the time of the child's placement in the PPEC center.

      (6) Staff development programs shall be provided to:

      (a) Facilitate the ability of the staff to function as a member of an interdisciplinary team that includes health professionals and the parent or legal guardian;

      (b) Improve communication skills to facilitate a collaborative relationship between the parent or legal guardian and professionals;

      (c) Increase understanding of the effects that childhood illness has on the child's development and the parent or guardian;

      (d) Increase understanding of and how to cope with the effects of childhood illnesses;

      (e) Cover a variety of topics including:

      1. Issues of death and dying;

      2. Awareness of services available at the following:

      a. Hospital;

      b. School; and

      c. Community, state, and professional organizations; and

      3. Fostering of advocacy skills; and

      (f) Develop case management skills to assist the family in:

      1. Setting priorities; and

      2. Planning and implementing the child's care at home.

      (7) Each PPEC center shall provide training in the implementation of new technology.


      Section 12. Physical Environment. (1) The building shall:

      (a) Be suitable for the purpose intended; and

      (b) Maintain a minimum of sixty (60) square feet of space per child, exclusive of the following:

      1. Kitchen;

      2. Bathroom;

      3. Storage areas;

      4. Stairways;

      5. Unfinished basements; and

      6. Attics.

      (2) The PPEC center shall conform to or exceed the minimum standards for day care centers as specified in the most current version of the Kentucky Building Code, incorporated by reference in 815 KAR 7:120.

      (3) Plumbing approval. Prior to licensure, all specifications shall be approved by the Kentucky Division of Plumbing, Department of Housing, Buildings and Construction.

      (4) Transportation. Emergency transportation to a hospital shall be achieved within twenty (20) minutes normal driving time or less, with a PPEC center staff member accompanying the child unless the child’s parent or legal guardian is immediately available to accompany the child to the hospital.

      (5) Unless medically contraindicated, the PPEC center shall maintain a temperature range of seventy-two (72) degrees to eighty (80) degrees Fahrenheit.

      (6) Accessibility. Each PPEC center shall meet requirements for making buildings and facilities accessible to and usable by persons with a disability pursuant to KRS 198B.260 and 815 KAR Chapter 7.

      (7) Fire safety. Each PPEC center shall:

      (a) Be approved by the State Fire Marshal's office prior to licensure; and

      (b) Retain a copy of the current fire inspection report on file.

      (8) Housekeeping and maintenance services.

      (a) Housekeeping. Each PPEC center shall:

      1. Maintain a clean and safe facility free of unpleasant odors; and

      2. Ensure that odors are eliminated at their source by prompt and thorough cleaning of commodes, urinals, bedpans, and other sources.

      (b) Maintenance. The premises shall be well kept and in good repair as follows:

      1. The center shall insure that the grounds are well kept and the exterior of the building, including the sidewalks, steps, porches, ramps, and fences are in good repair;

      2. The interior of the building including walls, ceilings, floors, windows, window coverings, doors, plumbing, and electrical fixtures shall be in good repair;

      3. Garbage and trash shall be stored in areas separate from those used for the preparation and storage of food and shall be removed from the premises regularly. Containers shall be cleaned regularly;

      4. A pest control program shall be in operation in each center. Pest control services shall be provided by maintenance personnel of the facility or by contract with a pest control company. The compounds shall be stored under lock;

      5.a. Sharp wastes, including needles, scalpels, razors, or other sharp instruments used for patient care procedures shall be segregated from other wastes and aggregated in puncture resistant containers immediately after use.

      b. Needles and syringes shall not be recapped, cut, dismantled, or destroyed after use, but shall be placed intact directly into a puncture resistant container.

      c. The containers of sharp wastes shall either be incinerated, on site or off site, or disposed of in a sanitary landfill approved pursuant to 401 KAR 47:005 through 401 KAR 47:180; and

      6. The center shall establish a written policy for the handling and disposal of all infectious, pathological, and contaminated waste if the center generates them. Any incinerator used for the disposal of waste shall be in compliance with 401 KAR 59:020 or 401 KAR 61:010.

      a.(i) Infectious waste shall be placed in double impervious plastic bags and each bag shall be two (2) mils in thickness.

      (ii) A bag, when full, shall not exceed twenty-five (25) pounds.

      (iii) All bags shall be securely closed and a tag, which reads "INFECTIOUS WASTE" and identifies the center from which the waste is being removed, shall be attached to the bag in a conspicuous manner.

      b. The following wastes shall be disposed of by incineration, be autoclaved before disposal, or be carefully poured down a drain connected to a sanitary sewer:

      (i) Blood;

      (ii) Blood specimens;

      (iii) Used blood tubes; or

      (iv) Blood products.


      Section 13. Emergency Procedures. (1) There shall be a working telephone, which is neither locked nor a pay station, in the center.

      (2) Emergency telephone numbers shall be posted on or in the immediate vicinity of all telephones. (16 Ky.R. 302; Am. 554; 755; eff. 10-18-1989; 1479, 1762; eff. 5-5-2017.)