# Montgomery County Code — Part II. Local Laws, Ordinances, Resolutions, Etc. ## Chapter 25. Hospitals, Sanitariums, Nursing and Care Homes. ### Article III. Health Standards and Regulations. **Sec. 25-24. Application of article.** This Article applies to hospitals, nursing homes, personal care homes and domiciliary care homes. State and federal law and regulations that apply to these institutions, except licensing procedures, are incorporated into this Article. The other provisions of this Article apply only to the extent that they impose higher standards or stricter requirements than State and federal law and regulations. **Sec. 25-24A. Family councils.** (a) In this Section, “nursing home” includes nursing homes (as defined in Section 25-1) and any other facility in the County that is: (1) required to be licensed under State law as a: (A) comprehensive and extended care facility; or (B) licensed assisted living facility; or (2) subject to sections 1395i-3 or 1396r of Title 42 of the United States Code. (b) Each nursing home must comply with federal law and regulations, including the Nursing Home Reform Act of 1987, that protect the rights of residents and their families and representatives to associate and to participate in resident and family groups, such as a family council. This requirement applies even if the nursing home is not otherwise subject to the federal law. (c) The nursing home must consider and respond in writing to any written grievance or other written communication from a family council within 10 days after receiving the communication. (d) The nursing home must maintain a “regulatory” file and a “public” file containing duplicate copies of each communication and response described in subsection (c). Copies of the records in the regulatory file must be complete and unedited. The same records in the public file must delete any information that identifies an individual resident. (1) A resident or prospective resident, or any person representing either, may review the public file during normal business hours and at any other time that the nursing home agrees to make the file available. (2) The nursing home promptly must comply with a request by a licensing authority or the County’s Long-Term-Care Ombudsman to review any record in either file. (e) The nursing home must give each new or prospective resident the following written information provided by the family council: (1) the name, address, and phone number of a current member of the family council; (2) a brief description of the purpose and function of the family council; and (3) instructions on how the resident or prospective resident may review the files described in subsection (d). **Sec. 25-25. Approval of establishment.** (a) The establishment of any hospital shall require the prior approval of the council, sitting as the county board of health. (b) An application shall be filed with the county health officer in the form of a preliminary report containing the name of the hospital, the kind or kinds of service to be provided and the location and physical description of the institution, together with such other information as shall be prescribed by or acceptable to him. The health officer shall notify all professionally and officially concerned parties, organizations and agencies of the filing of the application, set a public hearing not later than six (6) months after the filing of the application and forward the application to the board. (c) The board shall not approve an application for establishment unless: (1) There is demonstrated a public need for the establishment at the time and place and under the circumstances proposed. (2) The proposal is broadly supported by lay and professional associations and groups in the county. (3) The hospital, if specialized, has a close working relationship with a general hospital to ensure that a full spectrum of diagnostic and treatment services will be readily available. (d) Subject to the provisions of paragraph (c) of this section, the board in approving establishment shall take into consideration and be empowered to request information and advice as to: (1) The availability of facilities or services such as preadmission, ambulatory or home care services which may serve as alternatives or substitutes for the whole or any part of the proposed construction. (2) The need for special equipment in view of existing utilization of comparable equipment at the time and place and under the circumstances proposed. (3) The possible economies and improvements in service to be anticipated from the operation of joint central services including but not limited to laboratory, research, radiology, pharmacy, laundry and purchasing. (4) The adequacy of financial resources and sources of future revenue. (5) The record and reputation of the applicant as an owner or operator of a hospital or similar institution. (e) The board shall take no action on any application until after proper notice has been given and a public hearing has been held. The board shall give public notice at least forty-five (45) days prior to the date of the proposed hearing. (f) The board shall by resolution approve or disapprove the application within sixty (60) days of the hearing, unless it extends the time for decision. **Sec. 25-26. Approval of construction plans.** Plans for construction of a structure to be used as a hospital, nursing home, personal care home or domiciliary care home shall be submitted to the director for approval prior to commencement of construction. Hospitals shall submit a resolution approving establishment as required by section 25-25 with their construction plans. **Sec. 25-27. Buildings to be detached; exceptions.** Any new building designed as a nursing, convalescent, or care home and any existing building proposed for conversion for such use, must be a completely detached structure, no part of which is used for any other purpose. However, an existing building may be converted to such use if: (a) The building is unattached and accessible for fire fighting purposes and evacuation of patients at all levels on 3 sides, as approved by the Department of Permitting Services. (b) It is separated from adjacent structures on the fourth side by a fire wall extending from the ground to thirty (30) inches above the roof, and having a four-hour fire resistance rating (the equivalent of a solid eight-inch-thick brick wall). (c) It complies with all other governing laws or ordinances. Nursing, convalescent and care homes now located in buildings which do not comply with this section shall relocate in acceptable buildings. **Sec. 25-28. Approval of water supply, plumbing, etc., systems.** No system of water supply, plumbing, sewage, garbage or refuse disposal for institutions shall be installed nor shall any such system be materially altered or extended until complete plans and specifications for the installation, alteration or extension, together with such information as may be required, have been submitted to and approved by the department and divisions of building and fire protection. **Sec. 25-29. Location; exposure to smoke, odors and dust.** Homes shall be so located that they are free from undue noises, and from railroads, freight yards, main traffic arteries, schools and children's playgrounds. The homes shall not be exposed to smoke, foul odors or dust from nearby industrial plants. **Sec. 25-30. Service road.** Each home shall be served by a good road, which is kept passable at all times of the year. **Sec. 25-31. Telephones.** There shall be a telephone in the building and such additional telephones or extensions as are required to summon help promptly in case of fire or other emergencies. Pay stations or locked telephones do not meet this requirement. **Sec. 25-32. Construction requirements generally.** Construction shall provide for the safety and protection of patients and personnel. Walls and floors shall be of a character to permit frequent washing, cleansing and painting. The construction of the building shall be such as to prevent the entrance and harborage of rats and other rodents. The building shall be kept in good repair. **Sec. 25-33. Stairways.** (a) Stairwells shall be enclosed at each floor level including the first floor level, unless the fire authorities specifically waive this regulation for the first floor level. This regulation is waived in institutions having an approved sprinkler system. All new homes opening after the date of approval of this regulation by the state board of health shall comply with this regulation before opening. Those in existence as of the date of approval of this regulation by the state board of health shall be required to comply within one (1) year from that date. (b) Where the stairway to the basement is located directly beneath a stairway from the first to the second floor, the walls and soffit of the basement stairs shall be lined with metal lath covered with cement or vermiculite plaster and the door at the head of such stair shall be metal covered and self-closing. (c) All fire escapes and interior stairways which are to be used for the evacuation of patients shall be forty-two (42) inches in width in institutions opening after the date of establishment of this regulation. (d) Stairways shall be provided with hand rails. (e) Nursing and care homes with five (5) beds or less shall be exempt from the provisions of subsections (a), (b) and (c) of this section. **Sec. 25-34. Heating.** (a) The building shall be equipped with a central heating unit adequate to maintain a minimum temperature of seventy (70) degrees Fahrenheit at all times in the patient area. (b) The heating unit shall be enclosed by a fire resistive wall and ceiling, the entrance to which shall be equipped with an approved fire door with a self-closing device. Nursing and care homes with five (5) beds or less are excepted from this requirement, but such homes shall cover the ceiling above the furnace with fire resistive materials. (c) Stoves and individual room heaters are a fire hazard and are not acceptable. (d) Chimneys, flues and pipes connected with the heating facility shall be checked and cleaned annually. (e) Asbestos, cinderblock and metal protectors shall be used whenever contact with the heating facilities presents a fire hazard. (f) The fuel supply shall be handled according to the regulations of the division of fire protection. If coal is used, ashes shall not be stored in flammable containers pending disposal. **Sec. 25-35. Ventilation.** (a) Generally. The building shall be adequately ventilated at all times. Special attention shall be given to the ventilation of patients' quarters so as to supply fresh air and prevent the accumulation of objectionable odors. (b) Toilets. Toilets without outside ventilation may not be used unless there is adequate system of forced ventilation. **Sec. 25-36. Lighting.** (a) Generally. Each patient's room shall be lighted by outside windows and shall also have artificial light adequate for reading and other uses as needed. All entrances, hallways, stairways, inclines, ramps, cellars, attics, storerooms, kitchens, laundries and service units shall have sufficient artificial lighting to prevent accidents and promote efficiency of service. (b) Emergency lighting. Emergency lighting shall be provided and readily available to personnel on duty. Open flame shall not be used for illumination. **Sec. 25-37. Elevators.** Elevators and machinery shall be maintained, checked and kept in good condition at all times. **Sec. 25-38. Fire protection generally.** (a) Generally. All institutions shall be free from fire hazards and comply with all fire laws, ordinances, rules and regulations applicable thereto and designed for fire prevention and control. (b) Inspections. Institutions shall be inspected and approved by the division of fire protection. (c) Placement of patients--Class A structures. In class A structures placement of patients is limited only by established space and facilities requirements. (d) Same--Class B structures. In class B structures placement of patients is limited to ground floors (that is, floors with ground level exits) and two (2) floors above the ground floor, or a total of three (3) floors. (e) Same--Class C structures. In class C structures placement of patients is limited to bedridden and blind patients on the ground floor and ambulant patients on one (1) floor above the ground floor. (f) Personnel quarters in classes B and C structures. In classes B and C structures, one (1) additional floor may be used as quarters for personnel. (g) Basement exits. There shall be provided a minimum of two (2) exits from the basement, remote from each other, at least one (1) of which is to the exterior. Nursing and care homes with five (5) beds or less are excepted from this requirement. (h) Fire detectors. Fire detectors installed in accordance with NBFU Pamphlet # 72 are required in the ceiling of the cellar, kitchen, laundry and furnace room and head of cellar stairs. Alarms which function with sprinkler systems meet this requirement. Nursing and care homes with five (5) beds or less are excepted from this requirement. (i) Stairways to be unobstructed; maintenance of fire exit doors. Stairways shall be kept free of obstructions and fire exit doors maintained in such working order that patients will be able to operate them. (j) Smoking by patients. If patients are allowed to smoke, smoking shall be carefully supervised and all smoking materials and matches kept under surveillance by personnel of institution. (k) Sprinkler systems. Every sprinkler system in an institution shall be installed by experienced personnel regularly engaged in making sprinkler installations, using only materials and methods approved by the Underwriters' Laboratories, Inc., or the National Board of Fire Underwriters, for "light hazard occupancy," in accordance with NBFU Pamphlet # 13. In inaccessible or "blind" spaces no sprinklers are required unless the spaces conceal steam pipes, electric wiring or hot air ducts. No protection is required in roof spaces or ceilings over open porches. "Wet" type systems are permitted only where no more than three (3) sprinkler heads are subject to any risk of being frozen in cold weather. Antifreezing solutions are not permitted. The system shall include a water motor alarm gong; shall be provided with F.D. Siamese connection, a three-inch check valve and a three-inch pipe between same and the main line system. Where not on public water, water supply may be based on six thousand (6,000) gallons (minimum) pneumatic storage tank supply,or equivalent elevated tank system, in either case conforming with the National Board of Fire Underwriters' standards. **Sec. 25-39. Housekeeping facilities; maintenance of premises generally.** Housekeeping facilities and services are required to be such that comfortable and sanitary living conditions for patients and employees are maintained constantly. Accumulated waste material shall be removed from the confines of the building daily. The premises shall be kept free from rodent and insect infestation. **Sec. 25-40. Plumbing, etc., facilities.** (a) Construction, installation and maintenance. All plumbing, plumbing fixtures, sterilizers and other similar equipment shall be so constructed, installed and maintained to prevent cross connections or other sanitary hazards, as required by the state board of health and county regulations. (b) Bath and toilet facilities-Required. A sanitary bath, water closet and lavatory shall be provided on each floor where patients or personnel sleep. (c) Same-Minimum requirements. There shall be at least the following: (1) One (1) water closet for each eight (8) patients. (2) One (1) bath or shower for each twelve (12) patients. (3) One (1) lavatory for each four (4) patients. (It is recommended that one (1) lavatory be provided in each patient's room.) (d) Clinical sink, etc. A clinical sink or bedpan hopper shall be provided for washing of bedpans and the like. Nursing and care homes with five (5) beds or less are excepted from this requirement. (e) Handrails for tubs. Stationary handrails shall be provided for use of infirm patients in getting in and out of tubs. **Sec. 25-41. Water supply generally.** The water supply shall be approved by the state board of health. There shall be an ample supply of hot water available at all times for general use. **Sec. 25-42. Sewage disposal.** Sewage shall be discharged in a municipal sewerage system where such system is available. Otherwise, the sewage shall be collected, treated and disposed of in an independent sewerage system which complies with the standards approved by the state board of health. **Sec. 25-43. Garbage, etc., storage and disposal.** (a) Containers. Garbage shall be kept in watertight metal containers with tight-fitting covers. They shall be emptied at frequent intervals and shall be thoroughly scoured and aired before using again. (b) Burning. Infectious waste materials shall be burned on the premises. Other garbage may also be burned if no satisfactory garbage collection service is available. If burning is the method used for disposal of garbage, an approved incinerator shall be available for the purpose. Wire baskets are not acceptable for they constitute a fire hazard. (c) Storage space. Storage space should be provided for garbage and trash awaiting pickup. **Sec. 25-44. Screens.** All outside doors, windows and other outside openings shall be screened with wire screen or its equal with not less than sixteen (16) meshes per linear inch. All screen doors shall be equipped with self-closing devices and, when closed, fit tightly enough to prevent entrance of flies, mosquitoes and other insects. Window screens shall fit closely enough to keep out insects and be easily adjustable so that they will not serve as a block for the evacuation of patients in case of fire. **Sec. 25-45. Cleaning of linens, etc.** The institution shall make provisions for the proper cleansing of linens and other washable goods. **Sec. 25-46. Food service.** (a) Personnel. (1) Generally. The food service department shall be under the supervision of a person skilled in the selection, handling, preparation and serving of food and the supervision and management of food handlers. There shall be a sufficient number of cooks, dishwashers and maids to properly prepare three (3) well-balanced meals daily. (2) Clothing, etc. It is mandatory that all cooks and food handlers wear clean garments (uniforms are desirable) and hair nets or clean caps, and keep their hands and fingernails clean at all times. (3) Education and Instruction. Adequate instructions for employees in acceptable and sanitary food handling practices are required. Educational material and services are available from the department. (4) Standards and Inspections. All institutions caring for six (6) or more persons shall comply with grade A standards established by the county board of health in its regulations for eating and drinking establishments. All institutions shall be inspected regularly by the department as to the cleanliness of food and food containers and as to the protection of food from spoilage. (b) Physical facilities. (1) Generally. There are seven (7) major phases of work including: Receiving of food and supplies, storage, preliminary preparation, cooking, serving, return of soiled dishes and dishwashing, and garbage disposal. All or part of these units may be provided in the main kitchen. (2) Location: a. The food service department shall be located in the main building or an attached building. It is recommended that it be located on the ground floor. If the food service rooms are located below the ground floor, adequate light and ventilation shall be provided by windows. b. To facilitate receiving food supplies and the disposal of waste, a convenient outside entrance shall be planned. c. No toilet rooms or sleeping rooms shall open directly into any kitchen or ward serving pantry. (3) Space. Space requirement varies from twelve (12) square feet to as much as thirty (30) square feet per bed depending upon the type of patient served. a. There shall be an aisle of at least three (3) feet between working areas, and wider is desirable if the aisle is used as a passageway. b. Ceiling height shall be at least eight (8) feet, and higher is desirable. (4) Storage. a. The amount of storage space needed is dependent upon frequency of deliveries. It is recommended that its location be within easy access to the receiving area and the kitchen. b. The storeroom shall be cool, well ventilated and fitted with metal shelving, metal bins or covered galvanized cans for storage of staple foods. c. All supplies shall be stored off the floor and away from the wall so as to allow for cleaning. All precautions shall be taken against the invasion of rodents and insects, the seepage of dust and water leakage or other sources of contamination. Care shall be exercised in the rotation of stored foods so that the sold stock is used first. (5) Refrigeration. a. Where delivery is on a bi-weekly basis, a space of one and one-half (1 1/2) to two (2) cubic feet per person, including personnel, is required. Size would have to be adjusted to other schedules of delivery. b. Where separate refrigeration can be provided, recommended temperatures for storing perishable foods are: thirty-two (32) degrees to thirty-eight (38) degrees Fahrenheit for meats, forty (40) degrees Fahrenheit for dairy products and forty-five (45) to fifty (50) degrees Fahrenheit for fruits and vegetables. If it is impracticable to provide separate refrigeration, the temperature shall be maintained at forty (40) degrees Fahrenheit or less. (c) Preparing and serving food. (1) Normal Diet. a. A well-balanced diet of good quality food, correctly prepared and sufficient in quantity to meet the nutritional needs of the patients shall be served three (3) times daily. This shall include for each day: 1. Three (3) cups of milk per person. 2. Two (2) servings of fruit (one citrus). 3. One (1) to two (2) servings of meat, poultry or fish. 4. A minimum of four (4) eggs weekly. 5. Two (2) tablespoons of butter or fortified margarine. 6. Cereals or bread (whole wheat or enriched) every meal. 7. Potatoes once a day. 8. Two (2) servings of vegetables (one (1) leafy green or yellow), in addition to potatoes. 9. Simple desserts (stewed or canned fruit, custard or pudding, ice cream, etc.) b. The method of serving food shall be such that the food reaches the patient in good condition. Hot foods should be served hot; cold foods should be served cold. c. Special attention shall be given to the texture of food given patients without dentures or with poor dentures because of their difficulty of mastication. d. A time schedule for service of meals to patients and personnel shall be established, and it is recommended that meals be served approximately five (5) hours apart but it shall not be longer than fourteen (14) hours from the evening meal until breakfast. (2) Therapeutic or Special Diets. Therapeutic diets shall be provided as ordered by the patient's physician as part of the course of treatment of the patient. Therapeutic or special diets as ordered by physicians shall be posted in the kitchen. (3) Menus. a. Menus shall be planned and written one (1) week in advance in order to insure variety and an adequate diet. This help to plan kitchen work efficiently and to facilitate marketing. A copy of menus shall be posted in the kitchen. b. Menus showing food actually served each day shall be recorded and kept on file. Nursing and care homes with five (5) beds or less are excepted from his requirements. (4) Distribution of Food. a. A satisfactory method of food distribution shall be provided. In institutions of more than one (1) story, where more than six (6) patients above the first floor receive bedside tray service, a dumbwaiter or elevator or ward serving pantries shall be provided. b. Cracked and chipped china shall not be used. (5) Domestic Animals. Domestic animals are not permitted in any place where food is prepared or served. (d) Dining rooms. (1) Lighting an Ventilation. Dining rooms shall be well lighted and ventilated. (2) Location. It is recommended that dining rooms be located adjacent to the kitchen in order to facilitate the serving of food. (3) Space, etc. Dining areas shall be adequate for both patients and personnel. Twelve (12) square feet per person is recommended whether dining room or cafeteria service is used. When wheel chair patients are fed in the dining room, greater floor space per person will be necessary. The kitchen shall not be used as a dining room for patients or personnel. (e) Milk supply. (1) Source. The source of supply and distribution shall be approved by the state department of health or local authority. Pasteurized milk shall be used. (2) Storage. Milk must be stored in tightly-covered containers. (f) Ice. Ice that is used in direct contact with food and drink shall be obtained from sanitary sources and handled in a sanitary manner. (g) Cleansing of food containers. (1) Generally. Centralized dishwashing is advocated, even with decentralized food service, because it limits noise on floors, lessens the number of employees required and allows for better control of breakage, and supervision of operation. (2) Separate Room. A separate room for dishwashing is desirable. It should be compact, light and airy. (3) Location of Dishwashing Unit. The dishwashing unit may be directly adjacent to the dining room; however, in locating the unit care shall be taken so that the service of soiled dishes will not interfere with the routing of service. (4) Equipment. a. Provision of a three-compartment sink or a dishwashing machine in the dishwashing unit is mandatory. Nursing and care homes with five (5) beds or less may use a two-compartment sink with a spray rinse. b. The dishwashing unit shall also include tables for soiled and clean dishes, storage cupboards and trucks for transporting dishes to and from the unit. If dishwashing is decentralized, provision of a three-compartment sink and tables or a dishwashing machine in each serving pantry is mandatory. (5) Procedure. a. All food containers shall, following the last preceding use, be washed until visibly clean in warm water containing an ample quantity of soap or alkaline cleanser. b. After cleaning, all food containers shall be rinsed with clear running water or immersed in a suitable receptacle containing clear water. c. All food containers, after cleaning and rinsing, shall be disinfected by one of the following procedures: 1. Immersion in water at a temperature of not less than one hundred eighty (180) degrees Fahrenheit for not less than one (1) minute, or 2. Immersion in a solution containing not less than one hundred (100) parts per million available chlorine for one (1) minute and allowed to drain on a wire or corrugated metal rack. d. After cleaning, rinsing and disinfecting, the food containers shall be stored in such a manner as not to become contaminated before reuse. e. The wiping of food containers after washing, rinsing and disinfecting is prohibited. f. The results obtained with dishwashing machines shall be equal to those obtained by the method outlined above. (h) Facilities for personnel. (1) Handwashing Facilities. It is mandatory that handwashing facilities be provided in all kitchens, ward serving pantries and washrooms used by food handlers. They shall be equipped with an adequate supply of soap, disposable towels, and hot and cold running water. The use of the common towel is prohibited. Hands shall not be washed in sinks where food is prepared. (2) Lockers. Lockers or cloakrooms for personnel shall be provided and wraps shall not be hung in the kitchen area. (3) Rest Rooms. Rest rooms shall be provided for personnel. **Sec. 25-47. Admission policies.** Admission policies shall be as set forth in the regulations of the state department of health. In addition thereto, the following requirements shall apply: (a) Physician's statement required prior to admission of patient. Every operator of a nursing home and care home shall obtain a statement from a licensed physician as to the health condition and medical and nursing needs of a patient before such patient is admitted. Such statement shall include evidence from a physician satisfactory to the county health officer that the patient is free from tuberculosis in a communicable state. (b) Discretion to be exercised. Institutions shall exercise discretion to avoid admitting patients whose condition indicates the need for a type of service and care that is not available in the institution. **Sec. 25-48. Medical care for patients generally.** Every institution shall make provision for every patient to receive medical care by a physician when needed. Every operator of a nursing home and hospital shall promptly provide medical or nursing care whenever required for any patient. If any patient becomes acutely ill or shows a sudden mental deterioration, the next of kin, or some person responsible for the care and maintenance of the patient or designated by him shall be notified at once. Any specific order given by a physician for the treatment or care of any patient shall be reduced to writing by the operator of the institution or by the physician and no medical treatment shall be rendered patients except upon the order of a physician. **Sec. 25-49. Patient accommodations generally.** (a) Rooms. (1) Location; Light. Each patient's room shall be an outside room with a satisfactory amount of natural light. (2) Outside Door. Each patient's room shall have a door opening into an exit or into a hall leading to an exit. (3) Inside Rooms. Patients shall not be kept in rooms in which the only means of outside communication is through another room. Nursing and care homes with five (5) beds or less are excepted from this requirement. (4) Internal Access. Each room must have internal access to the rest of the building. (5) Basement Rooms. Patients shall not be kept in rooms extending below the ground level. (6) Segregation for Privacy. Where both male and female patients are admitted, the rooms shall be segregated so as to allow for privacy. (7) Isolation Rooms. There shall be made available one or more rooms which shall be used for isolation of patients with communicable diseases and for seriously ill or terminal cases. Nursing and care homes with five (5) beds or less are excepted from this requirement. (b) Floor and window space. (1) Floor Space. Beds shall be spaced so as to provide adequate room for nursing procedures, and to prevent transmission of infection. The following allowance of floor space is considered a minimum: Rooms for only one (1) patient, one hundred (100) square feet. Rooms for two (2) or more patients, eighty (80) square feet per bed. Care homes may calculate day-room space up to twenty-five (25) percent of the required floor area. The usable floor area for floors having sloping walls shall be calculated for bed occupancy only for that area having a ceiling height of eight (8) feet and fifty (50) percent of the area having a ceiling height between four (4) feet and seven (7) feet six (6) inches; provided, that at least fifty (50) percent of the total area has a ceiling height of eight (8) feet. Beds shall be placed at least three (3) feet apart. (2) Window Area. The window area shall not be less than ten (10) square feet per bed. Half of this shall be openable. (c) Furnishings. (1) Bed, Mattress and Pillows. A bed, mattress and pillows shall be provided for each patient. (2) Bedding and Linen. A sufficient supply of clean bedding and bed linen shall be in use and available at all times. (3) Chair and Dresser, etc. In addition to the bed, the patient unit shall be provided with at least one (1) chair and either a dresser, locker or compartment bedside table to accommodate the patient's personal possessions such as toilet articles and clothing. (4) Cleaning and Disinfection. After the discharge of each patient the complete unit shall be thoroughly cleaned, including all articles of equipment that were used for the special care of the patient; such articles as bedpans and thermometers shall be disinfected. (d) Signal system. A signal system shall be maintained for patients to use in calling nurses and attendants. Hand bells are acceptable for use in small institutions. **Sec. 25-50. Facilities and equipment for patient care.** (a) Space requirements. (1) Cleaning and Storage of Nursing Supplies and Equipment. There shall be adequate space and facilities for the proper cleaning and storage of nursing supplies and equipment. This space shall be removed from patient contacts and kept stocked and in order so that the contents are easily available for use by the nurse or attending staff. Care homes having five (5) beds or less are excepted from this requirement. (2) Storage and Preparation of Medicines. Suitable provisions shall be made for the storage and preparation of medicines. Care homes having five (5) beds or less are excepted from this requirement. (b) Equipment and supplies for bedside care. There shall be sufficient equipment for nursing care according to the type of patient. The following is not a complete list of nursing equipment needed for the care of patients, the aim, rather, has been to include certain minimum essentials and point out special precautions which shall be taken in their use. (1) Linen. a. The following articles of linen are required for the treatment or care of the patient and to keep the bed in a comfortable and sanitary condition: Large sheets Draw sheets* Pillow slips Bedspreads Bath towels Face towels Bath blankets* Wash cloths Bedpan covers* Mattress covers Hot water bottle covers* Ice cap covers* Bath mats *Care homes with five (5) beds or less are excepted. b. Individual towels and wash cloths shall be provided for each patient. c. Bedpan covers shall not be used interchangeably. (2) Utensils and Other Supplies Needed. a. There shall be individual wash basins, mouth wash cups and drinking glasses for each patient. b. In addition to the above articles there shall be the following articles for general use*: Mouth thermometers Rectal thermometers Hypodermic syringes and needles Bath thermometers Hot water bottles Ice caps Enema apparatus Douche apparatus Scales Urinals Bedpans Rubber sheeting Rectal tubes Catheters First aid dressings Tongue depressors Applicators Rubber rings Side boards for beds Wheelchairs Curved basins Clinical medicine glasses Covered water pitchers *Care homes having five (5) beds or less are excepted from this requirement. c. Hot water bags shall be covered before placing in beds or on a patient. The greatest care shall be exercised in their use to see that water is not too hot and bags are not leaking. The water shall not be over one hundred twenty (120) degrees Fahrenheit. d. A bath thermometer shall be used to test water. e. Electric heating pads shall not be used. (c) Restraints. (1) When Permitted. Restraints shall be applied only as an essential measure to prevent the patient from harming himself or others, after alternative measures have been proven unsuccessful. (2) Physician's Order-Required. There shall be a written order signed by a physician approving the use of restraints either at the time they are applied to the patient, or in case of emergency, as soon as possible and not more than twenty-four (24) hours after they have been applied by the person in charge of the institution. (3) Same-Time Limitation; Additional Orders. The physician's order for restraint shall not extend beyond twenty-four (24) hours. If restraint is required beyond this period the physician's order shall be written at twenty-four-hour intervals. (4) Form. The form of restraint used shall not cause injury to patients. (5) Locking Doors-Generally. Patients shall not be kept behind locked doors, that is, doors which patients cannot open, unless a patient becomes too difficult to manage, in which case the room shall be located on the first floor and the door shall not be locked with a key. (6) Same-By Patients. Patients shall not be permitted to lock doors to their rooms. (d) Handling and storage of medicines. (1) Generally. All medicines and stimulants shall be plainly labeled and stored in a specially designated, well-illuminated locked medicine cabinet, closet or storeroom and be accessible only to nursing personnel. The medicine cabinet or closet shall be located near running water to facilitate the preparation of doses. (2) Narcotics, etc. Narcotics, sedatives and other dangerous drugs shall be securely locked and accessible only to the nurse in charge. (3) Old Medications. Old medications including prescriptions for patients who have left the institution shall be discarded. (e) Handwashing facilities. There shall be adequate handwashing facilities with soap and a sufficient supply of linen or paper towels so that a fresh towel can be used for every handwashing. The use of a common towel is prohibited. **Sec. 25-51. Personnel.** (a) Medical attendance. (1) Patient's Physician. All persons admitted to any nursing or convalescent home shall be under the care of a licensed physician. The name, address and telephone number of the physician attending each patient shall be recorded for ready reference. (2) Emergency Physicians. All institutions shall arrange for one (1) or more licensed physicians to be called in an emergency. (3) Physician's Order for Medication or Treatment. No medication or treatment shall be given except on the written order of a physician. (4) Physicians' Visits. Patients in nursing homes shall be visited by a licensed physician at least every two (2) months. (b) Nursing service. (1) Head Nurse. Nursing homes shall have a qualified nurse responsible for the nursing service. A qualified nurse shall mean a graduate nurse registered in this state, or a practical nurse licensed in this state; provided, that a graduate nurse eligible for registration in this state or a practical nurse eligible for licensure in this state may be considered qualified for three (3) months pending registration or licensure in this state. (2) Personnel Generally; Minimum Bedside Care Required. Sufficient personnel shall be employed to give adequate care to patients both day and night. A minimum of two (2) hours of bedside care per patient per day is required. (3) Relief Personnel. Provisions shall be made for relief personnel during vacation or other relief periods. (4) Circulative Nurses; Emergency Procedures. a. In institutions located in structures equipped with an automatic sprinkler system approved by the fire marshal, a minimum of one (1) nursing employee for each twenty-five (25) patients shall be circulating throughout the institution at all times. b. In institutions located in structures not equipped with an approved automatic sprinkler system, a minimum of one (1) nursing employee for each twenty-five (25) patients shall be circulating throughout the institution at all times; provided, that between the hours of 11:00 p.m. and 7:00 a.m. one (1) nursing employee for each fifteen (15) patients shall be circulating throughout the institution at all times and be available in case of fire or other emergency. However, in calculating the number of nursing employees required to be circulating at all times between the hours of 11:00 p.m. and 7:00 a.m., in addition to at least one (1), credit of one-half person may be allowed from sixteen (16) to forty-five (45) patients for an employee, owner, operator or licensee who is actually on the premises and is able and readily available to respond to emergencies. c. All persons assigned duties in nursing homes shall be instructed in emergency procedures and as to the locations of all patients and means of evacuation in emergencies. (5) Personal Attention and Care of Patients. Each patient shall be given such personal attention and care including personal attention and care including personal hygiene, as is ordered or indicated. (c) Dental and specialized care. Dental care and other specialized forms of medical and surgical services shall be arranged for on the order of the attending physician. **Sec. 25-52. Reports.** Any occurrence, such as epidemic outbreaks, poisonings or other unusual occurrences which threaten the welfare, safety or health of any patient admitted to any institution shall be immediately reported to the state board of health and the county health officer. The institution shall furnish such information related to such occurrences as the state board of health and county officer may require. All institutions shall submit annual reports to the state board of health and county health officer, as required.