Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule establishes standards for all
assisted living facilities licensed pursuant to sections
198.005
and
198.073,
RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second
Regular Session (2006)) and required to meet assisted living facility standards
pursuant to section 198.073.3, RSMo (CCS HCS SCS SB 616, 93rd
General Assembly, Second Regular Session (2006)) and section
198.076,
RSMo 2000.
PUBLISHER'S NOTE: The secretary of state has
determined that the publication of the entire text of the material which is
incorporated by reference as a portion of this rule would be unduly cumbersome
or expensive. This material as incorporated by reference in this rule shall be
maintained by the agency at its headquarters and shall be made available to the
public for inspection and copying at no more than the actual cost of
reproduction. This note applies only to the reference material. The entire text
of the rule is printed here.
AGENCY NOTE: All rules relating to long-term care
facilities licensed by the department are followed by a Roman Numeral notation
which refers to the class (either Class I, II, or III) of standard as
designated in section 198.085.1., RSMo.
(1) Facilities licensed as assisted living
facilities shall be inspected pursuant to the standards outlined herein
beginning April 1, 2007. An assisted living facility may request, in writing to
the department, to comply with these standards prior to April 1, 2007. Upon
receipt of the request, the department shall conduct an inspection to determine
compliance with the standards outlined herein prior to issuing a license
indicating such compliance.
(2)
Consumer Education Requirements. The facility shall disclose to a prospective
resident, or legal representative of the resident, information regarding the
services the facility is able to provide or coordinate, the cost of such
services to the resident, and the grounds for discharge or transfer as
permitted or required by the Omnibus Nursing Home Act, Chapter 198, RSMo and
the department's regulations, including the provisions set forth in section
(29) of this rule. II
(3) Nothing
in this rule shall be construed to allow any facility that has not met the
requirements of 198.073(4) and (6), RSMo, (CCS HCS SCS SB 616, 93rd General
Assembly, Second Regular Session (2006)) and
19
CSR 30-86.045 to care for any individual with a
physical, cognitive or other impairment that prevents the individual from
safely evacuating the facility with minimal assistance. I/II
(4) Definitions. For the purpose of this
rule, the following definitions shall apply:
(A) Appropriately trained and qualified
individual means an individual who is licensed or registered with the state of
Missouri in a health care related field or an individual with a degree in a
health care related field or an individual with a degree in a health care,
social services, or human services field or an individual licensed under
Chapter 344, RSMo, and who has received facility orientation training under
19
CSR 30-86.042(18), and dementia
training under section
660.050,
RSMo, and twenty-four (24) hours of additional training, approved by the
department, consisting of definition and assessment of activities of daily
living, assessment of cognitive ability, service planning, and interview
skills;
(B) Area of refuge-A space
located in or immediately adjacent to a path of travel leading to an exit that
is protected from the effects of fire, either by means of separation from other
spaces in the same building or its location, permitting a delay in evacuation.
An area of refuge may be temporarily used as a staging area that provides
relative safety to its occupants while potential emergencies are assessed,
decisions are made, and evacuation is begun;
(C) Assisted living facility (ALF)-Is as
defined in
19 CSR
30-83.010;
(D) Chemical restraint-Is as defined in
19 CSR
30-83.010;
(E) Community based assessment-Documented
basic information and analysis provided by appropriately trained and qualified
individuals describing an individual's abilities and needs in activities of
daily living, instrumental activities of daily living, vision/hearing,
nutrition, social participation and support, and cognitive functioning using an
assessment tool approved by the department, that is designed for community
based services and that is not the nursing home minimum data set. The
assessment tool may be one developed by the department or one used by a
facility which has been approved by the department;
(F) Evacuating the facility-For the purpose
of this rule, evacuating the facility shall mean moving to an area of refuge or
from one smoke section to another or exiting the facility;
(G) Home-like-Means a self-contained
long-term care setting that integrates the psychosocial, organizational and
environmental qualities that are associated with being at home. Home-like may
include, but is not limited to the following:
1. A living room and common use areas for
social interactions and activities;
2. Kitchen and family style eating area for
use by the residents;
3. Laundry
area for use by residents;
4. A
toilet room that contains a toilet, lavatory and bathing unit in each
resident's room;
5. Resident room
preferences for residents who wish to share a room, and for residents who wish
to have private bedrooms;
6.
Outdoor area for outdoor activities and recreation; and
7. A place where residents can give and
receive affection, explore their interests, exercise control over their
environment, engage in interactions with others and have privacy, security,
familiarity and a sense of belonging;
(H) Individualized service plan (ISP)- Shall
mean the planning document prepared by an assisted living facility, which
outlines a resident's needs and preferences, services to be provided, and the
goals expected by the resident or the resident's legal representative in
partnership with the facility;
(I)
Keeping residents in place-Means maintaining residents in place during a fire
in lieu of evacuation where a building's occupants are not capable of
evacuation, where evacuation has a low likelihood of success, or where it is
recommended in writing by local fire officials as having a better likelihood of
success and/or a lower risk of injury;
(J) Minimal assistance-
1. Is the criterion which determines whether
or not staff must develop and include an individualized evacuation plan as part
of the resident's service plan;
2.
Minimal assistance may be the verbal intervention that staff must provide for a
resident to initiate evacuating the facility;
3. Minimal assistance may be the physical
intervention that staff must provide, such as turning a resident in the correct
direction, for a resident to initiate evacuating the facility;
4. A resident needing minimal assistance is
one who is able to prepare to leave and then evacuate the facility within five
(5) minutes of being alerted of the need to evacuate and requires no more than
one (1) physical intervention and no more than three (3) verbal interventions
of staff to complete evacuation from the facility;
5. The following actions required of staff
are considered to be more than minimal assistance:
A. Assistance to traverse down stairways
;
B. Assistance to open a door;
and
C. Assistance to propel a
wheelchair;
(K) Physical restraint-Any manual method or
physical or mechanical device, material, or equipment attached to or adjacent
to the resident's body that the individual cannot remove easily which restricts
freedom of movement or normal access to one's body. Physical restraints
include, but are not limited to, leg restraints, arm restraints, hand mitts,
soft ties or vests, lap cushions, and lap trays the resident cannot remove
easily. Physical restraints also include facility practices that meet the
definition of a restraint, such as the following:
1. Using side rails that keep a resident from
voluntarily getting out of bed;
2.
Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that
a resident's movement is restricted;
3. Using devices in conjunction with a chair,
such as trays, tables, bars, or belts, that the resident cannot remove easily,
that prevent the resident from rising;
4. Placing the resident in a chair that
prevents a resident from rising; and
5. Placing a chair or bed so close to a wall
that the wall prevents the resident from rising out of the chair or voluntarily
getting out of bed;
(L)
Significant change-means any change in the resident's physical, emotional or
psychosocial condition or behavior that will not normally resolve itself
without further intervention by staff or by implementing standard
disease-related clinical interventions, that has an impact on more than one (1)
area of the resident's health status, and requires interdisciplinary review or
revision of the individualized service plan, or both;
(M) Skilled nursing facility-Means any
premises, other than a residential care facility, assisted living facility or
an intermediate care facility, which is utilized by its owner, operator or
manager to provide for twenty-four (24) hour accommodation, board and skilled
nursing care and treatment services to at least three (3) residents who are not
related within the fourth degree of consanguinity or affinity to the owner,
operator or manager of the facility. Skilled nursing care and treatment
services are those services commonly performed by or under the supervision of a
registered professional nurse for individuals requiring twenty-four
(24)-hours-a-day care by licensed nursing personnel including acts of
observation, care and counsel of the aged, ill, injured or infirm, the
administration of medications and treatments as prescribed by a licensed
physician or dentist, and other nursing functions requiring substantial
specialized judgment and skill;
(N)
Skilled nursing placement-Means placement in a skilled nursing facility as
defined in subsection (4)(M) of this rule; and
(O) Social model of care-Means long-term care
services based on the abilities, desires, and functional needs of the
individual delivered in a setting that is more homelike than institutional,
that promote the digni-t y, individuality, privacy, independence and autonomy
of the individual, that respects residents' differences and promotes residents'
choices.
(5) The
operator shall designate an individual for administrator who is currently
licensed as an administrator by the Missouri Board of Nursing Home
Administrators, in accordance with Chapter 344, RSMo. II
(6) The operator shall be responsible to
assure compliance with all applicable laws and regulations. The administrator
shall be fully authorized and empowered to make decisions regarding the
operation of the facility and shall be held responsible for the actions of all
employees. The administrator's responsibilities shall include oversight of
residents to assure that they receive care as defined in the individualized
service plan. II/III
(7) The
administrator cannot be listed or function in more than one (1) licensed
facility at the same time unless he or she serves no more than five (5)
facilities within a thirty (30)-mile radius and licensed to serve in total no
more than one hundred (100) residents, and the administrator has an individual
designated as the daily manager of each facility. However, the administrator
may serve as the administrator of more than one (1) licensed facility if all
facilities are on the same premises. II
(8) The administrator shall designate, in
writing, a staff member in charge in the administrator's absence. If the
administrator is absent for more than thirty (30) consecutive days, during
which time he or she is not readily accessible for consultation by telephone
with the delegated individual, the individual designated to be in charge shall
be an administrator currently licensed by the Missouri Board of Nursing Home
Administrators, in accordance with Chapter 344, RSMo. Such thirty- (30-)
consecutive day absences may only occur once within any consecutive twelve-
(12-) month period. II/III
(9) The
facility shall not care for more residents than the number for which the
facility is licensed. However, if the facility operates a non-licensed adult
day care program for four (4) or fewer participants within the licensed
facility, the day care participants shall not be included in the total facility
census. Adult day care participants shall be counted in staffing determination
during the hours the day care participants are in the facility.
II/III
(10) The facility shall not
admit or continue to care for residents whose needs cannot be met. If necessary
services cannot be obtained in or by the facility, the resident shall be
promptly referred to appropriate outside resources or discharged from the
facility. I/II
(11) All personnel
responsible for resident care shall have access to the legal name of each
resident, name and telephone number of resident's physician, resident's
designee or legally authorized representative in the event of emergency.
II/III
(12) All persons who have
any contact with the residents in the facility shall not knowingly act or omit
any duty in a manner that would materially and adversely affect the health,
safety, welfare, or property of residents. No person who is listed on the
Employee Disqualification List (EDL) maintained by the department as required
by section
198.070,
RSMo, shall work or volunteer in the facility in any capacity whether or not
employed by the operator. For the purpose of this rule, a volunteer is an
unpaid individual formally recognized by the facility as providing a direct
care service to residents. The facility is required to check the EDL for
individuals who volunteer to perform a service for which the facility might
otherwise have to hire an employee. The facility is not required to check the
EDL for individuals or groups such as scout groups, bingo leaders, or
sing-along leaders. The facility is not required to check the EDL for an
individual such as a priest, minister, or rabbi visiting a resident who is a
member of the individual's congregation. However, if a minister, priest, or
rabbi serves as a volunteer facility chaplain, the facility is required to
check the EDL since the individual would have potential contact with all
residents. I/II
(13) Prior to
allowing any person who has been hired in a full-time, part-time, or temporary
position to have contact with any resident, the facility shall, or in the case
of temporary employees hired through or contracted from an employment agency,
the employment agency shall, prior to sending a temporary employee to a
facility:
(A) Request a criminal background
check for the person, as provided in section
660.317,
RSMo. Each facility shall maintain documents verifying that the background
checks were requested, the date of each such request, and the nature of the
response received for each such request. II
1. The facility shall ensure that any person
hired or retained to have contact with any resident who discloses that he or
she has been convicted of, found guilty of, pled guilty to, or pled
nolo contendere to a crime, in this state or any other state,
which if committed in Missouri would be a class A or B felony violation of
Chapter 565, 566, or 569, RSMo, or any violation of section 198.070.3., RSMo,
or section
568.020, RSMo,
shall not be retained in such a position. I/II
2. Upon receipt of the criminal background
check, the facility shall ensure that if the criminal background check
indicates that the person hired or retained by the facility has been convicted
of, found guilty of, pled guilty to, or pled nolo contendere
to a crime, in this state or any other state, which if committed in Missouri
would be a class A or B felony violation of Chapter 565, 566, or 569, RSMo, or
any violation of section 198.070.3., RSMo, or section
568.020, RSMo,
the person shall not have contact with any resident unless and until the
facility obtains verification from the department that a good cause waiver has
been granted for each qualifying offense and maintains a copy of the
verification in the individual's personnel file; I/II
(B) Make an inquiry to the department, as
provided in section
660.315,
RSMo, as to whether the person is listed on the EDL. Each facility shall
maintain documents verifying that the EDL checks were requested, the date of
each such request, and the nature of the response received for each such
request. The inquiry may be made through the department's website;
II/III
(C) If the person has
registered with the department's Family Care Safety Registry (FCSR), the
facility may utilize the FCSR in order to meet the requirements of subsections
(13)(A) and (13)(B) of this rule. The FCSR is available through the
department's website; and
(D) For
persons for whom the facility has contracted for professional services (e.g.,
plumbing or air conditioning repair) that will have contact with any resident,
the facility shall either require a criminal background check or ensure that
the individual is sufficiently monitored by facility staff while in the
facility to reasonably ensure the safety of all residents. I/II
(14) A facility shall not employ,
as an agent or employee who has access to controlled substances, any person who
has been found guilty or entered a plea of guilty or nolo
con-tendere in a criminal prosecution under the laws of any state or
of the United States for any offense related to controlled substances. II
(A) A facility may apply in writing to the
department for a waiver of this section of this rule for a specific
employee.
(B) The department may
issue a written waiver to a facility upon determination that a waiver would be
consistent with the public health and safety. In making this determination, the
department shall consider the duties of the employee, the circumstances
surrounding the conviction, the length of time since the conviction was
entered, whether a waiver has been granted by the department's Bureau of
Narcotics and Dangerous Drugs pursuant to
19 CSR
30-1.034 when the facility is registered with that
agency, whether a waiver has been granted by the federal Drug Enforcement
Administration (DEA) pursuant to
21 CFR
1301.76 when the facility is also registered
with that agency, the security measures taken by the facility to prevent the
theft and diversion of controlled substances, and any other factors consistent
with public health and safety. II
(15) The facility must develop and implement
written policies and procedures which require that persons hired for any
position which is to have contact with any patient or resident have been
informed of their responsibility to disclose their prior criminal history to
the facility as required by section 660.317.5, RSMo. The facility must also
develop and implement policies and procedures which ensure that the facility
does not knowingly hire, after August 28, 1997, any person who has or may have
contact with a patient or resident, who has been convicted of, plead guilty or
nolo con-tendere to, in this state or any other state, or has
been found guilty of any Class A or B felony violation of Chapter 565, 566 or
569, RSMo, or any violation of subsection 3 of section
198.070,
RSMo, or of section
568.020, RSMo.
II/III
(16) All persons who have or
may have contact with residents shall at all times when on duty or delivering
services wear an identification badge. The badge shall give their name, title
and, if applicable, the status of their license or certification as any kind of
health care professional. This rule shall apply to all personnel who provide
services to any resident directly or indirectly. III
(17) Personnel who have been diagnosed with a
communicable disease may begin work or return to duty only with written
approval by a physician or physician's designee, which indicates any
limitations. II
(18) The
administrator shall be responsible to prevent an employee known to be diagnosed
with communicable disease from exposing residents to such disease. The
facility's policies and procedures must comply with the department's
regulations pertaining to communicable diseases, specifically
19
CSR 20-20.010 through
19
CSR 20-20.100. II /III
(19) The facility shall screen residents and
staff for tuberculosis as required for long-term care facilities by
19
CSR 20-20.100. II
(20) The administrator shall maintain on the
premises an individual personnel record on each facility employee, which shall
include the following:
(A) The employee's
name and address;
(B) Social
Security number;
(C) Date of
birth;
(D) Date of
employment;
(E) Documentation of
experience and education including for positions requiring licensure or
certification, documentation evidencing competency for the position held, which
includes copies of current licenses, transcripts when applicable, or for those
individuals requiring certification, such as certified medication technicians,
level I medication aides and insulin administration aides; printing the We b
Registry search results page available at
www.dhss.mo.gov/cnaregistry
shall meet the requirements of the employer's check regarding valid
certification;
(F) References, if
available;
(G) The results of
background checks required by section
660.317,
RSMo; and a copy of any good cause waiver granted by the department, if
applicable;
(H) Position in the
facility;
(I) Written statement
signed by a licensed physician or physician's designee indicating the person
can work in a long-term care facility and indicating any limitations;
(J) Documentation of the employee's
tuberculin screening status;
(K)
Documentation of what the employee was instructed on during orientation
training; and
(L) Reason for
termination if the employee was terminated due to abuse or neglect of a
resident, residents' rights issues or resident injury. III
(21) Personnel records shall be maintained
for at least two (2) years following termination of employment. III
(22) There shall be written documentation
maintained in the facility showing actual hours worked by each employee.
III
(23) No one individual shall be
on duty with responsibility for oversight of residents longer than eighteen
(18) hours per day. I/II
(24)
Employees who are counted in meeting the minimum staffing ratio and employees
who provide direct care to the residents shall be at least sixteen (16) years
of age. One employee at least eighteen (18) years of age shall be on duty at
all times. II
(25) Each facility
resident shall be under the medical supervision of a physician licensed to
practice in Missouri who has been informed of the facility's emergency medical
procedures and is kept informed of treatments or medications prescribed by any
other professional lawfully authorized to prescribe medications. III
(26) The facility shall ensure that each
resident being admitted or readmitted to the facility receives an admission
physical examination by a licensed physician. The facility shall request
documentation of the physical examination prior to admission but must have
documentation of the physical examination on file no later than ten (10) days
after admission. The physical examination shall contain documentation regarding
the individual's current medical status and any special orders or procedures to
be followed. If the resident is admitted directly from an acute care or another
long-term care facility and is accompanied on admission by a report that
reflects his or her current medical status, an admission physical shall not be
required. III
(27) Residents under
sixteen (16) years of age shall not be admitted. III
(28) The facility may admit or retain an
individual for residency in an assisted living facility only if the individual
does not require hos-pitalization or skilled nursing placement as defined in
this rule, and only if the facility:
(A)
Provides for or coordinates oversight and services to meet the needs, the
social and recreational preferences in accordance with the individualized
service plan of the resident as documented in a written contract signed by the
resident, or legal representative of the resident; II
(B) Has twenty-four (24) hour staff
appropriate in numbers and with appropriate skills to provide such services;
II
(C) Has a written plan for the
protection of all residents in the event of a disaster such as tornado, fire,
bomb threat or severe weather, including:
1.
Keeping residents in place;
2.
Evacuating residents to areas of refuge;
3. Evacuating residents from the building if
necessary; or
4. Other methods of
protection based on the disaster and the individual building design;
I/II
(D) Completes a
premove-in screening conducted as required by section 198.073.4(4), RSMo (CCS
HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)).
II
(E) The premove-in screening
shall be completed prior to admission with the participation of the prospective
resident and be designed to determine if the individual is eligible for
admission to the assisted living facility and shall be based on the admission
restrictions listed at section (29) of this rule; II
(F) Completes a community based assessment
conducted by an appropriately trained and qualified individual as defined in
section (4) of this rule:
1. Time frame
requirements for assessment shall be:
A.
Within five (5) calendar days of admission; II
B. At least semiannually; and II
C. Whenever a significant change has occurred
in the resident's condition, which may require a change in services.
II
2. The facility shall
use form MO 580-2835, Assessment for Admission To Assisted Living Facilities,
(9-06), incorporated by reference, provided by the Department of Health and
Senior Services, PO Box 570, Jefferson City, MO 65102-0570 and which is
available to long-term care facilities at
www.dhss.mo.gov or by telephone at (573)
526-8548. This rule does not incorporate any subsequent amendments or
additions; or II
3. The facility
may use another assessment form if approved in advance by the department;
II
(G) Develops an
individualized service plan (ISP), which means the planning document prepared
by an assisted living facility which outlines a resident's needs and
preferences, services to be provided, and goals expected by the resident or the
resident's legal representative in partnership with the facility; II
(H) Reviews the ISP with the resident, or
legal representative of the resident, at least annually or when there is a
significant change in the resident's condition which may require a change in
services; II
(I) Includes the
signatures of an authorized representative of the facility and the resident or
the resident's legal representative in the individualized service plan to
acknowledge that the service plan has been reviewed and understood by the
resident or legal representative; II
(J) Develops and implements a plan to protect
the rights, privacy, and safety of all residents and to protect against the
financial exploitation of all residents; and II
(K) Complies with the dementia specific
training requirements of subsection 8 of section
660.050,
RSMo. II
(29) The
facility shall not admit or continue to care for a resident who:
(A) Has exhibited behaviors that present a
reasonable likelihood of serious harm to himself or herself or others;
I/II
(B) Requires physical
restraint as defined in this rule; II
(C) Requires chemical restraint as defined in
this rule; II
(D) Requires skilled
nursing services as defined in section 198.073.4, RSMo for which the facility
is not licensed or able to provide; II
(E) Requires more than one (1) person to
simultaneously physically assist the resident with any activity of daily
living, with the exception of bathing and transferring; or II/III
(F) Is bed-bound or similarly immobilized due
to a debilitating or chronic condition. II
(30) The requirements of subsections (29)(D),
(E) and (F) shall not apply to a resident receiving hospice care, provided the
resident, his or her legally authorized representative or designee, or both,
and the facility, physician and licensed hospice provider all agree that such
program of care is appropriate for the resident. II
(31) Programs and Services Requirements for
Residents.
(A) The facility shall designate a
staff member to be responsible for leisure activity coordination and for
promoting the social model, multiple staff role directing all staff to provide
routine care in a manner that emphasizes the opportunity for the resident and
the staff member to enjoy a visit rather than simply perform a procedure.
II/III
(B) The facility shall make
available and implement self-care, productive and leisure activity programs
which maximize and encourage the resident's optimal functional ability for
residents. The facility shall provide person-centered activities appropriate to
the resident's individual needs, preferences, background and culture.
Individual or group activity programs may consist of the following:
1. Gross motor activities, such as exercise,
dancing, gardening, cooking and other routine tasks;
2. Self-care activities, such as dressing,
grooming and personal hygiene;
3.
Social and leisure activities, such as games, music and reminiscing;
4. Sensory enhancement activities, such as
auditory, olfactory, visual and tactile stimulation;
5. Outdoor activities, such as walking and
field trips;
6. Creative arts;
or
7. Other social, leisure or
therapeutic activities that encourage mental and physical stimulation or
enhance the resident's well-being. II/III
(C) Staff shall inform residents in advance
of any organized group activity including the time and place of the activity.
II/III
(32) Requirements
for Facilities Providing Care to Residents Having Mental Illness or Mental
Retardation Diagnosis.
(A) Each resident who
exhibits mental and psychosocial adjustment difficulty(ies) shall receive
treatment and services to address the resident's needs and behaviors as stated
in the individualized service plan. I/II
(B) If specialized rehabilitative services
for mental illness or mental retardation are required to enable a resident to
reach and to comply with the individualized service plan, the facility shall
ensure the required services are provided. II
(C) The facility shall maintain in the
resident's record the most recent progress notes and personal plan developed
and provided by the Department of Mental Health or designated administrative
agent for each resident whose care is funded by the Department of Mental Health
or designated administrative agent. III
(33) No facility shall accept any individual
with a physical, cognitive, or other impairment that prevents the individual
from safely evacuating the facility with minimal assistance unless the facility
meets all requirements of section
198.073,
RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006))
and those standards set forth in
19
CSR 30-86.045. I/II
(34) The facility shall follow appropriate
infection control procedures. The administrator or his or her designee shall
make a report to the local health authority or the department of the presence
or suspected presence of any diseases or findings listed in
19
CSR 20-20.020, sections (1)-(3) according to the
specified time frames as follows:
(A)
Category I diseases or findings shall be reported to the local health authority
or to the department within twenty-four (24) hours of first knowledge or
suspicion by telephone, facsimile, or other rapid communication;
(B) Category II diseases or findings shall be
reported to the local health authority or the department within three (3) days
of first knowledge or suspicion;
(C) Category III-The occurrence of an
outbreak or epidemic of any illness, disease or condition which may be of
public health concern, including any illness in a food handler that is
potentially transmissible through food. This also includes public health
threats such as clusters of unusual diseases or manifestations of illness and
clusters of unexplained deaths. Such incidents shall be reported to the local
authority or to the department by telephone, facsimile, or other rapid
communication within twenty-four (24) hours of first knowledge or suspicion.
I/II
(35) Protective
oversight shall be provided twenty-four (24) hours a day. For residents
departing the premises on voluntary leave, the facility shall have, at a
minimum, a procedure to inquire of the resident or resident's guardian of the
resident's departure, of the resident's estimated length of absence from the
facility, and of the resident's whereabouts while on voluntary leave.
I/II
(36) Residents shall receive
proper care as defined in the individualized service plan. I/II
(37) In case of behaviors that present a
reasonable likelihood of serious harm to himself or herself or others, serious
illness, significant change in condition, injury or death, staff shall take
appropriate action and shall promptly attempt to contact the person listed in
the resident's record as the legally authorized representative, designee or
placement authority. The facility shall contact the attending physician or
designee and notify the local coroner or medical examiner immediately upon the
death of any resident of the facility prior to transferring the deceased
resident to a funeral home. I/II
(38) The facility shall encourage and assist
each resident based on his or her individual preferences and needs to be clean
and free of body and mouth odor. II
(39) If the resident brings unsealed
medications to the facility, the medications shall not be used unless a
pharmacist, physician or nurse examines, identifies and determines the contents
to be suitable for use. The person performing the identification shall document
his or her review. II/III
(40)
Self-control of prescription medication by a resident may be allowed only if
approved in writing by the resident's physician and included in the resident's
individualized service plan. A resident may be permitted to control the storage
and use of nonprescription medication unless there is a physician's written
order or facility policy to the contrary. Written approval for self-control of
prescription medication shall be rewritten as needed but at least annually and
after any period of hospitalization. II/III
(41) All medication shall be safely stored at
proper temperature and shall be kept in a secured location behind at least one
(1) locked door or cabinet. Medication shall be accessible only to persons
authorized to administer medications. II/III
(A) If access is controlled by the resident,
a secured location shall mean in a locked container, a locked drawer in a
bedside table or dresser or in a resident's private room if locked in his or
her absence, although this does not preclude access by a responsible employee
of the facility.
(B) Schedule II
controlled substances shall be stored in locked compartments separate from
non-controlled medications, except that single doses of Schedule II controlled
substances may be controlled by a resident in compliance with the requirements
for self-control of medication of this rule.
(C) Medication that is not in current use and
is not destroyed shall be stored separately from medication that is in current
use. II/III
(42) All
prescription medications shall be supplied as individual prescriptions except
where an emergency medication supply is allowed. All medications, including
over-the-counter medications, shall be packaged and labeled in accordance with
applicable professional pharmacy standards, and state and federal drug laws.
Labeling shall include accessory and cautionary instructions as well as the
expiration date, when applicable, and the name of the medication as specified
in the physician's order. Medication labels shall not be altered by facility
staff and medications shall not be repackaged by facility staff except as
allowed by section (43) of this rule. Over-the-counter medications for
individual residents shall be labeled with at least the resident's name.
II/III
(43) Controlled substances
and other prescription and non-prescription medications for administration when
a resident temporarily leaves a facility shall be provided as follows:
(A) Separate containers of medications for
the leave period may be prepared by the pharmacy. The facility shall have a
policy and procedure for families to provide adequate advance notice so that
medications can be obtained from the pharmacy.
(B) Prescription medication cards or other
multiple-dose prescription containers currently in use in the facility may be
provided by any authorized facility medication staff member if the containers
are labeled by the pharmacy with complete pharmacy prescription labeling for
use. Original manufacturer containers of non-prescription medications, along
with instructions for administration, may be provided by any authorized
facility medication staff member.
(C) When medications are supplied by the
pharmacy in customized patient medication packages that allow separation of
individual dose containers, the required number of containers may be provided
by any authorized facility medication staff member. The individual dose
containers shall be placed in an outer container that is labeled with the name
and address of the facility and the date.
(D) When multiple doses of a medication are
required and it is not reasonably possible to obtain prescription medication
labeled by the pharmacy, and it is not appropriate to send a container of
medication currently in use in the facility, up to a twenty-four (24)-hour
supply of each prescription or non-prescription medication may be provided by a
licensed nurse in United States Pharmacopeia (USP) approved containers labeled
with the facility name and address, resident's name, medication name and
strength, quantity, instructions for use, date, initials of individual
providing, and other appropriate information.
(E) When no more than a single dose of a
medication is required, any authorized facility medication staff member may
prepare the dose as for in-facility administration in a USP approved container
labeled with the facility name and address, resident's name, medication name
and strength, quantity, instructions for use, date, initials of person
providing, and other appropriate information.
(F) The facility may have a policy that
limits the quantity of medication sent with a resident without prior approval
of the prescriber.
(G) Returned
containers shall be identified as having been sent with the resident, and shall
not later be returned to the pharmacy for reuse.
(H) The facility shall maintain accurate
records of medications provided to and returned by the resident.
II/III
(44) Upon
discharge or transfer of a resident, the facility shall release prescription
medications, including controlled substances, held by the facility for the
resident when the physician writes an order for each medication to be released.
Medications shall be labeled by the pharmacy with current instructions for use.
Prescription medication cards or other containers may be released if the
containers are labeled by the pharmacy with complete pharmacy prescription
labeling. II/III
(45) Injections
shall be administered only by a physician or licensed nurse, except that
insulin injections may also be administered by a certified medication
technician or level I medication aide who has successfully completed the
state-approved course for insulin administration, taught by a
department-approved instructor. Anyone trained prior to December 31, 1990, who
completed the state-approved insulin administration course taught by an
approved instructor shall be considered qualified to administer insulin in an
assisted living facility. A resident who requires insulin, may administer his
or her own insulin if approved in writing by the resident's physician and
trained to do so by a licensed nurse or physician. The facility shall monitor
the resident's condition and ability to continue self-administration.
I/II
(46) The administrator shall
develop and implement a safe and effective system of medication control and
use, which assures that all residents' medications are administered by
personnel at least eighteen (18) years of age, in accordance with physicians'
instructions using acceptable nursing techniques. The facility shall employ a
licensed nurse eight (8) hours per week for every thirty (30) residents to
monitor each resident's condition and medication. Administration of medication
shall mean delivering to a resident his or her prescription medication either
in the original pharmacy container, or for internal medication, removing an
individual dose from the pharmacy container and placing it in a small cup
container or liquid medium for the resident to remove from the container and
self-administer. External prescription medication may be applied by facility
personnel if the resident is unable to do so and the resident's physician so
authorizes. All individuals who administer medication shall be trained in
medication administration and, if not a physician or a licensed nurse, shall be
a certified medication technician or level I medication aide. I/II
(47) Medication Orders.
(A) No medication, treatment or diet shall be
administered without an order from an individual lawfully authorized to
prescribe such and the order shall be followed. II/III
(B) Physician's written and signed orders
shall include: name of medication, dosage, frequency and route of
administration and the orders shall be renewed at least every three (3) months.
Computer generated signatures may be used if safeguards are in place to prevent
their misuse. Computer identification codes shall be accessible to and used by
only the individuals whose signatures they represent. Orders that include
optional doses or include pro re nata (PRN) administration
frequencies shall specify a maximum frequency and the reason for
administration. II/III
(C)
Telephone and other verbal orders shall be received only by a licensed nurse,
certified medication technician, level I medication aide or pharmacist, and
shall be immediately reduced to writing and signed by that individual. A
certified medication technician or level I medication aide may receive a
telephone or other verbal order only for a medication or treatment that the
technician or level I medication aide is authorized to administer. If a
telephone or other verbal order is given to a medication technician or level I
medication aide, an initial dosage shall not be administered until the order
has been reviewed by telephone, facsimile or in person by a licensed nurse or
pharmacist. The review shall be documented by the reviewer co-signing the
telephone or other verbal order. II
(D) The review shall be documented by the
licensed nurse's or pharmacist's signature within seven (7) days. III
(E) The facility shall submit to the
physician written versions of any oral or telephone orders within four (4) days
of the giving of the oral or telephone order. III
(F) Influenza and pneumococcal
polysac-charide immunizations may be administered per physician-approved
facility policy after assessment for contraindications-
1. The facility shall develop a policy that
provides recommendations and assessment parameters for the administration of
such immunizations. The policy shall be approved by the facility medical
director for facilities having a medical director, or by each resident's
attending physician for facilities that do not have a medical director, and
shall include the requirements to:
A. Provide
education to each resident or the resident's designee or legally authorized
representative regarding the potential benefits and side effects of the
immunization; II/III
B. Offer the
immunization to the resident or obtain permission from the resident's designee
or legally authorized representative when the immunization is medically
indicated unless the resident has already been immunized as recommended by the
policy; II/III
C. Provide the
opportunity to refuse the immunization; and II/III
D. Perform an assessment for
contraindications; II/III
2. The assessment for contraindications and
documentation of the education and opportunity to refuse the immunization shall
be dated and signed by the nurse performing the assessment and placed in the
medical record; or
3. The facility
shall with the approval of each resident's physician, access screening and
immunization through outside sources such as county or city health departments.
II/III
(G) The
administration of medication shall be recorded on a medication sheet or
directly in the resident's record and, if recorded on a medication sheet, shall
be made part of the resident's record. The administration shall be recorded by
the same individual who prepares the medication and administers it.
II/III
(48) The facility
may keep an emergency medication supply if approved by a pharmacist or
physician. Storage and use of medications in the emergency medication supply
shall assure accountability. When the emergency medication supply contains
controlled substances, the facility shall be registered with the Bureau of
Narcotics and Dangerous Drugs (BNDD) and shall be in compliance with
19 CSR
30-1.052 and other applicable state and federal
controlled substance laws and regulations. II/III
(49) Automated dispensing systems may be
controlled by the facility or may be controlled on-site or remotely by a
pharmacy.
(A) Automated dispensing systems may
be used for an emergency medication supply.
(B) Automated dispensing systems that are
controlled by a pharmacy may be used for continuing doses of controlled
substance and non-controlled substance medications. When continuing doses are
administered from an automated dispensing system that is controlled by a
pharmacy, a pharmacist shall review and approve each new medication order prior
to releasing the medication from the system. The pharmacy and the facility may
have a policy and procedure to allow the release of initial doses of approved
medications when a pharmacist is not available in lieu of a separate emergency
medication supply. When initial doses are used when a pharmacist is not
available, a pharmacist shall review and approve the order within twenty-four
(24) hours of administration of the first dose.
(C) Automated dispensing systems shall be
used in compliance with state and federal laws and regulations. When an
automated dispensing system controlled by the facility contains controlled
substances for an emergency medication supply, the facility shall be registered
with the BNDD. When an automated dispensing system is controlled by a pharmacy,
the facility shall use it in compliance with
20 CSR
2220-2.900. II/III
(50) Stock supplies of nonprescription
medication may be kept when specific medications are approved in writing by a
consulting physician, a registered nurse or a pharmacist. II/III
(51) Records shall be maintained upon receipt
and disposition of all controlled substances and shall be maintained separately
from other records, for two (2) years.
(A)
Inventories of controlled substances shall be reconciled as follows:
1. Controlled Substance Schedule II
medications shall be reconciled each shift; and II
2. Controlled Substance Schedule III-V
medications shall be reconciled at least weekly and as needed to ensure
accountability. II
(B)
Inventories of controlled substances shall be reconciled by the following:
1. Two (2) medication personnel, one of whom
is a licensed nurse; or
2. Two (2)
medication personnel, who are certified medication technicians or level I
medication aides, when a licensed nurse is not available. II
(C) Receipt records shall include
the date, source of supply, resident name and prescription number when
applicable, medication name and strength, quantity and signature of the
supplier and receiver. Administration records shall include the date, time,
resident name, medication name, dose administered and the initials of the
individual administering. The signature and initials of each medication staff
documenting on the medication administration record must be signed in the
signature area of the medication record. II
(D) When self-control of medication is
approved a record shall be made of all controlled substances transferred to and
administered from the resident's room. Inventory reconciliation shall include
controlled substances transferred to the resident's room. II
(52) Documentation of waste of
controlled substances at the time of administration shall include the reason
for the waste and the signature of another facility medication staff member who
witnesses the waste. If a second medication staff member is not available at
the time of administration, the controlled substance shall be properly labeled,
clearly identified as unusable, stored in a locked area, and destroyed as soon
as a medication staff member is available to witness the waste. When a second
medication staff member is not available and the controlled substance is
contaminated by patient body fluids, the controlled substance shall be
destroyed immediately and the circumstances documented. II/III
(53) At least every other month, a pharmacist
or registered nurse shall review the controlled substance record keeping
including reconciling the inventories of controlled substances. This shall be
done at the time of the drug regimen review of each resident. All discrepancies
in controlled substance records shall be reported to the administrator for
review and investigation. The theft or loss of controlled substances shall be
reported as follows:
(A) The facility shall
notify the department's Section for Long Term Care (SLTC) and other appropriate
authorities of any theft or significant loss of any controlled substance
medication written as an individual prescription for a specific resident upon
the discovery of the theft or loss. The facility shall consider at least the
following factors in determining if a loss is significant:
1. The actual quantity lost in relation to
the total quantity;
2. The specific
controlled substance lost;
3.
Whether the loss can be associated with access by specific
individuals;
4. Whether there is a
pattern of losses, and if the losses appear to be random or not;
5. Whether the controlled substance is a
likely candidate for diversion; and
6. Local trends and other indicators of
diversion potential;
(B)
If an insignificant amount of such controlled substance is lost during lawful
activities, which includes but are not limited to receiving, record keeping,
access auditing, administration, destruction and returning to the pharmacy, a
description of the occurrence shall be documented in writing and maintained
with the facility's controlled substance records. The documentation shall
include the reason for determining that the loss was insignificant;
and
(C) When the facility is
registered with the BNDD, the facility shall report to or document for the BNDD
any loss of any stock supply controlled substance in compliance with
19 CSR
30-1.034. II/III
(54) A physician, pharmacist or registered
nurse shall review the medication regimen of each resident. This shall be done
at least every other month. The review shall be performed in the facility and
shall include, but shall not be limited to, indication for use, dose, possible
medication interactions and medication/food interactions, contraindications,
adverse reactions and a review of the medication system utilized by the
facility. Irregularities and concerns shall be reported in writing to the
resident's physician and to the administrator/manager. If after thirty (30)
days, there is no action taken by a resident's physician and significant
concerns continue regarding a resident's or residents' medication order(s), the
administrator shall contact or recontact the physician to determine if he or
she received the information and if there are any new instructions.
II/III
(55) All medication errors
and adverse reactions shall be promptly documented and reported to the
administrator and the resident's physician. If the pharmacy made a dispensing
error, it shall also be reported to the issuing pharmacy. II/III
(56) Medications that are not in current use
shall be disposed of as follows:
(A) Single
doses of contaminated, refused, or otherwise unusable non-controlled substance
medications may be destroyed by any authorized medication staff member at the
time of administration. Single doses of unusable controlled substance
medications may be destroyed according to section (52) of this rule;
(B) Discontinued medications may be retained
up to one hundred twenty (120) days prior to other disposition if there is
reason to believe, based on clinical assessment of the resident, that the
medication might be reordered;
(C)
Medications may be released to the resident or family upon discharge according
to section (44) of this rule;
(D)
After a resident has expired, medications, except for controlled substances,
may be released to the resident's legal representative upon written request of
the legal representative that includes the name of the medication and the
reason for the request;
(E)
Medications may be returned to the pharmacy that dispensed the medications
pursuant to
20 CSR
2220-3.040 or returned pursuant to the Prescription
Drug Repository Program,
19
CSR 20-50.020. All other medications, including all
controlled substances and all expired or otherwise unusable medications, shall
be destroyed within thirty (30) days as follows:
1. Medications shall be destroyed within the
facility by a pharmacist and a licensed nurse or by two (2) licensed nurses or
when two (2) licensed nurses are not available on staff by two (2) individuals
who have authority to administer medications, one (1) of whom shall be a
licensed nurse or a pharmacist; and
2. A record of medication destroyed shall be
maintained and shall include the resident's name, date, medication name and
strength, quantity, prescription number, and signatures of the individuals
destroying the medications; and
(F) A record of medication released or
returned to the pharmacy shall be maintained and shall include the resident's
name, date, medication name and strength, quantity, prescription number, and
signatures of the individuals releasing and receiving the medications.
II/III
(57) Residents
experiencing short periods of incapacity due to illness or injury or
recuperation from surgery may be allowed to remain or be readmitted from a
hospital if the period of incapacity does not exceed forty-five (45) days and
written approval of a physician is obtained for the resident to remain in or be
readmitted to the facility. II
(58)
The facility shall maintain a record in the facility for each resident, which
shall include the following:
(A) Admission
information including the resident's name; admission date; confidentiality
number; previous address; birth date; sex; marital status; Social Security
number; Medicare and Medicaid numbers (if applicable); name, address and
telephone number of the resident's physician and alternate; diagnosis, name,
address and telephone number of the resident's legally authorized
representative or designee to be notified in case of emergency; and preferred
dentist, pharmacist and funeral director; III
(B) A review monthly or more frequently, if
indicated, of the resident's general condition and needs; a monthly review of
medication consumption of any resident controlling his or her own medication,
noting if prescription medications are being used in appropriate quantities; a
daily record of administration of medication; a logging of the medication
regimen review process; a monthly weight; a record of each referral of a
resident for services from an outside service; and a record of any resident
incidents including behaviors that present a reasonable likelihood of serious
harm to himself or herself or others and accidents that potentially could
result in injury or did result in injuries involving the resident;
and
(C) Any physician's orders. The
facility shall submit to the physician written versions of any oral or
telephone orders within four (4) days of the giving of the oral or telephone
order. III
(59) A record
of the resident census shall be retained in the facility. III
(60) Resident records shall be maintained by
the operator for at least five (5) years after a resident leaves the facility
or after the resident reaches the age of twenty-one (21), whichever is longer
and must include reason for discharge or transfer from the facility and cause
of death, as applicable. III
(61)
Staffing Requirements.
(A) The facility shall
have an adequate number and type of personnel for the proper care of residents,
the residents' social well being, protective oversight of residents and upkeep
of the facility. At a minimum, the staffing pattern for fire safety and care of
residents shall be one (1) staff person for every fifteen (15) residents or
major fraction of fifteen (15) during the day shift, one (1) person for every
twenty (20) residents or major fraction of twenty (20) during the evening shift
and one (1) person for every twenty-five (25) residents or major fraction of
twenty-five (25) during the night shift. I/II
|
Time
|
Personnel
|
Residents
|
| 7 a.m. to 3 p.m. (Day)* |
1 |
3-15 |
| 3 p.m. to 9 p.m. (Evening)* |
1 |
3-20 |
| 9 p.m. to 7 a.m. (Night)* |
1 |
3-25 |
*If the shift hours vary from those indicated, the hours of
the shifts shall show on the work schedules of the facility and shall not be
less than six (6) hours. III
(B) The administrator shall count toward
staffing when physically present in the facility. II
(C) The required staff shall be in the
facility awake, dressed and prepared to assist residents in case of emergency.
I/II
(D) Meeting these minimal
staffing requirements may not meet the needs of residents as outlined in the
residents' assessments and individualized service plans. I/II
(E) There shall be a licensed nurse employed
by the facility to work at least eight (8) hours per week at the facility for
every thirty (30) residents or additional major fraction of thirty (30). The
nurse's duties shall include, but shall not be limited to, review of residents'
charts, medications, and special diets or other orders, review of each
resident's adjustment to the facility, and observation of each individual
resident's general physical and mental condition. The nurse shall inform the
administrator of any problems noted, and these shall be brought to the
attention of the resident's physician. II/III
(62) Prior to or on the first day that a new
employee works in the facility he or she shall receive orientation of at least
two (2) hours appropriate to his or her job function. This shall include at
least the following:
(A) Job
responsibilities;
(B) Emergency
response procedures;
(C) Infection
control and handwashing procedures and requirements;
(D) Confidentiality of resident
information;
(E) Preservation of
resident dignity;
(F) Information
regarding what constitutes abuse/neglect and how to report abuse/neglect to the
department (1-800-392-0210);
(G)
Information regarding the Employee Disqualification List;
(H) Instruction regarding the rights of
residents and protection of property;
(I) Instruction regarding working with
residents with mental illness; and
(J) Instruction regarding person-centered
care and the concept of a social model of care, and techniques that are
effective in enhancing resident choice and control over his or her own
environment. II/III
(63)
In addition to the orientation training required in section (62) of this rule
any facility that provides care to any resident having Alzheimer's disease or
related dementia shall provide orientation training regarding mentally confused
residents such as those with Alzheimer's disease and related dementias as
follows:
(A) For employees providing direct
care to such persons, the orientation training shall include at least three (3)
hours of training including at a minimum an overview of mentally confused
residents such as those having Alzheimer's disease and related dementias,
communicating with persons with dementia, behavior management, promoting
independence in activities of daily living, techniques for creating a safe,
secure and socially oriented environment, provision of structure, stability and
a sense of routine for residents based on their needs, and understanding and
dealing with family issues; and II/III
(B) For other employees who do not provide
direct care for, but may have daily contact with, such persons, the orientation
training shall include at least one (1) hour of training including at a minimum
an overview of mentally confused residents such as those having dementias as
well as communicating with persons with dementia; and II/III
(C) For all employees involved in the care of
persons with dementia, dementia-specific training shall be incorporated into
ongoing in-service curricula. II/III
(64) All in-service or orientation training
relating to the special needs, care and safety of residents with Alzheimer's
disease and other dementia shall be conducted, presented or provided by an
individual who is qualified by education, experience or knowledge in the care
of individuals with Alzheimer's disease or other dementia. II/III
(65) Requirements for training related to
safely transferring residents.
(A) The
facility shall ensure that all staff responsible for transferring residents are
appropriately trained to transfer residents safely. Individuals authorized to
provide this training include a licensed nurse, a physical therapist, a
physical therapy assistant, an occupational therapist or a certified
occupational therapy assistant. The individual who provides the transfer
training shall observe the caregiver's skills when checking competency in
completing safe transfers, shall document the date(s) of training and
competency and shall sign and maintain training documentation. Initial training
shall include a minimum of two (2) classroom instruction hours in addition to
the on-the-job training related to safely transferring residents who need
assistance with transfers. II/III
(B) The facility shall ensure that a minimum
of one (1) hour of transfer training is provided by a licensed nurse annually
regarding safe transfer skills. II/III
*Original authority: 198.073, RSMo 1979, amended 1984,
1992, 1999, 2006, 2007 and 198.076, RSMo 1979, amended 1984,
2007.
