Rules of Department of Health and Senior Services Division 30—Division of Regulation and Licensure Chapter 20—Hospitals
Title Page
19 CSR 30-20.001 Anesthesiologist Assistants in Hospitals ...... 3 19 CSR 30-20.011 Definitions Relating to Hospitals ...... 3 19 CSR 30-20.015 Administration of the Hospital Licensing Program ...... 5 19 CSR 30-20.021 Organization and Management for Hospitals (Rescinded February 29, 2008) ...... 11 19 CSR 30-20.030 Construction Standards for New Hospitals ...... 11 19 CSR 30-20.040 Definitions Relating to Long-Term Care Units in Hospitals...... 25 19 CSR 30-20.050 Standards for the Operation of Long-Term Care Units in Hospitals ...... 26 19 CSR 30-20.060 Construction Standards for New Long-Term Care Units in Hospitals ...... 29 19 CSR 30-20.070 Standards for Registration as a Hospital Infectious Waste Generator ...... 30 19 CSR 30-20.080 Governing Body of Hospitals ...... 32 19 CSR 30-20.082 Chief Executive Officer in Hospitals ...... 32 19 CSR 30-20.084 Patients’ Rights in Hospitals ...... 33 19 CSR 30-20.086 Medical Staff in Hospitals...... 34 19 CSR 30-20.088 Central Services in Hospitals ...... 35 19 CSR 30-20.090 Dietary Services in Hospitals ...... 35 19 CSR 30-20.092 Emergency Services in Hospitals...... 36 19 CSR 30-20.094 Medical Records in Hospitals...... 37 19 CSR 30-20.096 Nursing Services in Hospitals...... 38
JASON KANDER (12/31/13) CODE OF STATE REGULATIONS 1 Secretary of State 19 CSR 30-20.097 Safe Patient Handling and Movement in Hospitals...... 40 19 CSR 30-20.098 Pathology and Medical Laboratory Services ...... 41 19 CSR 30-20.100 Pharmacy Services and Medication Management in Hospitals...... 42 19 CSR 30-20.102 Radiology Services in Hospitals ...... 44 19 CSR 30-20.104 Social Work Services in Hospitals ...... 45 19 CSR 30-20.106 Inpatient Care Units in Hospitals...... 45 19 CSR 30-20.108 Fire Safety, General Safety and Operating Features for Hospitals...... 45 19 CSR 30-20.110 Orientation and Continuing Education ...... 45 19 CSR 30-20.112 Quality Assessment and Performance Improvement Program ...... 46 19 CSR 30-20.114 Environmental Waste Management and Support Services...... 46 19 CSR 30-20.116 Infection Control in Hospitals ...... 48 19 CSR 30-20.118 Outpatient Services in Hospitals...... 48 19 CSR 30-20.120 Anesthesia Services in Hospitals ...... 48 19 CSR 30-20.122 Home-Care Services in Hospitals (Rescinded January 30, 2014)...... 49 19 CSR 30-20.124 Medical Services ...... 49 19 CSR 30-20.125 Unlicensed Assistive Personnel Training Program ...... 49 19 CSR 30-20.126 Obstetrical and Newborn Services in Hospitals...... 50 19 CSR 30-20.128 Pediatric Services in Hospitals...... 51 19 CSR 30-20.130 Post-Anesthesia Recovery Services in Hospitals ...... 51 19 CSR 30-20.132 Psychiatric Services in Hospitals ...... 51 19 CSR 30-20.134 Rehabilitation Services in Hospitals ...... 52 19 CSR 30-20.136 Respiratory Care Services in Hospitals ...... 52 19 CSR 30-20.138 Special Patient Care Services in Hospitals...... 53 19 CSR 30-20.140 Surgical Services in Hospitals ...... 53 19 CSR 30-20.142 Variance Requests ...... 53
2 CODE OF STATE REGULATIONS (12/31/13) JASON KANDER Secretary of State Chapter 20—Hospitals 19 CSR 30-20
Title 19—DEPARTMENT OF (1) ACLS—The American Heart Associa- fication as a nurse anesthetist by the Council HEALTH AND SENIOR SERVICES tion’s advanced cardiac life support program. on Certification of Nurse Anesthetists. Division 30—Division of Regulation and Licensure (2) Anesthetizing location—An area or room (10) Chief executive officer—The individual Chapter 20—Hospitals in which it is intended to administer any appointed by the governing body to act in its flammable or nonflammable inhalation anes- behalf in the overall management of the hos- 19 CSR 30-20.001 Anesthesiologist Assis- thetic agents in the course of examination or pital. Job titles may include administrator, tants in Hospitals treatment. superintendent, director, executive director, president, vice president and executive vice PURPOSE: This rule allows the use of anes- (3) APLS—The American College of Emer- president. thesiologist assistants in hospitals. gency Physician’s advanced pediatric life sup- port program. APLS may be used inter- (11) Chief operating officer—The individual (1) Anesthesiologist assistant—A person who changeably with PALS where required. appointed by the chief executive officer on meets each of the following conditions: behalf of the governing body or the individu- (A) Has graduated from an anesthesiolo- (4) ATLS—The American College of Sur- al who is responsible for the management of gist assistant program accredited by the geon’s advanced trauma life support pro- one (1) hospital in a multi-hospital organiza- American Medical Association’s Committee gram. tion under the direction of the chief executive on Allied Health Education and Accreditation officer of the organization. — or by its successor agency; (5) Authenticate To prove authorship, for (B) Has passed the certifying examination example, by written signature, identifiable (12) Class II biological safety cabinet—A administered by the National Commission on initials or computer key. The use of rubber ventilated cabinet for personnel, product and Certification of Anesthesiologist Assistants; stamp signatures is acceptable only under the environmental protection having an open (C) Has active certification by the Nation- following conditions: front with inward airflow for personnel pro- al Commission on Certification of Anesthesi- (A) The individual whose signature the tection, high-efficiency-particulate-air (HEPA)- ologist Assistants; rubber stamp represents is the only one who filtered laminar airflow for product protection (D) Is currently licensed as an anesthesiol- has possession of the stamp and is the only and HEPA-filtered exhausted air for environ- ogist assistant in the state of Missouri; and one who uses it; and mental protection. (E) Provides health care services delegated (B) The individual places in the adminis- by a licensed anesthesiologist. trative office of the hospital, with a copy to (13) Class 100 environment—An atmospher- the medical records director, a signed state- ic environment which contains less than one (2) Notwithstanding any other rule in this ment to the effect that s/he is the only one hundred (100) particles five-tenths (0.5) chapter, anesthesia in hospitals shall be who has the stamp and is the only one who microns or larger in diameter per cubic foot administered only by qualified anesthesiolo- will use it. of air, according to federal standard 209E. gists, physicians or dentists trained in anes- (14) Dentist—An individual who has received thesia, certified nurse anesthetists, anesthesi- (6) Biological safety cabinet—A containment a Doctor of Dental Surgery or Doctor of ologist assistants or supervised students in an unit suitable for the preparation of low to Dental Medicine degree and is currently approved educational program. Notwith- moderate risk agents where there is a need licensed to practice dentistry in Missouri. standing the provisions of sections 334.400 to for protection of the product, personnel and 334.430, RSMo, or the rules of the Missouri environment, according to National Safety (15) Department—Missouri Department of State Board of Registration for the Healing Foundation, Standard 49. Health and Senior Services. Arts, the governing body of every hospital (7) Board-admissible—That a physician has shall have full authority to limit the functions applied to a specialty board and has received (16) Hospital emergency transfer policy—A and activities that an anesthesiologist assis- a ruling that s/he has fulfilled the require- document that represents the usual and cus- tant performs in such hospital. Nothing in ments to take the certification examinations. tomary practices of a hospital with respect to this section shall be construed to require any Board certification must be obtained within the transfer of patients. The department uses hospital to hire an anesthesiologist who is not five (5) years after completion of the residen- objective indicators of patient status in rela- already employed as a physician prior to cy. tion to hospital capabilities to identify gener- August 28, 2003. al classifications of patients who should be (8) Board-certified—That a physician has ful- considered for transfer to a hospital with the AUTHORITY: sections 192.006 and 197.080, filled all requirements, has satisfactorily necessary capabilities, and indicates the gen- RSMo 2000.* Original rule filed Jan. 16, completed all written and oral examinations eral classifications of patients the hospital has 2007, effective Aug. 30, 2007. and has been awarded a board diploma in a the capabilities to receive through emergency *Original authority: 192.006, RSMo 1993, amended 1995 specialty field. transfer from another hospital. The hospital and 197.080, RSMo 1953, amended 1993, 1995. emergency transfer policy does not supersede (9) Certified registered nurse anesthetist—A the authority of a physician to determine 19 CSR 30-20.011 Definitions Relating to registered nurse who has graduated from a whether patients should be transferred on a Hospitals school of nurse anesthesia accredited by the case-by-case basis, but serves as an institu- Council on Accreditation of Educational Pro- tional baseline to assist physician staff in pro- PURPOSE: This rule defines terminology grams of Nurse Anesthesia or its predecessor viding consistent care decisions and is uti- used throughout this chapter. and has been certified or is eligible for certi- lized for quality assurance review.
ROBIN CARNAHAN (7/31/07) CODE OF STATE REGULATIONS 3 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
(17) Independent licensed practitioner—An (21) Medical services—Those preventive, examination conducted by the American individual who is a graduate of a profession- diagnostic and therapeutic measures per- Medical Record Association or who has the al school and is licensed to practice as a formed by, or at the request of, members of documented equivalent in education and health care provider in Missouri. the medical staff or an independent licensed training. practitioner in outpatient services. (18) Infection control officer—An individual (31) Qualified occupational therapist—An who is a licensed physician, licensed regis- (22) Operator—Shall mean any person as individual who is a graduate of an occupa- tered nurse, has a bachelor’s degree in labo- defined by section 197.020, RSMo who is tional therapy program approved by a nation- ratory science or has similar qualifications licensed or required to be licensed under the ally recognized accrediting body, or who cur- and has additional training or education provisions of sections 197.020–197.120, rently holds certification by the American preparation in infection control, infectious RSMo to establish, conduct or maintain a Occupational Therapy Association as an diseases, epidemiology and principles of hospital. The term person shall mean any occupational therapist or who has the docu- quality improvement. person determined by the department to have mented equivalent in training or experience the following: and is currently competent in the field. (19) Infectious waste—Waste capable of pro- (A) Ultimate responsibility for making and ducing an infectious disease. For a waste to implementing decisions regarding the opera- (32) Qualified physical therapist—An indi- be infectious, it must contain pathogens with tion of the hospital; and vidual who is licensed to practice profession- sufficient virulence and quantity so that expo- (B) Ultimate financial control of the oper- al physical therapy in Missouri. sure to the waste by a susceptible host could ation of the hospital. result in an infectious disease. Infectious (33) Qualified radiologic technologist—An waste shall include the following categories: (23) PALS—The American Heart Associa- individual who is a graduate of a program in (A) Blood and blood products—All human tion’s pediatric advanced life support pro- radiologic technology approved by the Coun- blood and blood products including serum, gram. PALS may be used interchangeably cil on Medical Education of the American plasma and other components known or sus- with APLS where required. Medical Association or who has the docu- pected to be contaminated with a transmissi- mented equivalent in education and training. ble infectious agent; (24) Pharmacist—An individual who is a (B) Contaminated surgical, dialysis and graduate of a school or college of pharmacy (34) Qualified social worker—A licensed laboratory wastes—Wastes generated by and is currently licensed to practice pharma- clinical social worker or a person who has a surgery, dialysis and laboratory departments cy in Missouri. bachelor’s degree in social work or a mas- in the process of caring for hospital patients ter’s degree in social work. who have communicable diseases capable of (25) Physician—An individual who has being transmitted to others via those wastes; received a Doctor of Medicine or Doctor of (35) Registered nurse—An individual who is (C) Cultures and stocks of infectious Osteopathy degree and is currently licensed a graduate of an approved school of nursing agents and associated biologicals—Cultures to practice medicine in Missouri. and who is licensed to practice as a registered and stocks of infectious agents shall be desig- nurse in Missouri. nated as infectious waste because of the high (26) Podiatrist—An individual who has concentrations of pathogenic organisms typi- received a Doctor of Podiatric Medicine (36) Registered or certified respiratory thera- cally present in these materials. Included in degree and is currently licensed to practice pist—An individual who has been registered this category are all cultures and stocks of podiatry in Missouri. infectious organisms as well as culture dishes or certified by the National Board for Respi- and devices used to transfer, inoculate and (27) Psychologist—An individual who is cur- ratory Therapy, Inc. after successfully com- mix cultures. Also included are animal car- rently licensed by the State Committee of pleting all education, experience and exami- casses, body parts and bedding from animals Psychologists under the provisions of Chapter nation requirements or an individual who has contaminated with infectious agents; 337, RSMo. been registered or certified prior to Novem- (D) Isolation wastes—Wastes generated by ber 11, 1982, by an organization acceptable hospitalized patients who have communicable (28) Qualified dietitian—An individual who to the Department of Health and Senior Ser- diseases capable of being transmitted to oth- is registered by the Commission on Dietetic vices. ers via those wastes; Registration of the American Dietetic Associ- (E) Pathology wastes—Autopsy wastes ation or who has the documented equivalent (37) Root cause analysis—A process for which consist of tissues, organs, body parts in education, training and experience, with idenifying the basic or causal factor(s) that and body fluids that are removed during evidence of relevant continuing education. underlie variation in performance, including surgery and autopsy. All these wastes shall be the occurrence or possible occurrence of a considered infectious waste; and (29) Qualified medical record administra- sentinel event. (F) Sharps—All discarded sharps including tor—A registered record administrator who hypodermic needles, syringes and scalpel has successfully passed an appropriate exam- (38) Sentinel event—An unexpected occur- blades. Broken glass or other sharp items that ination conducted by the American Medical rence involving death or serious physical or have come in contact with material defined as Record Association or who has the document psychological injury, or the risk thereof. Seri- infectious are included. equivalent in education and training. ous injury specifically includes loss of limb or function. The phrase “or the risk thereof” (20) Inpatient—A person admitted into a hos- (30) Qualified medical record technician—An includes any process variation for which a pital by a member of the medical staff for accredited record technician who has suc- recurrence would carry a significant chance diagnosis, treatment or care. cessfully passed the appropriate accreditation of a serious adverse outcome.
4 CODE OF STATE REGULATIONS (7/31/07) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
(39) Special care unit—An appropriately 19 CSR 30-20.015 Administration of the tance is determined. If the application is equipped area of the hospital where there is a Hospital Licensing Program approved, the hospitals may be named on the concentration of physicians, nurses and others licensure application and a single license who have special skills and experience to pro- PURPOSE: This rule formalizes the hospital issued. Also, an operator of a licensed hospi- vide optimal medical care for critically-ill licensing policies being carried out by the tal may submit a proposal to provide, at a patients. Department of Health. It prescribes proce- minimum, all of the required patient care ser- dures for the review of hospital records, vices at a geographical location which at the (40) Transfer agreement—A document which acceptance of plans of deficiency correction time of the proposal is not a part of the sets forth the rights and responsibilities of and suspension of a hospital license. licensed hospital. The location shall be with- two (2) hospitals regarding the interhospital in a one (1)-hour travel distance by custom- transfer of patients. (1) Persons intending to operate a hospital ary ground transportation in normal weather shall submit information to the Department of conditions. Before the Department of Health (41) Unit—A functional division or facility of Health and Senior Services, as set out in the approves the application, the applicant shall the hospital. application form (MO 580-0007(8-01)) submit an operational proposal to the director included herein. Within thirty (30) days after of the Department of Health for approval. At (42) Diversion—A plan to temporarily close receipt of the application, the applicant will a minimum the proposal shall include: a hospital emergency department to ambu- be notified of any omitted information or (A) A description of the patient care ser- lance traffic. This may be due to the emer- documents. After sixty (60) days any incom- vices that will be provided at each geograph- gency department being overwhelmed with plete application is null. Each application for ical location and how they will be integrated significantly critically ill or injured patients, license to operate a hospital shall be accom- with patient care services at other geographi- or an overwhelming number of minor emer- panied by the appropriate licensing fee cal locations which will be operated under gency patients, to the extent that the hospital required by section 197.050, RSMo. Each the single license. The description shall is unable to provide quality care or protect license shall be issued for the premises and include justification to support the applicant’s the health or welfare of the patients it serves. persons named in the application. allegation that the combined patient care hos- A diversion also may be implemented if the pital services will exceed the current benefits hospital has resource limitations, such as, no (2) Each license shall be issued only for the that are derived by the community(ies) where available beds in specialty care units or gen- premises and persons named in the applica- each individual currently licensed hospital is eral acute care, no surgical suites or short- tion. A license, unless sooner revoked, shall located. Or, if the operator currently is not ages of equipment or personnel. be issued for a period of up to a year. If dur- providing the service within the geographical (A) Defined service area—The geographic ing the period in which a license is in effect, location contained in the proposal, there shall area served by a defined group of hospitals a licensed operator which is a partnership, be evidence the service is needed in that loca- and emergency services. In areas where there limited partnership, or corporation undergoes tion; is a community-based emergency medical any of the following changes, whether by one (B) A description of the organizational services diversion plan, the service area(s) (1) or by more than one (1) action, the oper- structure of the proposed single licensed hos- defined as the catchment area by the plan will ator shall within fifteen (15) working days of pital; be the defined service area(s). In areas where such change apply for a new license: (C) Documentation of evidence that the (A) With respect to a partnership, a change there is not a community-based emergency hospital’s facilities in each geographical loca- in the majority interest of general partners; tion named in the proposal will be owned or medical services diversion plan, the defined (B) With respect to a limited partnership, a leased by the same operator and that the ser- service area will be a twenty (20)-mile radius change in the general partner or in the major- vices are operated under common manage- from a hospital. ity interest of limited partners; ment; (43) Immediate and serious threat—Having (C) With respect to a corporation, a change (D) Assurance that the hospital’s operation caused, or is likely to cause, serious injury, in the persons who own, hold or have the in each geographical location will be held out harm, impairment, or death to a patient. power to vote the majority of any class of to the public under a common name; securities issued by the corporation. If the (E) Assurance the hospital’s services in AUTHORITY: sections 192.006 and 197.080, corporation does not have stock, a change of each geographical location will be subject to RSMo 2000 and 197.154 and 197.293, RSMo owner occurs when the emerging entity has the bylaws and operating decisions of the Supp. 2005.* This rule was previously filed one (1) federal tax number; or same governing body; as 13 CSR 50-20.011. Original rule filed June (D) The board of directors with manage- (F) Assurance that members of the medical ment control is an entity other than the staff in each geographical location will be 2, 1982, effective Nov. 11, 1982. Amended: licensed operator. directed by a common medical director and Filed June 2, 1987, effective Sept. 11, 1987. will be subject to the same bylaws and oper- Amended: Filed Aug. 16, 1988, effective Dec. (3) An operator of two (2) or more licensed ating decisions of a common medical staff; 29, 1988. Amended: Filed Nov. 21, 1995, hospitals may submit application to the (G) Assurance the hospital’s operations in effective July 30, 1996. Amended: Filed Oct. Department of Health to operate the hospitals each geographical location will be adminis- 6, 1998, effective April 30, 1999. Amended: as a single licensed hospital. The two (2) or tered by a common chief executive officer Filed June 28, 2001, effective Feb. 28, 2002. more licensed hospitals may be separated by through appropriate delegation of duties; Amended: Filed Sept. 20, 2005, effective a distance which can be traveled in no more (H) Assurance the licensed hospital’s ser- April 30, 2006. than one (1) hour by customary ground trans- vices in each geographical location will be portation in normal weather conditions. The integrated and, when services are provided at *Original authority: 192.006, RSMo 1993; amended 1995; 197.080, RSMo 1953, amended 1993, 1995; operator shall designate a permanent hospital multiple locations, that they will be super- 197.154, RSMo 2004; and 197.293, RSMo 2000, 2004 base from which the one (1)-hour travel dis- vised by a common director who is provided
ROBIN CARNAHAN (7/31/07) CODE OF STATE REGULATIONS 5 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
with adequate assistance in supervision of the of the applicant’s proposal. The Department cussing the operations of the hospital, either services; of Health shall be given two (2) weeks specifically or generally, with any representa- (I) Assurance that the single licensed hos- advance notice of the public hearings. tives of the department; and pital’s medical records department is inte- (B) No supervisor or individual with grated and the records are easily accessible to (4) The license shall state the maximum authority to hire and fire in a licensed hospi- patient care staff; licensed bed capacity, the person(s) to whom tal shall prohibit his/her employees from dis- (J) Assurance the applicant’s proposal is granted and the date and expiration date and closing information which the employee rea- not in violation of other federal, state and additional information, such as a specialty sonably believes evidences a violation of any local regulations; hospital designation, that the department may applicable state or federal law or regulation. (K) Assurance that the applicant, either require. At least forty-five (45) days prior to This subsection shall not be construed as— separately at each geographical location or in the expiration date of an existing license, the 1. Permitting an employee to leave combination, will provide all required patient department shall notify the operator that the his/her assigned work areas during normal care services, including emergency services, license application is due for renewal. A reli- work hours without following applicable in accordance with Chapter 197, RSMo and censure application shall be submitted no rules and policies pertaining to leaves, unless the employee is requested by the Department 19 CSR 30-20.021(3) and in accordance with more than ninety (90) days and not less than of Health to officially appear before depart- acceptable standards of practice; thirty (30) days prior to the expiration date of ment representatives; (L) Assurance that services and beds at one the existing license. Each application for 2. Authorizing an employee to represent (1) geographical location will not be reallo- license, except application from governmen- tal units, shall be accompanied by a licensing the employee’s personal opinions as the opin- cated to another geographical location prior ions of his/her employer; or to the operator requesting and obtaining fee in accordance with section 197.210, RSMo. 3. Precluding the operator from taking approval from the Certificate of Need pro- appropriate disciplinary actions against any gram, whenever appropriate, and the Depart- employee. ment of Health; (5) Appointed representatives of the Depart- (M) Approval from the Certificate of Need ment of Health shall be allowed to inspect a hospital as required in section 197.100, (8) Inspection. The department shall conduct program if the operator’s proposal includes a licensure compliance inspections of hospitals request to provide a patient care service in a RSMo. The chief executive officer or designee shall grant access to information as required by section 197.100, RSMo. geographical location of the hospital which is requested by the department for the purpose Inspections will normally be announced to not currently a part of the hospital’s license of evaluating compliance with hospital licens- the facility at least seventy-two (72) hours in when the proposal is subject to the Missouri ing requirements. Requested records may advance. Complaint investigations may be Certificate of Need law, sections include, but are not limited to, incident unannounced. 197.300–197.365, RSMo; reports, quality of care reports, peer review (N) Assurance that skilled nursing unit, reports, committee minutes, policies and pro- (9) Inspection Findings. intermediate care unit and residential care cedures, training records, medical records or (A) Whenever an authorized representative unit services provided within the licensed any other documents which are necessary to of the department finds, during an inspection, hospital are physically located at a geograph- complete the inspection. All information and that a hospital is not in compliance with the ical location of the hospital where all of the reports obtained by the Department of Health provisions of the Hospital Licensing Law, required patient care services are provided shall be kept confidential as required in sec- sections 197.010–197.120, RSMo, the chief on-site in accordance with Chapter 197, tion 197.477, RSMo. executive officer or designee shall be RSMo and 19 CSR 30-20.021(3); informed of the general nature of findings in (O) Assurance that the applicant’s propos- (6) Appointed representatives of the Depart- an exit conference conducted prior to the rep- al will not jeopardize the health and safety of ment of Health’s Bureau of Hospital Licens- resentative’s departure from the premises. individuals who reside within the geographi- ing and Certification shall be allowed to Within ten (10) working days after each cal locations which will be served by the sin- review patient medical records and hospital licensing inspection, a written report shall be gle licensed hospital. The applicant shall employee personnel records in the course of prepared by the department detailing the specifics of each deficiency. A copy of the demonstrate that the proposal contains provi- conducting an investigation of allegations report and a written correction order shall be sion for services which exceed or are compa- against an employee or previous employees of sent to the hospital’s chief executive officer rable to the services currently being provided a hospital or allegations of substandard care or designee. The report shall state each defi- to the community, or will provide adequate regarding a patient transferred to the hospital ciency separately and shall reference the spe- justification to convince the Department of from another licensed facility. The represen- tatives shall first provide written assurance cific statute or administrative rule violated. If Health the service is no longer needed within that information obtained from the patient’s the facility believes that deficiencies are not the geographical location where the service is medical record or from the employee’s per- applicable or are not based upon laws or currently provided; and sonnel record will be maintained confiden- rules, a request for review may be submitted (P) Assurance that the applicant presented tial. to the office of the director of the department. the proposal at a public hearing within the (B) Should the findings of the inspection community where the currently licensed hos- (7) The operator shall have a written policy constitute an immediate and serious threat to pital(s) is located. The proposal shall provide pertaining to employees reporting misman- the safety or health of the patients, public or evidence that the entire community was ade- agement of violations of applicable laws and hospital staff, a condition of substantial non- quately notified at least two (2) weeks in rules. At a minimum the policy shall include compliance shall be considered to exist. The advance, of the public hearings. The written the following provisions: department representative shall verbally con- record of the hearings, including the commu- (A) No supervisor or individual with hir- vey any determination of substantial noncom- nity response to the proposal, shall be sub- ing or firing authority in a licensed hospital pliance to the chief executive officer or mitted to the Department of Health as a part shall prohibit any of its employees from dis- designee at the exit conference. Findings of
6 CODE OF STATE REGULATIONS (7/31/07) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
substantial noncompliance shall be docu- O. Inadequate supervision to prevent D. High number of nosocomial infec- mented in the normal reporting method physical altercations; or tions caused by cross contamination from described in subsection (9)(A) of this rule. P. Lack of appropriate use, care plan- staff and/or equipment/supplies. (C) The following guidelines, applicable to ning or monitoring of patients when any type 7. Failure to correctly identify individu- the inspection, shall be used by the licensing of retraint, including but not limited to phys- als— representative to determine if a finding dur- ical or chemical restraint, is utilized. A. Blood products given to wrong ing an inspection constitutes an immediate 3. Failure to protect from psychological individual; and serious threat to the health and safety of harm— B. Surgical procedure/treatment per- one (1) or more patients. The guidelines used A. Application of chemical/physical formed on wrong individual or wrong body to determine immediate and serious threat restraints without clinical indications; part; serve only as guides for authorized depart- B. Presence of behaviors by staff such C. Administration of medication or ment representatives to use when making the as threatening or demeaning, resulting in dis- treatments to wrong individual; or determination. plays of fear, unwillingness to communicate, D. Discharge of an infant to the 1. Failure to protect from abuse— and recent or sudden changes in behavior by wrong individual. A. Serious injuries such as head trau- individuals; or 8. Failure to safely administer blood ma or fractures; C. Lack of intervention to prevent products and safely monitor organ transplan- B. Non-consensual sexual interac- individuals from creating an environment of tation— tions; e.g., sexual harassment, sexual coer- fear. A. Wrong blood type transfused; cion or sexual assault; 4. Failure to protect from undue adverse B. Improper storage of blood prod- C. Unexplained serious injuries that medication consequences and/or failure to ucts; have not been investigated; provide medications as prescribed— C. High number of serious blood D. Staff striking or roughly handling A. Administration of medication to an reactions; an individual; individual with a known history of allergic D. Incorrect cross match and utiliza- E. Staff yelling, swearing, gesturing reaction to that medication; tion of blood products or transplantation or calling an individual derogatory names; B. Lack of monitoring and identifica- organs; or F. Bruises around the breast or genital tion of potential serious drug interaction, side E. Lack of monitoring for reactions area; or effects, and adverse reactions; during transfusions. G. Suspicious injuries; e.g., black 9. Failure to provide safety from fire, C. Administration of contraindicated eyes, rope marks, cigarette burns, unex- smoke and environment hazards and/or fail- medications; plained bruising. ure to educate staff in handling emergency D. Pattern of repeated medication 2. Failure to prevent neglect— situations— errors without intervention; A. Lack of timely assessment of indi- A. Nonfunctioning or lack of emer- E. Lack of diabetic monitoring result- viduals after injury; gency equipment and/or power source; ing or likely to result in serious hypoglycemic B. Lack of supervision for individual B. Smoking in high risk areas; or hyperglycemic reaction; or with known special needs; C. Incidents such as electrical shock, F. Lack of timely and appropriate C. Failure to carry out doctor’s fires; orders; monitoring required for drug titration. D. Ungrounded/unsafe electrical D. Repeated occurrences such as falls 5. Failure to provide adequate nutrition equipment; which place the individual at risk of harm and hydration to support and maintain E. Widespread lack of knowledge of without intervention; health— emergency procedures by staff; E. Access to chemical and physical A. Food supply inadequate to meet F. Widespread infestation by hazards by individuals who are at risk; the nutritional needs of the individual; insects/rodents; F. Access to hot water of sufficient B. Failure to provide adequate nutri- G. Lack of functioning ventilation, temperature to cause tissue injury; tion and hydration resulting in malnutrition; heating or cooling system placing individuals G. Non-functioning call system with- e.g., severe weight loss, abnormal laboratory at risk; out compensatory measures; values; H. Use of non-approved space H. Unsupervised smoking by an indi- C. Withholding nutrition and hydra- heaters, such as kerosene, electrical, in resi- vidual with a known safety risk; tion without advance directive; or dent or patient areas; I. Lack of supervision of cognitively D. Lack of potable water supply. I. Improper handling/disposal of haz- impaired individuals with known elopement 6. Failure to protect from widespread ardous materials, chemicals and waste; risk; nosocomial infections; e.g. failure to practice J. Locking exit doors in a manner that J. Failure to adequately monitor indi- standard precautions, failure to maintain ster- does not comply with NFPA 101; viduals with known severe self-injurious ile techniques during invasive procedures K. Obstructed hallways and exits pre- behavior; and/or failure to identify and treat nosocomi- venting egress; K. Failure to adequately monitor and al infections— L. Lack of maintenance of fire or life intervene for serious medical/surgical condi- A. Pervasive improper handling of safety systems; or tions; body fluids or substances from an individual M. Unsafe dietary practices resulting L. Use of chemical/physical restraints with an infectious disease; in high potential for food-borne illnesses. without adequate monitoring; B. High number of infections or con- 10. Failure to provide initial medical M. Lack of security to prevent abduc- tagious diseases without appropriate report- screening, stabilization of emergency medical tion of infants; ing, intervention and care; conditions and safe transfer for individuals N. Improper feeding/positioning of C. Pattern of ineffective infection and women in active labor seeking emergen- individual with known aspiration risk; control precautions; or cy treatment—
ROBIN CARNAHAN (7/31/07) CODE OF STATE REGULATIONS 7 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
A. Individuals turned away from visions of the Hospital Licensing Law, sec- beyond the date of cessation of patient ser- emergency room (ER) without medical tions 197.010–197.120, RSMo and 19 CSR vices for ownership transfer. The suspension screening exam; 30-20.011–19 CSR 30-20.070, the depart- of a hospital’s current license shall not exceed B. Women with contractions not med- ment may take action to suspend or to revoke one hundred eighty (180) days beyond the ically screened for status of labor; the operator’s license to operate the hospital. date of cessation of patient services for reno- C. Absence of ER or obstetrical (OB) The operator has the right to appeal the vation construction. The department may not medical screening records; department’s decision in accordance with grant more than one (1) suspension to a hos- D. Failure to stabilize emergency section 197.071, RSMo. pital’s licensed operator within any twelve medical condition; or (12)-month period and shall grant no suspen- E. Failure to appropriately transfer an (12) If, for a period in excess of fourteen (14) sion for a period of more than one hundred individual with an unstabilized emergency days, a facility ceases to provide patient care eighty (180) days from the date of cessation medical condition. or to otherwise operate as a hospital within of inpatient services. the definition of section 197.020.2, RSMo, (E) No inpatients shall be housed within (10) Settlement Agreement. except in the case of a strike, an act of God the hospital from the initial date of cessation (A) Ten (10) working days following or written approval of the department, the of inpatient services until operation of the receipt of the written inspection report, the facility shall surrender its license to the hospital is restored with Department of chief executive officer or designee shall pro- department. The facility shall not operate Health approval. vide the department with a written plan for again as a hospital until an application for a (F) No inpatient services shall be provided correcting the cited deficiencies or a request hospital license is submitted with assurance in the hospital during the period of time that for reconsideration of the deficiency. The that the facility complies with the require- inpatient services are discontinued. plan of correction shall specify the means the ments in 19 CSR 30-20.030 and the Depart- (G) When suspension of the license is hospital will employ for correcting the cited ment of Health issues a license. requested for a renovation or construction deficiencies and the date that each corrective proposal, the licensed operator shall submit measure will be completed. If a request for (13) Requested Suspension of License. If any plans for the renovation to the department for reconsideration is submitted, the request shall hospital wishes to cease operation for a peri- review and shall have received the depart- contain rationale or documentation to provide od of time but retain its current hospital ment’s approval of those plans prior to the evidence that the deficiency should not have license, the Department of Health, upon writ- date of cessation of patient services at the been cited. Failure of the facility to submit a ten request from the licensed operator, may hospital. plan of correction or a request for reconsid- grant approval for suspension of the hospital’s (H) The licensed operator shall notify the eration of the deficiency acceptable to the license for a specified time. department no less than fourteen (14) days director of the department or designee—with- (A) Not less than fourteen (14) days prior prior to the resumption of inpatient services in the time frame specified—shall be grounds to cessation of patient services at the hospital, that the hospital is ready for review/inspec- for the department to suspend the facility’s the licensed operator shall submit to the tion for approval to reoccupy the hospital license if there remains a substantial failure to department a written request for continuance. with inpatients. comply with the requirements established (B) The written request for the suspension (I) Within ten (10) working days of notifi- under sections 197.010–197.120, RSMo and of the license shall include the reasons for cation, the department shall respond in writ- 19 CSR 30-20.011–19 CSR 30-20.070. The cessation of patient services, the anticipated ing to the licensed operator with the findings operator has the right to appeal the depart- length of cessation of patient services, what of its review/inspection for the resumption of ment’s decision in accordance with section safeguards the hospital will institute to pro- licensed hospital services at the hospital. 197.071, RSMo. vide security to the institution, the preventive (B) Upon receipt of the required plan of maintenance measures used to assure that all (14) Involuntary Suspension or Revocation of correction for achieving licensure compli- equipment will be kept in good working order the License. ance, the department shall review the plan to and evidence that the hospital is financially (A) Whenever the department determines determine the appropriateness of the correc- solvent to meet the conditions of the request that substantial noncompliance exists in a tive action. If the plan is acceptable, the and will remain so throughout the period of hospital, the department may immediately department shall notify the chief executive cessation of patient services. suspend or revoke the license of the facility or officer or designee, in writing, and indicate (C) Approval may be granted only for the order cessation of use of any portion of the that implementation of the plan should pro- suspension of a hospital’s current license if noncompliant services or buildings. ceed. If the plan is not acceptable, the depart- the cessation of patient services is for one (1) (B) The department shall document its ment shall notify the chief executive officer of the following reasons: action in writing in addition to the report or designee, in writing, and indicate the rea- 1. The renovation of the hospital’s facil- detailing the findings of the inspection. A sons why the plan is not acceptable. Within ity to upgrade to current licensure standards copy shall be submitted to the hospital’s chief ten (10) working days from the receipt of the and to correct licensure or federal certifica- executive officer or designee. notice, a revised, acceptable plan of correc- tion physical plant deficiencies; (C) The hospital shall expedite corrections tion shall be provided to the department. 2. The transfer of the operation of the required to relieve the involuntary suspension hospital to a new operator to allow sufficient or revocation. (11) Follow-up Inspections. Upon expiration time for the new operator to obtain a new (D) The operator may elect to seek appeal of the target dates for correction of deficien- license; or or relief from the Administrative Hearing cies specified in the approved plan of correc- 3. Other reasons which will not result in Commission in accordance with section tion, the department may make a follow-up a deterioration of the hospital physical plant 197.071, RSMo, or the operator may elect to inspection to determine whether the required or its programs and which will be in the best first request a review of the action by the corrective measures have been acceptably interest of the citizens it serves. office of the director of the department. accomplished. If the follow-up inspection (D) The suspension of a hospital’s current finds the facility fails to comply with the pro- license shall not exceed ninety (90) days
8 CODE OF STATE REGULATIONS (7/31/07) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
ROBIN CARNAHAN (3/31/06) CODE OF STATE REGULATIONS 9 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
10 CODE OF STATE REGULATIONS (3/31/06) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
AUTHORITY: sections 192.006, 197.080, the same will be made available at the Office be performed, approximate space needed for and 197.293, RSMo 2000.* This rule was of the Secretary of State at a cost not to these functions and the interrelationship of previously filed as 13 CSR 50-20.015. Origi- exceed actual cost of copy reproduction. The various functions and spaces. The program nal rule filed April 9, 1985, effective July 11, entire text of the rule is printed here. This also shall describe how essential services can 1985. Amended: Filed Nov. 4, 1992, effective note refers only to the incorporated by refer- be expanded in the future as the demand June 7, 1993. Amended: Filed Nov. 21, 1995, ence material. increases. Appropriate modifications or dele- effective July 30, 1996. Amended: Filed Oct. tions in space requirements may be made 6, 1998, effective April 30, 1999. Amended: (1) New Hospital General Requirements. when services are shared or purchased, pro- Filed June 28, 2001, effective Feb. 28, 2002. (A) A new hospital is one for which plans vided the program indicates where the ser- Amended: Filed April 30, 2004, effective are submitted to the Department of Health for vices are available and how they are to be Dec. 30, 2004. review and approval after November 11, 1982 provided. for the construction of a new facility, expan- *Original authority: 192.006, RSMo 1993, amended sion or renovation of an existing hospital or (2) Planning and Construction Procedure. 1995; 197.080, RSMo 1953, amended 1993, 1995; and the conversion of an existing facility not pre- (A) Plans and specifications shall be pre- 197.293, RSMo 2000. viously and continuously licensed as a hospi- pared for the construction of all new hospitals tal under Chapter 197, RSMo. A new hospi- and additions to and major remodeling of tal shall be designed to provide all of the existing hospitals. The plans and specifica- facilities required by this rule and arranged to tions shall be prepared by an architect or a 19 CSR 30-20.021 Organization and Man- accommodate all of the functions required by professional engineer licensed to practice in agement for Hospitals this rule and to provide comfortable, sanitary, Missouri. (Rescinded February 29, 2008) fire-safe, secure and durable facilities for the (B) Construction shall be in conformance patients. In major alteration projects and with plans and specifications approved by the AUTHORITY: sections 192.006 and 197.080, additions to an existing licensed hospital, Department of Health. The Department of RSMo 2000 and 197.154, RSMo Supp. 2005. only that part of the total hospital affected by Health shall be notified within five (5) days This rule was previously filed as 13 CSR 50- the project is subject to this rule. after construction begins. If construction of 20.021 and 19 CSR 10-20.021. Original rule (B) These minimum requirements are not the project is not started within one (1) year filed June 2, 1982, effective Nov. 11, 1982. intended in any way to restrict innovations after the date of approval of the plans and Amended: Filed April 9, 1985, effective Sept. and improvements in design, construction or specifications, the plans and specifications 28, 1985. Amended: Filed June 2, 1987, operating techniques. Plans and specifica- shall be resubmitted to the Department of effective Sept. 11, 1987. Amended: Filed Nov. tions and operational procedures which con- 16, 1987, effective March 26, 1988. Amend- tain deviations from these requirements may Health for its approval and shall be amended, ed: Filed June 14, 1988, effective Oct. 13, be approved if it is determined that the pur- if necessary, to comply with the then current 1988. Amended: Filed Aug. 16, 1988, effec- poses of the minimum requirements have rules before construction work commences. tive Dec. 29, 1988. Amended: Filed Nov. 21, been fulfilled. Some facilities may be subject 1995, effective July 30, 1996. Amended: to the requirements of more than one (1) reg- (3) General Design. Filed Oct. 6, 1998, effective April 30, 1999. ulating agency. While every effort has been (A) Site. Amended: Filed June 28, 2001, effective Feb. made to ensure coordination, facilities mak- 1. The facility shall be located so it is 28, 2002. Amended: Filed April 30, 2004, ing requests for changes in services and reasonably accessible to the community effective Dec. 30, 2004. Emergency amend- request for new construction or renovations served, close to where competent medical ment filed Sept. 1, 2005, effective Sept. 11, are cautioned to verify requirements of other and professional consultation is readily avail- 2005, expired March 9, 2006. Amended: agencies involved. able and where employees can be recruited Filed Feb. 1, 2006, effective July 30, 2006. (C) Requests for deviations from the and retained. Rescinded: Filed June 27, 2007, effective Feb. requirements of this rule shall be in writing to 2. Fire lanes shall be provided and kept 29, 2008. the Department of Health. Approvals for clear to provide immediate access for the fire deviations shall be in writing and both fighting equipment. requests and approvals shall become a part of 3. Paved roads shall be provided within 19 CSR 30-20.030 Construction Standards the permanent Department of Health records for New Hospitals the lot lines to provide access to the main for the facility. entrance, emergency entrance, entrances (D) Alterations or additions to existing serving community activities and to service PURPOSE: This rule establishes up-to-date hospitals shall be programmed so construc- construction standards for new hospitals to entrances, including loading and unloading tion will minimize disruptions of existing docks for delivery trucks. Hospitals having an help ensure accessible, functional, fire-safe functions. Access to exits and fire protections organized emergency service shall have the and sanitary facilities. shall be maintained so the safety of the occu- emergency entrance well marked to facilitate pants will not be jeopardized during con- PUBLISHER’S NOTE: The secretary of state struction. entry from the public roads or streets serving has determined that the publication of the (E) The owner of each new facility or the the site. Access to the emergency entrance entire text of the material which is incorpo- owner of an existing facility being added to or shall not conflict with other vehicular traffic rated by reference as a portion of this rule undergoing major alterations shall provide a or pedestrian traffic. Paved walkways shall be would be unduly cumbersome or expensive. program—scope of services—which de - provided for necessary pedestrian traffic. Therefore, the material which is so incorpo- scribes space requirements, staffing patterns, 4. Documentation of parking needs shall rated is on file with the agency who filed this departmental relationships and other basic be provided by the hospital as part of the pro- rule, and with the Office of the Secretary of information relating to the objectives of the gram. State. Any interested person may view this facility. The program may be general but it (B) Special Design Considerations for the material at either agency’s headquarters or shall include a description of each function to Handicapped.
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 11 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
1. One-half (1/2) of one percent (1%) of (B) Every bed shall have aisles at least (F) A toilet is required adjacent to each bed capacity or two (2) parking spaces, three feet (3') wide on both sides. The aisle room with direct access without entering the whichever is greater, shall be provided for between adjacent beds may serve both beds corridor. It shall contain a water closet with a handicapped visitors. Parking spaces for and may serve as access to facilities serving bedpan cleanser and also may contain a lava- handicapped staff members shall be provided both beds. Each aisle between a bed and wall tory. It may serve more than one (1) room, as required. Parking spaces for handicapped shall serve as access only to facilities serving but in no case more than four (4) beds. A persons shall be at least twelve feet (12') the adjacent bed, except the window and the lavatory equipped with a faucet with goose- wide and on level grade. Parking spaces for heating unit. An aisle, not less than four feet neck spout and wrist blades shall be provided handicapped shall be located so there is (4') wide in multi-bed rooms and not less in each room. The lavatory shall be accessi- access to sidewalks without going behind than three feet (3') wide in single-bed rooms, ble without entering a toilet unless the toilet other parked cars. shall be provided at the foot of each bed. serves only one (1) bed. 2. Walkways and curbs from the street Aisles shall be continuous and clear of any (G) A separate closet or built-in wardrobe, or parking spaces to the building entrance built-in equipment with the exception of a suitable for hanging full-length garments on shall be designed to facilitate travel by people heating or air-conditioning unit not more than clothes hangers and for storage of personal in wheelchairs or on crutches. three feet (3') high and extending not more effects, shall be provided for each bed. 3. Parking spaces and one (1) or more than nine inches (9") into a side aisle. A unit (H) General lighting, switchable at the entrances to a facility shall be designed to combining a side table and electrical facilities door, shall be sufficient to provide a light facilitate the building’s use by handicapped specially designed for convenience to the intensity of fifteen (15) foot-candles in all persons. patient and for convenient access for patient parts of the room. A nonswitchable night 4. At least one (1) primary grade-level care may be installed in a side aisle. light, arranged to avoid shining in the entrance to the building shall be arranged to (C) Each bed in a multi-bed room shall be patients’ eyes, shall be provided. A reading be fully accessible to handicapped persons. provided with cubicle curtains or equivalent light, switchable from the bed, shall be pro- 5. At least one (1) drinking fountain, facilities arranged to contain adjacent floor vided for each bed. The toilet light shall be one (1) toilet and one (1) hand washing facil- space and to provide intermittent visual pri- switchable at the toilet door. A switchable ity shall be available on each floor for physi- vacy, but shall not restrict patient access to light shall be provided at each lavatory. All switches for lighting in patient areas shall be cally handicapped patients and staff. At least the lavatory and toilet. of the quiet operating type. Duplex grounding one (1) wheelchair shower shall be provided (D) One (1) or more windows, with sash type convenience outlets shall be provided as in the patient area. Floors where the handi- not more than three feet (3') above the floor follows: one (1) on each side of each bed in capped are specifically excluded from the and with gross area not less than ten percent the headwall for clinical equipment, one (1) entire area, such as boiler rooms, need not (10%) of the floor area of the room, shall be at each lavatory and at least one (1) outlet on meet these requirements. provided. If the building has an engineered each wall space in the room. If television and 6. A public telephone, drinking fountain smoke control system which complies with electric beds are installed, grounding type and toilets with hand washing facilities acces- Standard for Air Conditioning and Ventilating receptacles shall be provided for each. Systems 1978 published by the National Fire sible to handicapped visitors shall be located (I) The nurses’ call system shall be Protection Association, windows are not in the hospital. installed in accordance with subparagraphs 7. In an alteration project and additions required to be operable. Otherwise, at least (26)(F)1.A.–F. of this rule. to an existing hospital, only that portion of one (1) window or screened vent to the out- (J) Oxygen supply outlets and clinical suc- the total hospital affected by the project, side in each patient room shall be operable. tion outlets shall be accessible from each bed including that part of adjacent areas used for Operable windows may be operable by a tool in accordance with paragraph (27)(F)3. of access by the handicapped, must comply with located in the nursing unit. Operable win- this rule. paragraphs (3)(B)1.–6. of this rule. dows not restricted to emergency use shall be (K) At least one (1) room in the hospital equipped with screens. Windows shall be shall meet the following isolation require- (4) General Design of Nursing Unit—Adult exposed to an outside area not less than thir- ments: Medical, Surgical and Post-Partum Care ty feet (30') horizontally opposite the window 1. Entrance from the corridor shall be (except special care areas such as recovery and containing no construction which would through an anteroom which contains facilities rooms, intensive care units and psychiatric further diminish the exposure of the window to assist staff in maintaining aseptic condi- units). to natural light. tions. The anteroom shall contain a lavatory (A) Every room shall have direct access to (E) Access to the corridor shall be either or sink equipped for handwashing, storage a corridor, shall have a window and shall con- direct or through a vestibule and through one spaces for clean and soiled materials and tain a lavatory, closets and electrical and (1) or more doors. A single door leaf may be gowning facilities; mechanical facilities. No room shall contain used if it is at least forty-four inches (44") 2. The door to the room shall have a more than four (4) beds. No bed shall have wide. If double doors are used, both leaves viewing panel for observation from the ante- more than one (1) bed between it and the shall equal at least forty-four inches (44") room; and window wall. The room area exclusive of toi- and one (1) leaf shall be at least thirty-two 3. A private toilet containing a water let rooms, closets, lockers, wardrobes, inches (32") wide. Doors shall not swing into closet and a tub or shower shall be provided. alcoves or vestibules shall be not less than the corridor unless recessed to avoid intru- A handwashing facility shall be located in the one hundred (100) square feet in a single-bed sion into the flow of traffic. The door hard- toilet or in the patient room. room nor less than eighty (80) square feet for ware shall permit entry and egress without (L) If suitable psychiatric facilities are not each bed in a multi-bed room. The ceiling the use of hands. The toilet door shall swing available in the community, at least one (1) shall be not less than eight feet (8') above the out except when equipped with emergency room shall be equipped to provide for dis- floor. rescue hardware. turbed patients needing close supervision.
12 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
This room shall be designed to minimize the in an individual room or enclosure which unless the special care unit is on the same potential for escape, injury or suicide. The provides space for the private use of the floor as the main waiting room. door to this room shall swing outward and be bathing fixture and for drying and dressing. (J) A clean workroom with work counter recessed so it does not intrude on the flow of At least one (1) shower on each patient floor handwashing facility and storage space shall traffic. shall have space for a wheelchair. At least one be provided unless an alternate system for (1) shower shall be provided for each twelve storage and distribution of clean and sterile (5) A service area shall be located in or be (12) beds in post-partum units. supplies is approved. readily available to each nursing unit. The (K) A work counter with a sink, waste location and disposition of each service area (6) Special Care Units. receptacle and linen receptacle shall be pro- will depend upon the number and types of (A) Special care patients may be housed in vided unless it can be shown that the soiled beds to be served. Each service area may be single-bed rooms or in multi-bed rooms. If holding room is part of a system for collect- arranged and located to serve more than one multi-bed rooms are provided, at least one (1) ing soiled materials. (1) nursing unit, but at least one (1) service single-bed room shall be provided for each (L) Facilities for flushing and washing bed- area shall be provided on each nursing floor. unit. In any case, one (1) room shall be set up pans shall be provided within the unit. In addition to a nurses’ station, nurses’ for isolation techniques. (M) A nourishment station with counter, office, equipment storage room, charting (B) All beds shall be arranged to permit sink, ice dispenser and refrigerator shall be facilities and staff toilet facilities, service direct visual observation by nursing staff or located in or adjacent to the unit. areas shall include: patient shall be electronically monitored. (N) Storage space for equipment shall be (A) Janitors’ closet with mop sink, mop (C) Natural lighting by windows shall be provided. Space shall be provided in the unit rack and space for equipment; available to each patient. One (1) window for emergency equipment and supplies. (B) A medicine preparation area containing may serve more than one (1) patient space, (O) A medicine preparation facility con- a work counter with sink, refrigerator and but not more than two (2). Window sills shall taining a work counter with sink, refrigerator locked storage for biologicals and drugs; not be more than three feet (3') above the and locked storage for biologicals and drugs (C) At least one (1) treatment room with floor. Unless the building is designed with an shall be provided. handwashing sink for each floor. If all patient engineered smoke control system in accor- (P) A toilet room equipped with water rooms are single, this room may be omitted; dance with Standard for Air Conditioning and closet and lavatory shall be provided for staff. (D) A clean workroom or clean holding Ventilating Systems 1978 published by the A lounge shall be provided for staff. Facilities room. The clean workroom shall contain a National Fire Protection Association, at least for safekeeping of coats and personal belong- work counter and handwashing and storage one (1) window in each room shall be opera- ings of personnel shall be provided. facilities including cart parking space. The ble. The use of a tool located in the unit is (Q) A janitors’ facility shall be located clean holding room shall be part of a system acceptable for window operation. within or adjacent to the special care unit. for storage and distribution of clean and ster- (D) Clearance between beds in multi-bed ile supply materials and shall be similar to rooms shall not be less than six feet (6'). (7) Emergency Facilities. the clean workroom except that the work Clearance between the bed and adjacent wall (A) As a minimum, hospitals shall provide counter and handwashing facilities may be shall not be less than three feet (3') and a the following: omitted; clear aisle of at least four feet (4') shall be 1. A sheltered entrance at grade level (E) A soiled workroom or soiled holding provided between the foot of the bed and accessible to the pedestrian and a sheltered room. The soiled workroom shall contain a wall. Single-bed rooms or solid wall cubicles ambulance unloading area; clinical sink or equivalent flushing rim fix- shall have a minimum clear area of one hun- 2. At least one (1) treatment room with ture, work counter with a sink suitable for dred twenty (120) square feet and a minimum handwashing facilities, cabinets, medication handwashing, waste receptacle and linen dimension of ten feet (10'). storage space, work counter, suction and oxy- receptacle. A soiled holding room shall be (E) Viewing panels shall be provided in gen outlets, X-ray film illuminator and space part of a system for collection and disposal of doors and walls for observation of patients. for storage of emergency equipment; soiled materials and shall be similar to the Glazing in viewing panels shall be nonshat- 3. A patient’s toilet convenient to the soiled workroom except that the clinical sink tering glass. treatment room; and and work counter may be omitted; (F) A handwashing lavatory shall be pro- 4. A janitors’ closet. (F) Clean linen storage space in a separate vided in each patient’s room. In multi-bed (B) Hospitals providing a fully equipped closet or as a designated area within the clean rooms, a lavatory is to be provided at a ratio emergency service shall have, in addition to workroom or holding room. If a closed cart of no less than one (1) lavatory for each six paragraphs (7)(A)1., 2. and 4. of this rule, system is used, storage may be in an alcove; (6) beds. the following: (G) A nourishment station with a sink, (G) Each special care unit shall have a toi- 1. A reception and control area conve- refrigerator, storage cabinets, icemaker, ice let facility which is directly accessible from nient to the emergency entrance, waiting dispenser and equipment for serving nourish- the unit. In multi-bed rooms, toilets are to be room and treatment rooms; ments between meals; provided at a ratio of one (1) toilet for each 2. Public waiting space with toilet facil- (H) Space for parking stretchers and six (6) beds. Portable water closet units may ities, public telephone and drinking fountain; wheelchairs located out of the path of normal be used. 3. Storage space for wheelchairs and traffic; and (H) Individual lockers shall be provided for stretchers out of line of traffic; (I) In nursing units, bathtubs or showers the storage of patients’ clothing and personal 4. Clean supply storage space and clean shall be provided at the rate of one (1) for effects. Lockers shall be large enough to per- utility facilities; and each twelve (12) beds which are not other- mit hanging of full-length garments. 5. Soiled work area containing a clinical wise served by bathing facilities within (I) A separate waiting room shall be pro- sink, work counter with handwashing facility patients’ rooms. Each tub or shower shall be vided for visitors to special care patients and waste and soiled linen receptacles.
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 13 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
(8) Surgical Facilities. be provided. It shall contain a work counter suction outlets and clinical air, shall be pro- (A) If surgical facilities are provided, the and sink. vided for newborn infants. number of operating rooms, recovery beds (N) Storage space for equipment and sup- (C) Labor beds shall be provided at the and the size of the service areas shall be plies shall be provided. rate of two (2) for each delivery room. In based on the scope of services to be provid- (O) Appropriate areas shall be provided in facilities having only one (1) delivery room, ed. the surgical suite for male and female per- two (2) labor rooms shall be provided; and (B) The surgical suite shall be located and sonnel to change clothes. The areas shall con- one (1) labor room shall be large enough to arranged to preclude unrelated traffic through tain lockers, showers, toilets, handwashing function as an emergency delivery room with the suite. lavatories and space for donning scrub suits a minimum of one hundred sixty (160) square (C) Each general operating room shall have and boots. These areas shall be arranged to feet and shall have at least two (2) oxygen and a minimum clear area of three hundred sixty provide a one (1)-way traffic pattern so that two (2) suction outlets. All other labor rooms (360) square feet exclusive of fixed and mov- personnel entering from outside the surgical shall be single-bed or two (2)-bed rooms with able cabinets and shelves. The minimum suite can shower, change and move directly a minimum clear area of one hundred (100) dimension shall be eighteen feet (18'). Ceil- into the surgical suite. Similarly, space shall square feet in single-bed rooms and eighty ings shall be at least nine feet six inches be designed for the removal of scrub suits and (80) square feet per bed in two (2)-bed (9'6") high to accommodate surgical lights. boots in the change area so that personnel rooms. (D) Operating rooms for surgical cysto- using it will avoid physical contact with clean (D) Each labor room shall contain a lava- scopic and other endoscopic procedures shall personnel. tory equipped for handwashing. Each labor have a minimum clear area of two hundred (P) Space outside the flow of traffic shall room shall have access to a toilet room with- fifty (250) square feet exclusive of fixed and be provided for storage of stretchers. out entering the corridor. One (1) toilet room movable cabinets and shelves. (Q) A janitors’ closet containing a floor may serve two (2) labor rooms. (E) A control station located to permit receptor or service sink and storage space for (E) At least one (1) shower shall be pro- visual surveillance of all traffic which enters housekeeping supplies and equipment shall vided for labor room patients. the operating suite shall be provided. be provided exclusively for the surgical suite. (F) In facilities having or expecting to have (F) An emergency communications system (R) At least one (1) post-anesthesia recov- more than one thousand five hundred (1,500) connecting the operating rooms and the sur- ery room shall be provided. This room shall births annually, a recovery room containing not less than two (2) beds shall be provided. gical suite control station shall be provided. contain a nurses’ station, a drug distribution station, clinical gases, handwashing facilities, This room shall contain handwashing facili- (G) A high speed autoclave shall be conve- clinical sink and storage space. ties, clinical sink and storage space for sup- niently located to serve all operating rooms. (S) If the program defines an outpatient plies and equipment. The room shall be (H) Space for the storage and preparation surgery load, separate areas shall be provided designed to provide at least three feet (3') of medications shall be provided. where outpatients can change clothing. This clear on each side of each recovery bed. (I) A minimum of one (1) scrub station shall include a waiting room, lockers, toilets, (G) A control station located to permit shall be provided for each operating room. handwashing lavatories and a clothing change visual surveillance of all traffic which enters (J) A soiled workroom for the exclusive or gowning area with a traffic pattern similar the obstetrical suite shall be provided. use of the surgical suite staff or a soiled hold- to that of the staff clothing change area in (H) A supervisor’s office or station shall ing room, that is part of a system for collec- subsection (8)(O) of this rule. be provided. tion and disposal of soiled material, shall be (T) If outpatient surgical procedures are (I) A high speed autoclave shall be conve- provided. The soiled workroom shall contain performed, a separate recovery area with niently located to serve all delivery rooms. a clinical sink or equivalent flushing-type fix- handwashing facilities shall be provided for (J) A janitors’ closet containing a floor ture, work counter with a double sink, sink those patients not subjected to general anes- receptor or service sink, mop rack and space equipped for handwashing, waste receptacle thesia. for equipment shall be provided exclusively and linen receptacle. A soiled holding room for the obstetrical suite. shall be similar to the soiled workroom (9) Obstetrical Facilities. (K) A nurses’ toilet and lounge shall be except that the work counter may be omitted. (A) If obstetrical facilities are provided, located near the labor rooms. (K) A clean workroom or a clean supply the number of delivery rooms, labor rooms (L) Scrub stations shall be provided at the room shall be provided. A clean workroom is and recovery beds and the size of the service ratio of one (1) for each delivery room. required when clean materials are assembled areas shall depend upon the estimated obstet- (M) A soiled workroom or soiled holding within the surgical suite prior to use. A clean rical workload as described in the program. room for the exclusive use of the obstetrical workroom shall contain a work counter, sink The post-partum patient area and the obstet- suite staff shall be provided. The soiled work- equipped for handwashing and space for rical suite shall be located and arranged to room shall contain a clinical sink or equiva- clean and sterile supplies. A clean supply preclude unrelated traffic through the suite. lent flushing-type fixture; work counter with room shall be provided when the program (B) Each delivery room shall have a mini- double sink, waste receptacle and linen defines a system for the storage and distribu- mum clear area of three hundred (300) square receptacle. A soiled holding room shall be tion of clean and sterile supplies which would feet exclusive of fixed and movable cabinets similar to the soiled workroom except that the not require the use of a clean workroom. and shelves. The minimum dimensions shall work counter may be omitted. (L) A separate room shall be provided for be sixteen feet (16'). Ceilings shall be at least (N) A clean workroom or clean supply storage of flammable anesthetics unless the nine feet six inches (9'6") high. An emergen- room shall be provided. A clean workroom use of flammable anesthetics is prohibited in cy communication system shall connect the with a work counter with sink and storage writing by hospital board action. delivery room with the obstetrical suite con- space for clean and sterile supplies is (M) An anesthesia workroom for cleaning, trol station. Separate resuscitation facilities, required when materials are assembled in the testing and storing anesthesia equipment shall including electrical outlets, oxygen outlets, obstetrical suite.
14 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
(O) An equipment storage room shall be nursery and the workroom. Glazing shall be (F) At least one (1) interview room shall be provided. Space shall be assigned for stretch- nonshattering glass. located in or adjacent to the pediatric unit. er parking. (J) A janitors’ closet shall be provided for (G) A minimum of two hundred (200) (P) Appropriate change areas shall be pro- the exclusive use of the nursery area. It shall square feet of storage space shall be provided vided for male and female personnel working contain a floor receptor or service sink and within or adjacent to the unit. within the obstetrical suite. The areas shall storage space for equipment and supplies. (H) At least one (1) isolation room with contain lockers, showers, toilets, lavatories (K) A room with handwashing facilities toilet, sink, shower or tub shall be provided. equipped for handwashing and space for don- shall be provided where mothers may be (I) An anteroom with sink wrist controls ning scrub suits and boots. These areas shall given instructions and demonstrations in shall provide access to the isolation room be arranged to provide a one (1)-way traffic methods of feeding, bathing and dressing from the corridor. pattern so that personnel entering from out- their infants. (J) A nurses’ station, with a nurses’ side the obstetrical suite can shower, change lounge, physicians’ charting area and a med- and move directly into the obstetrical suite. (11) Observation Nursery (if required by pro- ication room shall be provided. The medica- The space for removal of scrub suits and gram). tion room shall have access only through the boots in the change area shall be designed so (A) The observation nursery shall provide nurses’ station. that personnel using it can avoid contact with for infants suspected of having a condition (K) A treatment room shall be provided clean personnel. not conducive to care in the normal infant and equipped with an examination table and nursery. Normal infants born at home or in- counter with sink. A treatment room is not (10) Normal Infant Nursery (if required by transit may be admitted to the normal infant required in those nursing units with all pri- program). nursery. If a private post-partum room is pro- vate rooms. (A) The nursery(ies) shall be located in the vided, the suspect infant may be housed with (L) An activity room with at least one hun- post-partum nursing unit and as close as pos- the mother until it can be admitted to the nor- dred fifty (150) square feet of space shall be sible to the delivery suite. Nurseries shall be mal nursery or transferred to another facility. provided. located and arranged to preclude unrelated (B) Floor space shall be provided at the (M) Clean and soiled workrooms as traffic. rate of thirty (30) square feet for each described in subsections (5)(D) and (E) of (B) No nursery shall open directly into bassinet. At least one (1) observation bassinet this rule shall be provided. another nursery. If doors are provided to shall be provided. (N) A janitors’ facility shall be provided nurseries for emergency evacuation, they (C) At least one (1) handwashing lavatory for each pediatric unit. shall be operable only from the nursery side with knee- or foot-action controls and goose- (O) Showers shall be provided at a ratio of neck spout shall be provided in the observa- and be recessed so as not to swing out into one (1) shower for each ten (10) beds. In tion nursery. Work space designed for the addition, one (1) tub room shall be provided. the corridor. normal nurseries may serve the observation (C) The number of bassinets shall exceed nursery. (14) Dietary Facilities. the number of obstetric beds by ten percent (A) Food service facilities shall be (10%) to accommodate multiple births, (12) Continuing care, intermediate care and designed and equipped to meet the require- extended hospitalizations and fluctuating intensive care nursery facilities shall be ments of the scope of services outlined in the patient loads. When a rooming-in program is designed as required by the functional needs program. used, the total number of bassinets may be of each program. The minimum floor area (B) To implement the type of food service reduced, but a nursery must still be provided. per infant station shall be forty (40) square selected, the following facilities shall be pro- (D) Each nursery shall contain no more feet. vided and designed: than sixteen (16) bassinets. 1. Receiving area; (E) At least twenty-four (24) square feet of (13) Pediatric Facilities. 2. Storage space including cold storage clear floor area shall be provided for each (A) If a hospital’s program provides for the for four (4) days’ supply; bassinet. At least two feet (2') shall be main- design and operation of a pediatric unit, it 3. Space and equipment for food prepa- tained between each bassinet and an aisle shall be located where the noise will not ration to facilitate efficient food preparation space of at least three feet (3') shall be main- intrude on the care of others. and to provide for a safe and sanitary envi- tained. (B) Pediatric patient rooms shall comply ronment; (F) An examining, treatment and work with requirements established in subsection 4. Conveniently located handwashing space room with facilities for charting, stor- (6)(D) of this rule when used for hospital facilities; age and handwashing shall be provided adja- beds. Patient rooms used for cribs shall con- 5. Space for tray assembly and distribu- cent to the nursery(ies). tain a minimum of sixty (60) square feet of tion carts; (G) At least one (1) handwashing facility clear area for each crib with no more than six 6. Dining space; with knee- or foot-action controls and goose- (6) cribs in each room. 7. Ware washing space located separate- neck spout shall be provided in each nursery. (C) The nursing station shall be designed ly and isolated from food preparation and (H) Space shall be provided for street to permit observation and communication serving area; clothing, cabinets for clean gowns and recep- between small children and the staff. 8. Three (3)-compartment sinks for pot tacles for used gowns and other soiled mate- (D) Toilet facilities, drinking fountains and washing; rial. This may be a part of the work space furniture shall be designed for small children. 9. Storage areas and washing facilities mentioned in subsection (10)(F) of this rule if (E) Equipment, such as the nurses’ call, for cans, carts and mobile tray conveyors; sufficient space is provided. shall be simple to operate and switches and 10. Waste stored so it is inaccessible to (I) Observation windows shall be provided plugs for critical equipment shall be located insects and rodents and accessible to the out- between the nursery and the corridor and the out of reach of young patients. side for pickup or disposal;
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 15 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
11. Office space for manager of dietary facilities. This shall be described in the pro- (19) Central Services. service accessible to food production area; gram. (A) A separate receiving-decontamination 12. Staff toilets with handwashing facil- (B) As a minimum, the following function- room shall be provided with work space and ities immediately available; al areas shall be provided: equipment for cleaning medical and surgical 13. Janitors’ closet with floor receptor 1. Dispensing area with handwashing equipment and for disposal of nonreusable or a service sink and storage space for equip- facilities; material. Handwashing facilities shall be pro- ment; and 2. Editing or order review area; vided. A soiled cart parking space shall be 14. Dietary facilities which comply with 3. Office and record storage area; and provided. 19 CSR 20-1.010. 4. Storage areas for bulk and active sup- (B) A clean workroom with space and equipment for sterilizing medical and surgical plies, a refrigerator, a vault for narcotics, equipment and supplies shall be provided. At (15) Radiology. acceptable safe space for volatile liquids and (A) Space shall be provided for diagnostic least two (2) pressure sterilizers designed to an area for parental admixtures if appropri- maintain two hundred fifty degrees Fahren- and therapeutic purposes as stated in the pro- ate. gram. heit (250°F) or one hundred twenty-one degrees Celsius (121°C) at fifteen pounds (15 (B) As a minimum, the radiology suite (18) Outpatient Clinic Services. lbs.) pressure shall be provided. shall contain the following: (A) The extent of administrative, clinical (C) Space is to be provided for storage of 1. Radiographic room. Radiation protec- and diagnostic facilities provided shall be clean supplies, sterile supplies and clean tion requirements of X ray and gamma-ray determined by the services contemplated and equipment. installations shall be in accordance with 19 the estimated patient load as described in the (D) Clean cart-storage space and cart-san- CSR 20-10.010–19 CSR 20-10.190; program. itizing facilities shall be provided. 2. Film-processing facilities and film- (B) If the facility is designed as an integral storage facilities; part of the hospital and is intended to serve (20) The area for medical records shall 3. Office and viewing areas; inpatients as well as outpatients, all applica- include: review and dictating space; work 4. Toilet with handwashing facilities. A ble requirements relating to general hospital areas for sorting, recording or microfilming toilet shall be accessible from each fluo- facilities shall apply. records; storage area for records; and office roscopy room without entering the general (C) Facilities shall be designed and space for the medical record administrator. corridor; arranged so they are available and accessible 5. Dressing area; to the physically handicapped. (21) Elevators. 6. Waiting room or alcove and a control (D) The entrance shall be at grade level (A) All hospitals having patient-care facil- station; and ities located on any floor other than the main and sheltered from the weather. 7. A holding area for stretcher patients entrance floor shall have electric or electro- (E) The lobby shall include wheelchair which is out of the direct line of normal traf- hydraulic elevators. storage space, reception and information fic. (B) Numbers of Elevators. counter or desk, waiting space, public toilet 1. At least two (2) hospital-type eleva- facilities, public telephone and drinking foun- (16) Laboratory. tors shall be installed where patient-care tain. (A) Laboratory facilities shall be provided facilities are located on any floor other than (F) General purpose examination rooms in the hospital or through an effective con- the main entrance floor. shall have minimum floor areas of eighty (80) tract arrangement with another laboratory 2. In hospitals with more than two hun- service acceptable to the Department of square feet, excluding spaces such as dred (200) beds located on floors other than Health to meet the workload described in the vestibule, toilet, closet and work counter. A the main entrance floor, the number of eleva- program. lavatory or sink equipped for handwashing tors shall be determined from a study of the (B) The following minimum services shall and a counter or shelf space for writing shall hospital operation and the estimated vertical be available in the hospital: be provided. transportation requirements. 1. Laboratory work counter with sink, (G) Treatment rooms for minor surgical (C) Details. vacuum, gas and electric services; and cast procedures shall have a minimum 1. Cars of hospital-type elevators shall 2. Handwashing sink; floor area of one hundred twenty (120) have inside dimensions that will accommo- 3. Storage cabinets; square feet with a minimum room dimension date a patient bed and attendants and shall be 4. Blood storage facilities with tempera- of ten feet (10'). The minimum floor area at least five feet (5') wide and eight feet (8') ture recorder and alarms; shall not include spaces used for vestibule, deep. The car door shall have a clear opening 5. Urine collection room with water toilet, closet and work counter. A lavatory or of not less than four feet (4'). closet and lavatory; and sink equipped for handwashing and a counter 2. Elevators shall be equipped with an 6. Blood collection facilities with a work or shelf space for writing shall be provided. automatic leveling device of the two (2)-way counter, handwashing facilities and space for (H) A nurses’ station with a communica- automatic maintaining type with an accuracy patient seating. tion system and facilities for charting and of plus or minus one-half inch (± 1/2"). storage of clinical records shall be provided. 3. Elevators, except freight elevators, (17) Pharmacy Facilities. (I) There shall be a drug storage area. shall be equipped with a two (2)-way special (A) The size and type of services to be pro- (J) A clean workroom or clean holding service switch to permit cars to bypass all vided in the pharmacy will depend upon the room shall be provided as described in sub- landing button calls and be dispatched direct- type of drug distribution system to be used in section (5)(D) of this rule. ly to any floor. the hospital and whether the hospital propos- (K) A soiled workroom or soiled holding 4. Elevator controls, alarm buttons and es to provide, purchase or share pharmacy room shall be provided as described in sub- telephones shall be accessible to wheelchair services with other hospitals or other medical section (5)(E) of this rule. occupants.
16 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
5. Elevator call buttons, controls and (A) If a facility is located outside of a ser- provide the capability to fight fires from door safety stops shall be of a type that will vice area or range of a public fire depart- flammable liquids, gases or grease and in not be activated by heat or smoke. ment, arrangements shall be made to have the energized electrical equipment. Portable fire 6. Elevator hoistway doors shall be rated nearest fire department respond in the case of extinguishers rated ABC may be used in lieu to maintain the integrity of the enclosure. fire. A copy of the agreement shall be kept on of Class A, Class B and Class C fire extin- file in the facility and a copy shall be for- guishers. Special situations such as computer (22) Linen and Refuse Chutes (if provided). warded to the Department of Health. If the rooms may require specific types of fire (A) Service openings to chutes shall not be agreement is changed, a copy shall be for- extinguishers. located in corridors or passageways but shall warded to the Department of Health. 12. Fire extinguishers shall be recharged be located in a room having a fire-resistance (B) General Operating Requirements. after use or as indicated by inspection. construction of not less than one (1) hour. 1. Every required exit, exit access or (C) Life Safety Requirements. Doors to the rooms shall be not less than exit discharge shall be maintained free of any 1. New facilities, additions to existing three-fourths (3/4)-hour labeled doors and obstructions or impediments at all times. facilities and alterations to existing facilities equipped with a closing device. 2. Automatic extinguishment systems, built in accordance with Chapters 5, 6, 7 and (B) Service openings for chutes shall have fire detection and alarm systems, smoke con- 12 of the Life Safety Code 1981, Standards approved self-closing one and one-half (1 tainment and evacuation systems, exit light- for the Installation of Air Conditioning and 1/2)-hour labeled fire doors. ing, fire and smoke doors and other equip- Ventilating Systems 1978 and Standard for (C) The minimum diameter of gravity ment required by this rule shall be tested at the Installation of Sprinkler Systems 1980, all chutes shall be not less than two feet (2"). intervals not to exceed six (6) months and published by the National Fire Protection (D) Chutes shall discharge directly into shall be continuously maintained in proper Association, shall be considered to be in full collection rooms separate from the incinera- operating condition. compliance with this rule if they also comply tor, laundry or other services. Separate col- 3. Fire-retardant protective coatings with subparagraph (24)(C)2.A. of this rule. lection rooms shall be provided for trash and shall be applied to paneling and other materi- 2. As a minimum, all new hospitals, for linen. The enclosure construction for the als at intervals as necessary to maintain the additions to existing hospitals and alterations rooms shall have a fire-resistance of not less required flame-retardant properties. to existing facilities shall comply with the fol- than one (1) hour. Doors to these collection 4. All draperies, curtains and cubicle lowing: rooms shall be three-fourths (3/4)-hour curtains shall be inherently flame retardant or A. An automatic extinguishment sys- labeled fire doors. treated and maintained to retard flame. tem shall be installed in accordance with the (E) Gravity chutes shall extend full diame- 5. A written fire safety and evacuation Standard for the Installation of Sprinkler Sys- ter through the roof with provisions for con- plan shall be available to all personnel. The tems 1980 published by the National Fire tinuous ventilation, as well as for fire and plan shall provide for the protection of all Protection Association. Operating rooms, X- smoke ventilation. Openings for fire and persons in the event of fire and for their evac- ray rooms, delivery rooms, telephone equip- smoke ventilation shall have an effective area uation to areas of refuge in or outside the ment rooms, electrical switchgear and distri- of not less than that of the chute diameter and building when necessary. All employees shall bution rooms and special care areas may be shall terminate not less than four feet (4') be periodically instructed and kept informed exempted from sprinkler coverage, provided above the roof and not less than six feet (6') respecting their duties under the plan. they are separated from other areas by one clear of other vertical surfaces. 6. Fire drills shall be held at least quar- (1)-hour fire-resistive construction and pro- terly for each shift and shall include the sim- vided with smoke detectors; (23) Dumbwaiters, Conveyors and Material ulated use of fire alarm signals and simula- B. Health care buildings of only one Handling Systems (if provided). tion of emergency fire conditions. The (1) story in height shall be constructed (A) Dumbwaiters, conveyors and material movement of patients is not required. according to one (1) of the following types: I handling systems, excluding pneumatic tubes, 7. Smoking shall be prohibited in any (443); I (332); II (111); II (222); II (000) or shall not open directly into a corridor or exit- room, ward or compartment where III (210) as described in the Standard Types way but shall open into a room enclosed by flammable liquids, combustible gases or oxy- Building Construction 1979 published by the construction having a fire-resistance of not gen are used or stored and in any other haz- National Fire Protection Association. All less than one (1) hour and provided with a ardous location. The areas shall be posted buildings with more than one (1) level below three-fourths (3/4)-hour labeled fire door with NO SMOKING signs. the level of exit discharge shall have all lower with a self-closing device. 8. The policies shall prohibit smoking levels separated from the level of exit dis- (B) Service-entrance doors to vertical throughout the hospital other than in specific charge by at least Type II (111) construction; shafts containing dumbwaiters, conveyors and designated areas where smoking may be per- C. Buildings two (2) stories or more material handling systems shall be rated to mitted. in height shall be of Type I (443), Type I maintain the integrity of the vertical shaft. 9. Combustible decorations are prohibit- (332) or Type II (222) construction as (C) Where horizontal conveyors and mate- ed unless they have been treated to retard described in the Standard Types Building rial handling systems penetrate fire-rated flame. Construction 1979 published by the National walls, openings shall be provided with one 10. Wastebaskets and other waste con- Fire Protection Association; and one-half (1 1/2)-hour labeled fire doors. tainers shall be of noncombustible material. D. Stairways, ramps, elevators hoist- Where they penetrate smoke partitions, open- 11. Class A portable fire extinguishers ways, light or ventilation shafts, chutes and ings shall be provided with three-fourths shall be provided and located to provide the other vertical openings between stories shall (3/4)-hour labeled fire doors. capability to fight fires in ordinary com- be enclosed with construction having at least bustible material such as wood, cloth, paper a one (1)-hour fire-resistance rating in build- (24) Fire Prevention and Protection for New and rubber. Class B and Class C portable fire ings up to and including three (3) stories. In and Existing Facilities. extinguishers shall be provided and located to buildings of more than three (3) stories, all
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 17 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
vertical openings shall be enclosed with con- if all doors along the means of egress are Health, shall be separated from adjacent struction having a two (2)-hour fire-resistance equipped with nonlockable hardware and if areas by construction having a one (1)-hour rating; the intervening room is not used to serve as fire-resistance rating; E. Doors in stair enclosures shall be an exit access for more than eight (8) patient U. Laboratories employing quantities self-closing and shall be kept in a closed posi- sleeping beds. This requirement shall not of flammable, combustible or hazardous tion. Exit doors shall bear a sign visible only apply to special care units with supervised materials which are considered a severe haz- in the direction of exit travel stating FIRE nursing care; ard shall be protected in accordance with the EXIT, KEEP DOOR CLOSED; L. Aisles, corridors and ramps Safety Standards for Laboratories in Health- F. All interior walls and partitions required for exit access from inpatient areas Related Institutions 1980 published by the shall be of noncombustible materials; in a hospital shall be at least eight feet (8') in National Fire Protection Association; G. Openings for the passage of ducts, clear and unobstructed width. Aisles, corri- V. Walls and ceilings throughout shall pipes or conduits in floors, walls or partitions dors and ramps in areas not intended for the have a Class B interior finish with one (1) that are required to have fire- or smoke-resist- housing, treatment or use of patients may be exception: individual rooms of not over four ing capability shall be protected by filling the a minimum of forty-four inches (44") in clear (4) patients in capacity may have a Class C space between the penetrating item and the and unobstructed width; interior finish in accordance with Section 6-5 barrier with material which will maintain the M. Rooms and any suite of rooms of of the Life Safety Code 1981 published by the rating of the barrier; more than one thousand (1,000) square feet National Fire Protection Association; H. Types of exits shall be limited to— shall have at least two (2) exit access doors W. Floors throughout the facility shall doors leading directly outside the building, remote from each other; have a Class II interior floor finish as interior stairs, smoke-proof towers, horizon- tal exits, and exit passageways; N. Patient sleeping rooms may be described in Section 6-5 of the Life Safety I. At least two (2) exits of the types subdivided with noncombustible partitions, Code 1981 published by the National Fire described in paragraphs (24)(C)2.–4. of this provided that the arrangement allows for Protection Association; rule shall be provided for each floor or fire direct and constant visual supervision by X. Corridors shall be separated from section of the building. These exits shall be nursing personnel. Rooms which are so sub- all other areas by partitions. Partitions shall remote from each other; divided shall not exceed five thousand be of noncombustible construction and may J. Horizontal exits. (5,000) square feet. If the space is equipped terminate the suspended ceiling. Corridor (I) At least thirty (30) net square with an electrically supervised smoke detec- partitions shall form tight joints with the ceil- feet per patient shall be provided within the tion system, direct visual supervision is not ing; aggregated area of corridors, patient rooms, required; Y. Vision panels in corridor partitions treatment rooms, lounge and other low hazard O. Every corridor shall provide access shall be constructed to resist the passage of areas on each side of the horizontal exit. On to at least two (2) approved exits. Means of smoke; floors other than patient floors, at least six (6) egress shall not pass through any intervening Z. Doors in corridor partitions shall square feet per occupant shall be provided on rooms or spaces other than corridors or lob- be constructed to resist the passage of smoke each side of the horizontal exit for the total bies; and shall be provided with latches of a type number of occupants in adjoining compart- P. Every exit or exit access shall be so suitable for keeping the door tightly closed; ments. arranged that no corridor, aisle or passageway AA. Smoke barriers shall be provid- (II) Partitions in a horizontal exit has a pocket or dead end exceeding thirty feet ed, regardless of building construction type, shall have a two (2)-hour fire rating and doors (30'); to divide into at least two (2) compartments shall have a one and one-half (1 1/2)-hour Q. Travel distance between any every story used by inpatients for sleeping or fire rating. patient room door and an exit shall not treatment or any story having an occupant (III) A single door may be used in exceed one hundred fifty feet (150'). Travel load of fifty (50) or more persons and to limit a horizontal exit if it serves one (1) direction distance between any point in a room and an on any story the length and width of each only and is at least forty-four inches (44") exit shall not exceed two hundred feet (200') smoke compartment to no more than one wide. and travel distance between any point in a hundred fifty feet (150'). Horizontal exits (IV) A horizontal exit in a corridor hospital sleeping room or suite and an exit may serve as smoke barriers; eight feet (8') or more in width serving as a access door of that room or suite shall not BB. Smoke barriers shall have a fire- means of egress from both sides of the exit exceed fifty feet (50'); resistance rating of at least one (1) hour; shall have the opening protection by a pair of R. All required exit ramps or stairs CC. Doors in smoke barriers shall be swinging doors each arranged to swing in the opposite direction from the other, with each shall discharge directly to the outside at grade substantial doors, such as one and three- door leaf being at least forty-four inches or be arranged so travel is through an exit fourth inches (1 3/4") thick solid-bonded core (44") wide. passageway discharging to the outside at wood or construction that will resist fire for (V) A vertical vision panel twenty- grade; at least twenty (20) minutes. Each door leaf four inches by four inches (24" × 4") of wire S. Doors leading directly to the out- shall have a wireglass vision panel not glass in steel frame shall be provided in each side of the building may be subject to locking exceeding one thousand two hundred ninety- horizontal exit door. Center mullions are pro- from the room side provided the door can be six (1,296) square inches in metal frames. hibited; opened from the inside without the use of a Corridor openings in smoke barriers shall be K. Every patient sleeping room shall key; protected by a pair of swinging doors, each have an exit access door leading directly to an T. Soiled linen rooms, paint shops, door to swing in a direction opposite from the exit-access corridor unless there is an exit trash collection rooms and rooms or spaces, other. The minimum door leaf width shall be door opening directly to the outside from the including repair shops used for the storage of forty-four inches (44"); and room at ground level. One (1) adjacent room, combustible supplies and equipment in quan- DD. Doors in smoke barriers shall be such as a sitting or anteroom, may intervene tities deemed hazardous by the Department of self-closing or they may be held open by an
18 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
automatic release device which shall be con- shall supply full-load requirements continu- 4. Automatic emergency electric service nected to a manual alarm system, an auto- ously with the alternate source supplying shall be provided to elements of the distribu- matic smoke detection system and a complete power on an emergency basis to selected cir- tion system as follows: automatic fire-extinguishing system. Activa- cuits when normal power supply is interrupt- A. Circuits essential for the safety of tion of any of these three (3) systems shall ini- ed. One (1) alternate source shall be an on- patients and personnel shall include: tiate the closing action of all doors by zone or site engine-driven generator facility utilizing (I) Illumination of means of egress; throughout the entire facility. on-site fuel. (II) Illumination for exit signs and (C) Switchgear and Switchboards. exit directional signs; (25) Construction. 1. Incoming line switchgear for primary (III) Task illumination for major (A) Every building and every portion of it voltage electrical services or distribution electrical equipment, major mechanical shall be designed and constructed to sustain switchboards for secondary voltage electrical equipment, pumps, elevator machinery, tele- all dead and live loads in accordance with services shall consist of dead-front metal phone switchboard and standby generator; accepted engineering practices and standards. enclosed assemblies of automatic circuit (IV) Alarm systems including fire (B) Foundations shall rest on natural solid alarms activated by manual stations, water- breakers or fused switches arranged to pro- bearing if a satisfactory bearing is available at flow alarm devices of the sprinkler system, vide service-disconnecting means and over- reasonable depths. Proper soil-bearing values fire and smoke detecting systems and alarms current and short-circuit protection for shall be established in accordance with rec- required for blood banks and medical gas sys- entrance feeders and for distribution feeder ognized standards. If solid bearing is not tems; encountered at practical depths, the structure conductors. (V) Paging or speaker systems if shall be supported on driven piles or drilled 2. Switchgear, switchboards, panel- intended for communication of emergency piers designed to support the intended load boards, switches and other equipment of the and disaster calls during outage of normal without detrimental settlement; except that main service and distribution systems for power. Radio transceivers where installed for one (1)-story buildings may rest on a fill both normal and emergency power shall be emergency use shall be capable of operating designed by a soils engineer. When engi- installed in separate dry, ventilated rooms for at least one (1) hour upon total failure of neered fill is used, site preparation and place- which have a one (1)-hour fire rating and are both normal and emergency power; and ment of fill shall be done under the direct reserved exclusively for electrical equipment. (VI) General illumination and at full-time supervision of the soils engineer. Piping of utility service systems carrying least one (1) receptacle in the vicinity of The soils engineer shall issue a final report water or other liquids shall not be installed in standby generators; on the compacted fill operation and certify its the electrical equipment room. B. Circuits essential to care, treatment compliance with the job specifications. All 3. Ratings of switchgear and switch- and protection of patients shall include: footings shall extend to a depth not less than board assemblies shall ensure that maximum (I) Task illumination and at least one foot (1') below the estimated maximum available short-circuit currents are safely one (1) receptacle serving the following areas frost line. interrupted. and functions related to patient care: anes- (D) Panelboards. thetizing locations, infant nurseries with a (26) Electrical Systems. 1. Panelboards supplying lighting and minimum of one (1) receptacle for each sta- (A) General Requirements. receptacle and appliance-branch circuits shall tion, medication preparation areas, pharmacy 1. Materials used in installations shall be located on the same floor as the loads they dispensing areas, psychiatric patient areas, be listed as complying with standards of serve. Each outlet shall be located no farther treatment rooms, nurses station, angiograph- Underwriters’ Laboratories, Inc. or a similar than one hundred feet (100') from its supply- ic room, cardiac catheterization room, emer- recognized agency where the standards have ing panelboard. gency treatment rooms, human physiology been established. (E) Standby Emergency Electric Service. laboratories and the headwall of each patient 2. After completion, all electrical sys- 1. An on-site engine-driven emergency room; and tems shall be tested and demonstrated to generator utilizing on-site fuel shall be pro- (II) Task illumination and all recep- show satisfactory compliance with the speci- vided to deliver electrical power during an tacles for—operating rooms, delivery rooms fied performance criteria and installation and labor rooms and recovery rooms, special interruption of normal power supply. There requirements. A written record of the results care units, acute hemodialysis rooms, post- shall be sufficient fuel on site to ensure con- of performance tests made on special systems operative recovery areas, nurses’ call sys- tinuous operation for twenty-four (24) hours. and equipment shall be furnished to the tems, bone and tissue banks, telephone equip- 2. Engine-generators shall be installed owner. Special systems shall include: high ment room, closets and blood banks; voltage cable “hi-pot” direct current test, iso- in separate dry, ventilated rooms which have C. Power circuits which serve the fol- lated power systems leakage currents, con- a one (1)-hour fire rating and are reserved lowing equipment shall be arranged for auto- ductive floors resistance values, equi-poten- exclusively for the engine-generator system matic connection to the standby emergency tial grounding systems continuity tests, fire equipment. Piping of utility service systems service: central suction systems serving med- alarm and smoke detection systems, emer- carrying water or other liquids which are not ical and surgical functions; clinical air sys- gency and disaster loud-speaker systems, serving the engine-generator system shall not tems serving medical and surgical functions, patient emergency call system, all other alarm be installed within the engine-generator if installed; sump pumps and other equipment systems, and standby emergency generator room. required to operate for the safety of major power, lighting and automatic transfer sys- 3. Standby emergency generators shall equipment; fire pump, if installed; and tems. be installed and arranged so that full voltage smoke ventilation and evacuation systems, if (B) Two (2) separate sources for electrical and frequency is available and supplying installed; and supply, a normal source and an alternate power to emergency loads within ten (10) D. Power circuits shall be arranged source, shall be provided. The normal source seconds after normal power is interrupted. for either delayed automatic or manual
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 19 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
connection to the standby emergency electri- workroom and the nourishment station of the one (1) for the electric bed, if used; and one cal service for the following equipment: nursing unit. (1) for each inside wall. (I) Equipment for comfort heating D. In multi-corridor nursing units, B. Nurseries shall have not less than of operating, delivery, labor and recovery additional visible signals shall be installed at one (1) duplex grounding-type receptacle for rooms; special care areas; nurseries; and gen- corridor intersections. each bassinet station. eral patient rooms. If the comfort heating sys- E. In rooms containing two (2) or C. Receptacles in each pediatric and tem of a facility utilizes electricity as the more calling stations, indicating lights shall psychiatric room shall be of the safe type or energy source, standby emergency electric be provided at each station. shall be provided with an on-off switch con- service shall be connected to the heating F. Nurses’ calling systems which pro- trol located outside the patient sleeping room equipment of rooms, corridors and other vide two (2)-way communication shall be at a controlled or supervised location. spaces in which general care patients are equipped with an indicating light at each call- 2. Corridors. located; ing station which lights and remains lighted A. Duplex grounding-type receptacles (II) One (1) or more elevators as long as the voice circuit is operating. of at least twenty (20) amperes for general selected to provide service to all floors. 2. In special care units such as intensive use and for floor cleaning equipment shall be Throw-over facilities shall be provided to per- care or coronary care where patients are located approximately fifty feet (50') apart in mit temporary operation of all elevators for under constant surveillance, the nurses’ call- all corridors. the release of patients or other persons from ing system may consist of a bedside station B. Receptacles in corridors of pedi- elevator cabs which may be trapped between that will actuate an audible and visual signal atric and psychiatric units shall be of the safe- floors; that can be readily observed. ty type or shall be controlled by switches (III) Supply and exhaust ventilating 3. Patient treatment specialty areas. located at a nurses’ station or other secure systems for surgical and obstetrical delivery A. Emergency calling stations which location. suites, infant nurseries, isolation rooms, may be used to summon assistance shall be 3. Anesthetizing locations. emergency treatment spaces and laboratory provided in—operating rooms; delivery and A. Each operating and delivery room fume hoods; labor rooms, recovery rooms, nurseries and shall have at least three (3) receptacles. (IV) Hyperbaric and hypobaric special care units. Receptacles in anesthetizing areas shall com- facilities, if provided; and B. Each toilet intended for patient use ply with the Standard for Inhalation Anes- thetics 1980 published by the National Fire (V) Automatically operated doors. within diagnostic and treatment areas shall be Protection Association. 5. Receptacles connected to the standby provided with an emergency call station B. In each anesthetizing location emergency electrical system shall be perma- which shall activate an audible and visual sig- where line voltage mobile X ray is used, an nently and distinctively identified in a uni- nal within the unit. additional receptacle distinctively marked for form manner. (G) Lighting Systems. X-ray use shall be provided. 6. All wiring for equipment and systems 1. All spaces occupied by people, C. All electrical equipment and essential to the safety of patients and person- machinery and equipment within buildings, devices, receptacles and wiring shall comply nel and for care, treatment and protection of approaches to buildings and parking lots shall with the Standards for Inhalation Anesthetics patients shall be kept entirely independent of be equipped with artificial lighting. 1980 published by the National Fire Protec- all other wiring, and equipment and shall not 2. Operating and delivery rooms shall tion Association. enter the same raceways, boxes or cabinets have general lighting in addition to local 4. Special areas. with other wiring, except when located in lighting provided by special lighting units at A. X-ray installations. Fixed and transfer switches and in exit or emergency the surgical and obstetrical tables. Each fixed mobile X-ray equipment installations shall lighting fixtures or in a common junction box special lighting unit at the tables, except for conform to Article 517 of The National Elec- attached to exit or emergency lighting fixture. portable units, shall be connected to an inde- trical Code 1981 published by the National (F) Nurses’ Call Systems. pendent circuit. Fire Protection Association. 1. Patient nursing units. 3. Nursing unit corridors shall have gen- B. X-ray film illuminator units. At A. In general, patient areas and each eral illumination with provisions for reduc- least one (1) double unit shall be installed in patient room shall be served by at least one tion of light level at night. each operating room and in the X-ray view- (1) calling station and each bed shall be pro- 4. Emergency lighting requirements ing room of the radiology department. vided with a call button. Two (2) call buttons shall be in accordance with paragraphs C. Ground-fault interrupters. The serving adjacent beds may be served by one (26)(E)1.–4. of this rule and the Standard for electrical circuit(s) to equipment in wet areas (1) calling station. Essential Electrical Service for Health Care shall be provided with five (5) milliampere B. A nurses’ call emergency station Facilities 1977 published by the National Fire ground fault interrupters. Wet areas include button or switch shall be provided for Protection Association. hydrotherapeutic tanks, if used, hydro-mas- patients’ use at each toilet, bath, sitz bath and (H) Convenience Receptacles. sage tubs, if used, and other locations identi- shower room intended for patient use. The 1. Patient areas. fied by hospital administration. Where station shall be accessible to a collapsed A. As a minimum, each patient room ground fault interrupters are used in critical patient lying on the floor. Inclusion of a pull shall have one (1) duplex grounding-type areas, provision shall be made to ensure that cord will satisfy this requirement. receptacle located in the headwall on each other essential equipment will not be affected C. Calls shall register at a nurse sta- side of each bed. One (1) duplex receptacle by a single interruption. tion or other floor unit station to indicate between beds of a two (2)-patient room may D. When the program requires a spe- location of call placed and shall actuate a vis- satisfy requirements for one (1) side of each cial grounding system to be installed in spe- ible signal in the corridor at the patients’ bed. One (1) duplex grounding-type recepta- cial care areas, the system shall comply with room door, in the clean workroom, the soiled cle shall be provided for television, if used; Article 517 of The National Electrical Code
20 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
1981 published by the National Fire Protec- (27) Mechanical Systems. tinuous firing at design load. In the case of tion Association. (A) General Requirements. electric boilers or total electric installations, (I) Fire Detection and Alarm Systems. 1. Prior to completion and acceptance of the dual fuel requirement may be waived 1. Approved, electrically supervised the facility, all heating, ventilating and air- depending on the type of electric service and manual and automatic detection and alarm conditioning systems shall be tested, balanced sources of supply to the building. systems shall be provided in accordance with and operated to demonstrate to the owner or 8. If coal-fired boilers are used, stack Chapter 12 of Life Safety Code 1981 pub- his/her representative that the installation and effluent shall comply with both state and fed- lished by the National Fire Protection Asso- performance of these systems conform to the eral environmental standards. ciation. requirements of the plans and specifications. 9. Boiler feed pumps, heating circulat- 2. Manual alarm initiating devices shall 2. Upon completion of the contract, the ing pumps, condensate return pumps and fuel be installed in the following locations: each owner shall be furnished with a complete set oil pumps shall be furnished in duplicate to exit from the fire area but no farther than one of manufacturer’s operating, maintenance provide normal and standby service. hundred fifty feet (150') from any point on and preventive maintenance instructions and 10. Steam boiler plants operating above the floor and installations shall be located so parts lists and procurement information with twenty pounds per square inch (20 psi) shall that no more than one hundred fifty feet numbers and description for each piece of be designed to supply zero (0) oxygen boiler (150') of horizontal distance on the same equipment and test results. The owner also feedwater to the boilers. floor must be traveled to reach a station; at shall be provided with instruction in the oper- 11. Boiler rooms shall be provided with each nurses’ station or other patient care con- ational use of systems and equipment. sufficient outdoor air to maintain combustion trol station and at the telephone switchboard. 3. The heating, ventilating and air-con- rates of equipment and to limit temperatures A. Automatic smoke detectors shall ditioning system shall be capable of providing in working stations to no more than ninety- seven degrees Fahrenheit (97°F). be installed in all corridors throughout the the temperatures and humidifies in the fol- (B) Heating, Ventilating and Air-Condi- building spaced no more than seventy-five lowing areas: tioning Systems. feet (75') apart and no more than thirty feet 1. All air supply, return and exhaust sys- (30') from the ends of corridors. The auto- Relative tems shall be mechanically operated. matic smoke detection system shall be elec- Area Humidity 2. All heating, ventilating and air-condi- trically interconnected with the fire alarm Designation Temperature (%) tioning systems shall be designed to maintain system and the sprinkler system. F° C° Min. Max. general pressure relationships and ventilation B. Water-flow switches of the sprin- rates as shown in Table 1 in paragraph kler systems shall be connected into the fire Operating Rooms 68–76 20–24 50 60 (27)(B)3. of this rule. alarm system to function as an automatic Delivery Rooms 70–76 21–24 50 60 3. See Table 1. alarm initiating device. Recovery Rooms 75 24 30 60 4. Constant volume systems shall be 3. Alarm signals shall provide audible Intensive Care Rooms 72–78 22–26 30 60 used in all areas of the hospital listed in Table indication of fire and shall be located and of Nursery Units 75 24 30 60 1 in paragraph (27)(B)3. of this rule; variable a character that they can be effectively heard Special Care air-volume systems may be used in areas not in all areas of the building above the ambient Nursery Unit 75–80 24–27 30 60 listed in this table and where direct patient noise level of normal occupancy conditions. Patient Care, Treatment, care is not affected. Consideration may be 4. Operation of any alarm initiating Diagnostic and given to special design innovations in areas of device, either manual or automatic, shall Related Areas 72–78 22–26 30 60 Table 1, provided that pressure relationship cause the following actions to automatically as an indication of direction of air flow and occur within a building: all alarms shall be 4. The heating system shall be capable total number of air changes during occupied activated on the fire floor, on the floor above of maintaining an indoor winter temperature periods in those areas listed in Table 1 are and on the floor below; alarms shall be acti- of seventy-five degrees Fahrenheit (75°F) in maintained. vated in at least one (1) continuously super- all other areas occupied by inpatients. The vised location; an alarm shall be transmitted heating system shall be capable of maintain- to the fire department or to an approved cen- ing an indoor winter temperature of seventy- tral station located outside the premises; zone two degrees Fahrenheit (72°F) in all nonpa- annunciators shall be energized to indicate tient areas. location of alarm initiation; smoke doors 5. The boiler plant shall have the capac- shall release and close on the fire floor, on ity to supply the normal utility requirements the floor above and on the floor below; of all systems and equipment. smoke dampers shall release and close on the 6. The number and arrangement of boil- fire floor to isolate the smoke zone and ers shall be such that when one (1) boiler smoke ventilation and evacuation systems, if breaks down or is shut down for routine installed, shall be activated. maintenance the remaining boiler(s) shall be 5. Zone annunciators shall be located at capable of carrying the normal building load. the switchboard and in at least one (1) con- 7. The boilers may be fired by coal, fuel tinuously supervised location. oil, natural gas, liquid propane gas or elec- 6. The smoke ventilation and evacuation tricity. All boilers shall be suitable for dual system, if installed, shall be designed so fuel firing with the standby fuel stored on- operation of a manual pull station will not site. The amount of on-site fuel storage shall actuate it. be adequate for ninety-six (96) hours of con-
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 21 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
Table 1 General Pressure Relationship and Ventilation of Certain Hospital Areas Minimum Minimum Pressure Air Changes Total Air All Air Relationship of Air per Changes per Exhausted Recirculated Area to Adjacent Hour Supplied Hour Supplied Directly to Within Designation Areas to Room to Room Outdoors Room Units
Operating Room (for recirculating air system) P 5 25 Optional No Operating Room (all-outdoor-air system) P 15 15 Yes No Trauma Room P 5 12 Optional No Examination and Treatment Room E 2 6 Optional Optional Delivery Room P 5 12 Optional No Nursery Unit P 5 12 Optional No Recovery Room P 2 6 Optional No Intensive Care P 2 6 Optional No Patient Room E 2 2 Optional Optional Patient Room Corridor E 2 2 Optional Optional Isolation Room 2 6 Yes No Isolation Room—Alcove or Anteroom 2 10 Yes No Examination Room E 2 6 Optional Optional Medication Room P 2 4 Optional Optional Pharmacy P 2 4 Optional Optional Treatment Room E 2 6 Optional Optional X-ray Fluoroscopy N 2 6 Yes No X-ray, Other Diagnostic Rooms V 2 6 Optional Optional Physical Therapy and Hydrotherapy N 2 6 Optional Optional Soiled Workroom or Soiled Holding N 2 10 Yes No Clean Workroom or Clean Holding P 2 4 Optional Optional Autopsy N 2 12 Yes No Darkroom N 2 10 Yes No Nonrefrigerated Body Holding Room N Optional 10 Yes No Toilet Room N Optional 10 Yes No Bedpan Room N Optional 10 Yes No Bathroom N Optional 10 Yes No Janitor’s Closet N Optional 10 Yes No Sterilizer Equipment Room N Optional 10 Yes No Linen and Trash Chute Rooms N Optional 10 Yes No Laboratory, General N 2 6 Optional Optional Laboratory, Media Transfer P 2 4 Optional No Food Preparation Centers E 2 10 Yes No Warewashing N Optional 10 Yes No Dietary Day Storage V Optional 2 Optional No Laundry, General V 2 10 Yes No Soiled Linen Sorting and Storage N Optional 10 Yes No Clean Linen Storage P Optional 2 Optional Optional Anesthesia Storage Central Services V Optional 8 Yes No Soiled or Decontamination Room N 2 6 Yes No Clean Workroom P 2 4 Optional Optional Equipment Storage V Optional 2 Optional Optional
P = Positive N = Negative E = Equal V = May Vary For maximum energy conservation, use of a recirculated filtered air system is preferred. An all-outdoor-air system may be used, where required by local codes, provided that appropriate heat recovery procedures are utilized for exhaust air. Heat recovery systems should be uti- lized where appropriate, especially for those areas where all air is required to be exhausted to the outside. Requirements for outdoor air changes may be deleted or reduced and total air changes per hour supplied may be reduced to 25% of the figures listed when the affected room is unoccupied and unused provided that indicated pressure relationship is maintained. In addition, positive provisions such as an inter- connect with room lights must be included to insure that the listed ventilation rates including outdoor air are automatically resumed upon reoccupancy of the space. This exception does not apply to certain areas such as toilets and storage which would be considered as in use even though unoccupied. Rooms normally used for diagnostic X rays and only occasionally for fluoroscopic procedures may utilize recirculated air without require- ments for all air to be exhausted directly to outdoors.
22 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
5. Wall intake boxes are prohibited as an rule. Where two (2) filter banks are required, Air Conditioning and Ventilating Systems acceptable means of introducing the required filter bank number 1 shall be located 1978 published by the National Fire Protec- two (2) air changes of outside air into patient upstream of the air-conditioning equipment tion Association. All fire and smoke dampers rooms. If incremental, electrohydronic or fan and filter bank number 2 shall be downstream shall be accessible for servicing. coil units are used, a separate system of one of the supply fan, recirculating spray water 19. Supply, return air and exhaust ducts hundred percent (100%) outside air properly systems, water reservoir-type humidifiers and which pass through a smoke partition shall be tempered year-round shall be used to intro- cooling coils. Drift eliminators shall be used provided with dampers at the partition and duce outside air to the patient rooms. This air downstream of cooling coils to prevent the controlled to close automatically to prevent quantity shall equal the amount of air being carry-over of moisture from the cooling coils flow of air or smoke when a smoke detector exhausted from the patient room’s toilet to filter bank number 2. Where terminal fil- located in the duct or at the smoke partition room, but in no case shall it be less than two ters are used in operating rooms and delivery is actuated. Dampers shall be equipped with (2) air changes per hour. If incremental heat- rooms, the second filter bank may be located remote control reset devices. On high-veloci- ing, ventilating and air conditioning units are immediately downstream of the first filter ty systems, a time delay shall be provided so used, the ventilating air passages shall be per- bank. the fan will be stopped prior to damper clos- manently closed. 13. Where only one (1) filter bank is ing. Engineered smoke evacuation systems 6. Outside air intakes shall be located no required, it shall be located upstream of the will be considered for approval on a case-by- less than twenty-five feet (25') from exhaust air-conditioning equipment unless an addi- case basis. outlets of ventilating systems, combustion tional pre-filter is employed. In this case, the 20. If the air changes required in Table equipment stacks, medical-surgical clinical pre-filter shall be upstream of the equipment 1 in paragraph (27)(B)3. of this rule do not suction discharges and plumbing vent stacks and the main filter may be located farther provide sufficient air for use by hoods and or from areas which may collect vehicular downstream. safety cabinets, additional make-up air shall exhaust and other noxious fumes. Plumbing 14. Filter frames shall be durable and be provided as necessary to maintain the and vacuum vents that terminate above the carefully dimensioned and shall provide an required room pressure relationship. level of the top of the air intake may be locat- airtight fit with the enclosing ductwork. All 21. Laboratory hoods shall meet the fol- ed as close as ten feet (10'). The bottom of joints between filter segments and the enclos- lowing general requirements: have an average outside air intakes serving central systems ing ductwork shall be gasketed or sealed to face velocity of not less than seventy-five feet shall be located no less than six feet (6') provide a positive seal against air leakage. (75') per minute, be connected to an exhaust above ground level, or if installed above the 15. A manometer shall be installed system which is separate from the building roof, no less than three feet (3') above the across each filter bank serving sensitive areas exhaust system, have an exhaust fan located at roof level. or central air systems. the discharge end of the system and have an 7. All air supplied to operating rooms, 16. Table 2 exhaust duct system of noncombustible corro- delivery rooms and nurseries shall be deliv- Filter Efficiencies for Central Ventilation and sion-resistant material designed to meet the ered at or near the ceiling of the area served. Air-Conditioning Systems in General Hospitals planned usage of the hood. All air returned from operating rooms, deliv- 22. Each laboratory hood which pro- ery rooms and nurseries shall be removed Minimum cesses infectious or radioactive materials near the floor level. Number of Filter shall have a minimum face velocity of one Area Designation Filter Beds Efficiencies 8. At least two (2) return air outlets Filter Filter hundred feet (100') per minute, shall be con- located remote from each other shall be pro- Bed #1 Bed #2 nected to an independent exhaust system shall vided in each operating and delivery room. have filters with a ninety-nine and ninety- 9. The bottoms of ventilation (supply (%) (%) seven one-hundredths percent (99.97%) effi- and return) openings shall not be less than six Operating Rooms, De- ciency in the exhaust stream; and shall be inches (6") above the floor of any room livery Rooms, Nurseries, designed and equipped to permit the safe Recovery Rooms and except as indicated in paragraph (27)(B)7. of Intensive Care Units 2 25 90 removal, disposal and replacement of con- this rule. taminated filters. 10. Corridors shall not be used to sup- Patient Care, Treatment, 23. Duct systems serving hoods in Diagnostic and ply air to or exhaust air from any room, Related Areas 2 25 90* which radioactive strong oxidizing agents are except that air from corridors may be used to used shall be constructed of stainless steel for ventilate bathrooms, toilet rooms, janitors’ Food Preparation a minimum distance of ten feet (10') above closets and small electrical or telephone clos- Areas and Laundries 1 80 — the hood and shall be equipped with wash- ets opening directly onto corridors provided Administrative, Bulk down facilities. that ventilation can be accomplished by Storage and Soiled 24. Exhaust hoods in food preparation undercutting of doors. Holding Areas 1 25 — centers shall comply with the requirements of 11. Medical isolation rooms and inten- The Standards for the Installation of Equip- *May be reduced to 80% for systems using all-outdoor- sive care rooms may be ventilated by induc- air. ment for the Removal of Smoke and Grease- tion units if the induction units contain only a Laden Vapors From Commercial Cooking reheat coil and if only the primary air sup- 17. Ducts which penetrate construction Equipment 1980 published by the National plied from a central system passes through intended for X-ray or other ray protection Fire Protection Association. All hoods and the reheat coil. shall not impair the effectiveness of the pro- cooktop surfaces shall be equipped with auto- 12. All central ventilation of air-condi- tection. matic fire suppression systems, automatic fan tioning systems shall be equipped with filters 18. Fire and smoke dampers shall be controls and fuel shutoff. having efficiencies no less than those speci- constructed, located and installed in accor- 25. The ventilation system for anesthesia fied in Table 2 in paragraph (27)(B)16. of this dance with the Standard for the Installation of storage rooms shall comply with The
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 23 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
Standard for Inhalation Anesthetics 1980 plenums shall have a flame spread rating of A—One outlet accessible to each bed. One published by the National Fire Protection twenty-five (25) or less and a smoke devel- outlet may serve two beds. Association. oped rating of fifty (50) or less as determined B—One outlet. Portable equipment for the (C) Piping systems shall be run in spaces by an independent testing laboratory in accor- administration of oxygen and suction may be that are generally accessible for maintenance dance with the Standard for Surface Burning considered acceptable in lieu of a piped sys- and repair. Piping shall be installed with ade- Characteristics of Building Materials 1979 tem. quate provision for expansion and contraction published by the National Fire Protection C—Two outlets for each bed or provide one and securely supported from the structure. Association. outlet with Y fitting. 1. Reverse return piping systems shall be 6. Duct linings shall not be used in sys- D—One outlet. utilized where necessary to maintain water tems supplying operating rooms, delivery E—One outlet for each bed. temperatures. rooms, recovery rooms, nurseries, isolation F—Two outlets. 2. Connections between dissimilar met- rooms and intensive care units unless termi- G—Three outlets. als shall be equipped with insulating unions nal filters of at least ninety percent (90%) or flanges. efficiency are installed downstream of the lin- 4. A separate dedicated waste anesthesia 3. Valves shall be installed in branches ings. gas exhaust system shall be provided, except from mains or risers in order to isolate sec- (F) All new hospitals shall be equipped nonflammable waste anesthesia gases may be tions of both the hot or chilled water systems. with central-piped oxygen and clinical suc- connected into the clinical suction system All risers shall be equipped with drain valves tion systems. Consideration also shall be provided the anesthesia gases are not detri- and vent cocks. given to installing central-piped nitrous mental to the clinical suction pumps and the 4. Valves shall be installed at all equip- oxide, nitrogen, clinical air, carbon dioxide pumps are vented directly to the atmosphere. ment connections for ease in servicing equip- and natural gas. (G) Plumbing Systems. ment. 1. All medical gases shall be installed in 1. All plumbing systems shall be (D) Duct systems shall be fabricated and accordance with the Standard For Non- designed and installed in accordance with installed in accordance with the Standard for flammable Medical Gas Systems 1977 pub- applicable state and local codes. Installation of Air Conditioning and Ventilat- lished by the National Fire Protection Asso- 2. Plumbing fixtures. ing Systems 1978 published by the National ciation. A. Plumbing fixtures shall be of non- Fire Protection Association. 2. All medical gas piping shall be iden- absorptive acid-resistant material. (E) Insulation. tified in some manner by the following color B. The water supply spout for a lava- 1. Insulation shall be installed in accor- code: oxygen—green, nitrous oxide—light tory and sink located in patient care area shall dance with the Commercial and Industrial blue, clinical air—yellow, carbon dioxide— be mounted so that its discharge point is a Insulation Standards Manual of the Midwest gray, nitrogen—black, and clinical suction— minimum distance of five inches (5") above Insulating Contractors Association (MICA). yellow. the rim of the fixture. All fixtures used by 2. Insulation shall be provided for the 3. Oxygen and clinical suction outlets medical and nursing staff and all lavatories following: boilers, smoke breeching and shall be installed as outlined in Table 3. used by patients and food handlers shall be stacks; steam supply and condensate return trimmed with valves which can be operated piping; hot water piping above one hundred Table 3 without the use of hands. When blade handles Station Outlets for Oxygen are used for this purpose, they shall not degrees Fahrenheit (100°F) and all hot water and Vacuum (Suction) Systems heaters, generators and converters; chilled Clinical exceed four and one-half inches (4 1/2") in water piping, refrigerant piping and other Location Oxygen Suction length, except that handles on scrub sinks and clinical sinks shall be not less than six inches process piping and equipment operating with Patient Room for Adult fluid temperatures below the ambient dew Medical, Surgical and (6") long. All lavatories and sinks shall be Postpartum Care and equipped with stop valves. point; water supply and drainage piping on for Pediatrics A A which condensation may occur; air ducts and C. Clinical sinks shall have a bedpan Examination and flushing device and shall have an integral trap casings with outside surface temperature Treatment Room for below the ambient dew point or temperature Nursing Unit B B in which the upper portion of a visible trap above eighty degrees Fahrenheit (80°F); and seal provides a water surface. Patient Room for Intensive other piping, ducts and equipment necessary Care C C D. Showers and tubs shall be provid- to maintain the efficiency of the systems. ed with nonslip surfaces. Nursery and Pediatric 3. Insulation on cold surfaces shall Nursery A A E. All scrub sinks shall be equipped include an exterior vapor barrier. with knee- or foot-operated controls. General Operating Room F F 4. Insulation, including finishes and F. Water closets in patient areas shall adhesives on the exterior surfaces of ducts, Cystoscopy and Special be quiet operating types. pipes and equipment, shall have a flame Procedure Room D D G. Stools in patient, diagnostic and spread rating of twenty-five (25) or less and a Recovery Room for Surgical treatment areas shall be the elongated bowl smoke developed rating of fifty (50) or less in and Obstetrical Patients E E type with nonreturn stops, backflow preven- accordance with the Standard for Installation Delivery Room F G ters and silencers. Seats shall be the split of Air Conditioning and Ventilating Systems Labor Room A A type. 1978 published by the National Fire Protec- H. Bedpan flushing devices shall be Treatment Room for tion Association. Emergency Care D D provided in each patient toilet room except 5. Linings and coatings, adhesives and those in psychiatric units, alcohol abuse units insulation on exterior surfaces of pipes and Autopsy Room — D and other ambulatory care facilities. ducts in building spaces used as air supply Anesthesia Workroom — D 3. Water supply systems.
24 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
A. The water supply systems shall be and delivery rooms, recovery rooms, nurs- 19 CSR 30-20.040 Definitions Relating to designed to supply water at sufficient pres- eries, food preparation centers, food service Long-Term Care Units in Hospitals sure to operate all fixtures and equipment facilities, food storage areas and other critical during maximum demand periods. areas; special precautions shall be taken to PURPOSE: This rule defines terminology B. Each water service main, branch protect any of these areas from possible leak- used throughout 19 CSR 30-20.050 and 19 main, riser and branch to a group of fixtures age or condensation from necessary overhead CSR 30-20.060. shall be valved. Stop valves shall be provided drainage piping systems. These special pre- at each fixture. cautions include requiring noncorrosive (1) Ambulatory resident. An ambulatory res- C. Backflow preventers and vacuum semi-circular drip troughs with a minimum ident shall mean a resident who is capable breakers shall be installed on hose bibbs, lab- four inch (4")-outside diameter to be installed mentally and physically of negotiating a nor- oratory sinks, janitors’ sinks, bedpan-flush- under the drainage pipe in the direction of mal path to safety using assistive devices or ing attachments, autopsy tables and on all slope to a point where the pipe leaves the pro- aides when necessary, including ascent and other fixtures to which hoses or tubing can be tected space and terminates at that point— descent of stairs. attached. usually at a wall. The trough shall be sup- (2) Competency evaluation program. The D. The water supply system shall be ported with noncorrosive strap hangers and completion of the state training agency’s for- designed to provide hot water at each hot screws from the pipe above. Trough joints merly required one hundred thirty-five (135)- water outlet at all times. Hot water at show- and hanging screw penetrations shall be ers and bathing facilities shall not exceed one hour nursing assistant training course before sealed to maintain watertight integrity hundred ten degrees Fahrenheit (110°F). Hot January 1, 1989 and the successful comple- throughout. water at handwashing facilities shall not tion of the state training agency’s special four D. Floor drains shall not be installed exceed one hundred twenty degrees Fahren- (4)-hour retraining program, which includes in general operating and delivery rooms. heit (120°F). taking and passing the final examination to Flushing rim-type floor drains may be 4. Hot water-heaters and tanks. Hot water the nursing assistant training course as heating equipment shall have sufficient installed in cystoscopic operating rooms. required in 13 CSR 15-13.010(7)(J); a chal- capacity to supply water at the temperatures E. Building sewers shall discharge lenge to the final examination of the nursing and amounts indicated in Table 4. Water tem- into a community sewerage system when assistant training course in accordance with peratures are to be taken at hot water point of available. If such a system is not available, a 13 CSR 15-13.010(7)(B)5.; or enrolling in use of inlet to processing equipment. facility providing sewage treatment shall con- and successfully completing the one hundred form to 10 CSR 20-6.010. seventy-five (175)-hour nursing assistant Table 4 training course as described in 13 CSR 15- Hot Water Use (28) Service Facilities. 13.010(6). (A) Space shall be provided for the main- Clinical Dietary Laundry tenance engineer’s office, maintenance shop (3) Intermediate care unit. Any unit other and storage for building maintenance sup- Gallons (per hour than a residential care unit or skilled nursing plies. per bed) 6 1/2 4 4 1/2 unit which is utilized by a hospital to provide Liters (per second (B) Service entrances to receiving rooms twenty-four (24)-hour accommodation, per bed) .007 .004 .005 shall be protected from the weather. board, personal care and basic health and Temperatures (°F) 110 120* 160** (C) General storage space excluding space nursing care services under daily supervision Temperature (°C) 43 49* 71** for receiving and the purchasing office shall of a licensed nurse. be provided at the rate of twenty (20) square *The rinse water temperature of automatic ware- feet per bed for the first four hundred (400) (4) Licensed nurse. A practical nurse or a washing equipment shall be one hundred eighty degrees Fahrenheit (180°F). beds and ten (10) square feet per bed for all registered nurse. **Sufficient hot water is to be delivered to the additional beds. Off-site storage space is laundry to maintain this temperature in the washing acceptable, however, one-half (1/2) of the (5) Long-term care unit. A unit attached to or machine during the entire wash and rinse period. required storage space shall be located in the contained within a hospital that is operated hospital. General storage shall be concentrat- solely or in combination as a skilled nursing 5. Consideration shall be given to the ed in one (1) area. unit, an intermediate care unit or a residential use of water softeners to soften domestic hot (D) Space and facilities shall be provided care unit. water and boiler water make-up whenever the for the sanitary storage and disposal of waste. water supply exceeds five (5) grain hardness. (E) If an incinerator is provided, it shall be (6) Nonambulatory resident or bed patient. A 6. Drainage systems. separated as required in subparagraph nonambulatory resident or bed patient is a A. Drain lines from sinks in which (24)(C)2.T. of this rule. person who is confined to bed eighty percent acid wastes may be poured shall be fabricat- (80%) of the time or who is unable to repo- ed from an acid-resistant material. AUTHORITY: sections 192.005.2 and sition him/herself in a chair unaided. B. Drain lines serving automatic 197.080, RSMo 1986.* This rule was previ- blood cell counters shall be of carefully ously filed as 13 CSR 50-20.031 and 19 CSR (7) Nursing assistant. An employee, includ- selected material to prevent undesirable 10-20.031. Original rule filed June 2, 1982, ing a nurse aid or orderly, who is assigned to chemical reactions between blood count effective Nov. 11, 1982. Amended: Filed June a long-term care unit of a hospital to provide wastes and plumbing system materials such 14, 1988, effective Oct. 13, 1988. or assist in providing direct resident health as copper, lead, brass and solder. care services under the supervision of a nurse C. Drainage piping shall not be *Original authority: 192.005.2, RSMo 1985 and 107.080, licensed under the Nursing Practice Act, installed in an exposed location in operating RSMo 1953. Chapter 335, RSMo.
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 25 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
(8) Nursing assistant trainee. An individual responsible for administering the state nurs- assistant in accordance with the governing newly employed full-time or part-time in a ing assistant training program and for admin- body bylaws of the hospital. long-term care unit as a nursing assistant who istering the state registry. (C) Visiting Hours. has not successfully completed an approved 1. Regular daily visiting hours shall be nurse assistant training program and who has (17) Training agency. An organization established and posted. not been employed as a nursing assistant in approved by the state training agency to spon- 2. Relatives or guardians and clergy, if the hospital’s long-term care unit for more sor the nursing assistant training program. requested by the resident or family, shall be than four (4) months. allowed to see critically-ill residents at any (18) Training and competency evaluation pro- time in keeping with the orders of the physi- (9) Nursing assistant training program. A gram. The completion of the state training cian. program, as described in 13 CSR 15-13.010 agency’s one hundred seventy-five (175)-hour (D) Medical records shall comply with 19 and approved by the Missouri Division of nursing assistant training course or a chal- CSR 30-20.021(3)(D). All medical orders Aging, for training nursing assistants who are lenge to the final examination of the nursing shall be renewed at least monthly. employed in long-term care units. assistant training course in accordance with (E) If the minimum staffing as required in 13 CSR 15-13.010(7)(B)5. sections (5)–(7) of this rule does not meet the (10) Practical nurse. An individual who is needs of the residents, the Department of licensed to practice as a practical nurse in AUTHORITY: sections 192.005.2 and Health shall inform the administrator, in writ- Missouri. 197.080, RSMo 1986.* This rule was previ- ing, how many additional personnel are need- ously filed as 13 CSR 50-20.040 and 19 CSR ed and of what type and shall give the basis (11) Registered nurse. An individual who is a 10-20.040. Original rule filed Nov. 29, 1982, for this determination. graduate of an approved school of nursing effective March 11, 1983. Amended: Filed (F) All residents shall have a comprehen- and who is licensed to practice as a registered May 31, 1989, effective Aug. 24, 1989. sive, accurate, standardized assessment com- nurse in Missouri. pleted within fourteen (14) days of admission. *Original authority: 192.005.2, RSMo 1985 and 197.080, The assessment is to be completed utilizing (12) Resident. A person who by reason of RSMo 1953. the resident assessment instrument developed aging, illness, disease or physical or mental by the Health Care Financing Administration infirmity requires care and services furnished for use in long-term care facilities. The by a long-term care unit and who resides in 19 CSR 30-20.050 Standards for the Oper- instrument includes a uniform minimum data this a unit and is cared for, treated or accom- ation of Long-Term Care Units in Hospi- set (MDS) of care screening and assessment modated there for a period exceeding twenty- tals elements, common definitions for these ele- four (24) consecutive hours. PURPOSE: This rule establishes standards ments and utilization guidelines. The assess- (13) Residential care unit. Any unit other for the administration, nursing staff and over- ment shall be documented on the MDS and than an intermediate care unit or skilled nurs- all operation of long-term care units in hos- shall include applicable resident assessment ing unit which is utilized by a hospital to pro- pitals to provide a high level of care. protocols. An assessment shall become the vide twenty-four (24)-hour accommodation, basis for the care and treatment to be provid- board, personal care and protective oversight, (1) Requests for deviations from the require- ed. including nursing care during short-term ill- ments of this rule shall be in writing to the ness or recuperation. Department of Health. Approvals for devia- (4) Nursing Assistant Orientation. tions shall be in writing and both requests and (A) The chief executive officer of the hos- (14) Skilled nursing unit. Any unit other than approvals shall be made a part of the perma- pital shall assure that individuals who are a residential care unit or an intermediate care nent Department of Health records for a facil- newly employed as nursing assistants in the unit which is utilized by a hospital to provide ity. long-term care unit receive an in-service ori- for twenty-four (24)-hour accommodation entation. At a minimum, the orientation shall board and skilled nursing care and treatment (2) Swing beds located in the acute part of a include an explanation of: the organizational services. Skilled nursing care and treatment hospital which may be used intermittently for structure of the long-term care unit, the unit’s services are those services commonly per- long-term care are exempt from the require- policies and procedures, the unit’s philosophy formed by or under the supervision of a reg- ments of this rule. of care, a description of the resident popula- istered nurse for individuals requiring twen- tion, job responsibilities and employee rules, ty-four (24) hours-a-day care by licensed (3) Administration. information on communicable diseases, nursing personnel. (A) A long-term care unit shall be licensed infection control procedures, resident rights as part of the hospital in which it is located or and emergency protocols. The hours of ori- (15) State registry. A record maintained by attached. The hospital governing body shall entation may be applied to the nursing assis- the state training agency which contains the be the legal authority for the long-term care tant training course if conducted in accor- identity of all individuals who have satisfied unit and shall be responsible for the overall dance with 13 CSR 15-13.010(6)(B). requirements to be nursing assistants in Mis- planning, directing, control and management (B) New employees of long-term care units souri and which shall be utilized to determine of the activities and functions of the long- who are nursing assistant trainees shall be if an applicant is qualified to fill the position term care unit. allowed to provide direct nursing care to res- of a nursing assistant in a long-term care unit. (B) The administration of the long-term idents only if they have received training and care unit shall be the responsibility of the have demonstrated competency with regard to (16) State training agency. The Missouri chief executive officer of the hospital. This the specific care being provided. A licensed Division of Aging is the agency designated as authority may be delegated to a qualified nurse shall be responsible for verifying the
26 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
competency and for documenting this in the (9) Medical Care. (11) Intermediate Care Unit. trainee’s personnel file. The in-service orien- (A) Medical care in long-term care units (A) An intermediate care unit as defined in tation program shall be supervised by a shall be under the direction of a physician 19 CSR 30-20.040(2) shall have either a licensed nurse who is on duty in the unit at member of the medical staff and appointed by registered nurse or a licensed practical nurse the time the orientation is provided. the governing body. in charge of the unit. (C) Nursing assistant trainees shall be (B) Each resident shall have the privilege (B) When the person in charge is a licensed clearly identified so that residents, family of selecting his/her own physician consistent practical nurse, a registered nurse shall be members, visitors and staff are aware that with hospital medical staff bylaws. available in the hospital for the supervision of patient care. they are in training. (C) Each resident shall be visited by the attending physician as often as medically nec- (C) A licensed nurse shall be available in the hospital for assistance to the unit twenty- (5) Competency Evaluation of Nursing Assis- essary but no less than every sixty (60) days. four (24) hours a day, seven (7) days a week. tants. The chief executive officer of the hos- (D) There shall be a mechanism for the review and evaluation on a regular basis of (D) The minimum ratios of staff engaged pital shall be responsible for assuring that all in direct patient care, exclusive of superviso- nursing assistants who were employed and the quality and appropriateness of medical care in the long-term care unit. ry staff, shall be the minimum ratios required trained as nursing assistants before July 1, in subsection (5)(C) of this rule. 1989 complete a competency evaluation pro- (10) Skilled Nursing Unit. (E) One (1) of the nursing personnel on the gram before January 1, 1990. (A) A skilled nursing unit as defined in 19 day shift shall be a licensed nurse. CSR 30-20.040(10) shall have a registered (F) In a multi-story facility, at least one (1) (6) Training and Competency Evaluation Pro- nurse on duty eight (8) hours a day and seven direct-care staff shall be on duty at all times gram. (7) days a week. on each occupied floor. (A) The chief executive officer of the hos- (B) The nursing service administrator shall (G) All medications shall be administered pital shall be responsible for assuring that all be responsible for the quality of nursing care by a licensed nurse or physician. nursing assistants employed in the long-term supervision of personnel providing nursing (H) A physical examination by a physician care unit after July 1, 1989 shall have com- care and for a program of in-service educa- shall be completed and recorded on the clin- pleted or will complete the training and com- tion for nursing personnel. ical record of each resident, preferably before admission, but not later than seven (7) days petency evaluation program. (C) Skilled nursing units shall employ after admission, unless the resident is accom- (B) Individuals may be employed as nurs- nursing personnel in sufficient numbers and panied on admission from a hospital or other ing assistant trainees in a long-term care unit sufficiently qualified to meet the needs of the long-term care unit by a record of a physical in order to complete the nursing assistant residents. Exclusive of supervisory staff, the examination completed within the past six (6) training and competency evaluation program. minimum ratio of nursing staff engaged in months. Physical examinations shall be per- This period of training cannot exceed four (4) direct patient care and treatment to residents formed at least annually. shall be as follows: months from the date of employment. (I) The unit shall not knowingly admit or continue to care for residents whose needs (7) Orientation In-Service Training and Con- Time Ratio of Staff to Residents* cannot be met by the unit directly or in coop- tinuing Education. 7 a.m. to 3 p.m. 1 staff person for each 10 resi- eration with community resources or other (A) The chief executive officer of the hos- (day) dents plus 1 additional staff person for any remainder of providers of care with which it is affiliated or pital shall assure the development of an in- 6 or more residents has contracts. Seriously disturbed mentally- service orientation and continuing education ill residents shall not be admitted or retained program offered by qualified instructors for 3 p.m. to 11 p.m. 1 staff person for each 15 resi- unless the unit can provide the care the resi- (evening) dents plus 1 additional staff the development of all personnel in the long- person for any remainder of dent needs. Provision shall be made for the term care unit that is appropriate to their job 8 or more residents care of residents with a communicable dis- functions. Orientation for all new personnel ease either in the hospital or in a suitable 11 p.m. to 7 a.m. 1 staff person for each 20 resi- room in the unit. Infection control policies shall begin the first day of employment in the (night) dents plus 1 additional staff long-term care unit and shall cover, at a min- person for any remainder of and procedures shall be followed. imum, prevention and control of infection 11 or more residents. and hospital policies and procedures, includ- (12) Residential Care Units. *The number of residents is based on occupied beds. ing emergency protocol, job responsibilities, (A) Policies and procedures shall be writ- ten to include at least medications, medical lines of authority, confidentiality of patient (D) On the day shift there shall be a regis- treatment and outside privileges. information, resident’s rights and preserva- tered nurse on duty; on both evening and (B) Nursing personnel shall have access to tion of patient dignity. night shifts there shall be a licensed practical the legal name of each resident and the name (B) The continuing education program for nurse or a registered nurse on duty. and telephone number of each resident’s nursing assistants shall focus on basic nursing (E) A registered nurse shall be available in physician and next of kin or responsible party skills, personal care skills, mental health and the hospital to assist during the time a in the event of emergency. social service needs and basic restorative ser- licensed practical nurse is in charge. (C) At least one (1) staff person at least vices. (F) In a multi-story facility, at least one (1) eighteen (18) years of age shall be on duty at direct-care staff person shall be on duty at all all times. (8) Training Record. Written records of the times for each occupied floor. (D) There shall be one (1) licensed nurse employee’s training shall be maintained in the (G) All skilled nursing units shall comply on duty at least (8) hours per week for every employee’s personnel file. with subsections (11)(G)–(I) of this rule. thirty (30) residents plus one (1) additional
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 27 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
licensed nurse on duty at least eight (8) hours citizen and to this end may voice grievances long as the quality and delivery of those per week for any remainder of sixteen (16) or and recommend changes in policies and ser- goods or services conform with policies and more residents. vices to facility staff or to outside representa- procedures of the hospital. (E) Only ambulatory residents shall be tives of his/her choice and shall be free from admitted to the residential care unit. restraint, interference, coercion, discrimina- (14) Personal Funds and Property of Resi- (F) Those residents who require the use of tion or reprisal. dents. a walker or wheelchair shall be housed on a (G) Each resident may manage his/her per- (A) No hospital shall be required to hold floor which has direct exit at grade or which sonal financial affairs and, to the extent that any personal funds or money in trust unless has a ramp with a slope not greater than one the facility assists in the management, may some other governmental agency placing res- to twelve (1:12) leading to grade or which have his/her personal financial affairs man- idents in the facility makes this requirement. has no more than two (2) steps to grade. The aged in accordance with section (9) of this (B) Authorizations by the resident, his/her steps shall have a handrail. Those residents rule. designee or legal guardian for the hospital to who use a wheelchair shall be able to reach (H) No resident shall be mentally or phys- use the personal funds of the resident shall be the equipment unassisted and demonstrate the ically abused. Each resident shall be free in writing and kept with the resident’s record ability to transfer to and from a wheelchair from chemical and physical restraints except or with the personal funds account. without assistance. when the restraints are authorized in writing (C) When a resident is admitted, s/he and by a physician for a specific period of time or his/her next of kin or legal guardian shall be (13) Resident’s Rights and Grievance Proce- when the restraints are necessary in an emer- provided with a statement explaining the res- dures for Long-Term Care Units. gency to protect the resident from injury to ident’s rights regarding personal funds. (A) A complete copy of each official noti- him/herself or others. In an emergency, phys- fication from the Department of Health of ical restraints may be authorized by a regis- (D) Resident’s personal funds that are held violations, deficiencies, licensure approvals, tered nurse. This action shall be reported in trust shall be kept separate from the hospi- disapprovals and responses shall be retained promptly to a physician, always within twen- tal funds. and made available at the unit for inspection ty-four (24) hours. (E) There shall be a written account for when requested by staff, residents, families (I) Each resident shall be assured confi- each resident showing receipts to and dis- or legal representatives of the residents and dential treatment of all information contained bursements from the personal funds of each the public. in his/her records, including information con- resident. (B) Each resident shall be informed of tained in an automatic data bank; his/her (F) A written statement of all receipts and his/her rights and responsibilities as a resi- written consent shall be required for the disbursements showing the current balance dent and of all rules governing resident con- release of information to persons not other- shall be given on a quarterly basis to the res- duct and responsibilities. A copy of all the wise authorized under law to receive it. ident, his/her designee or legal guardian. information shall be posted in a conspicuous (J) Each resident shall be treated with con- (G) When personal funds and possessions location in the facility and copies shall be sideration, respect and full recognition of held in trust by the hospital are returned to available to anyone requesting the informa- his/her dignity and individuality, including the resident or his/her designee or guardian tion. Prior to or at the time of admission, a privacy in treatment and in care for his/her before or after the resident’s discharge, the copy of the information shall be provided to personal needs. resident or his/her designee or guardian shall each resident or his/her designee, next of kin (K) No resident shall be required to per- give the hospital a receipt for the funds and or legal guardian. form services for the unit that are not includ- possessions returned. (C) Each resident shall be informed in ed for therapeutic purposes in the plan of (H) There is no duty on the part of the hos- writing, prior to or at the time of admission care. pital to invest a resident’s funds held in trust and during his/her stay, of services available (L) Each resident may communicate, asso- or to increase the principal. in the unit and of related charges, including ciate and meet privately with persons of (I) Any owner, manager, employee or affil- any charges for services not covered under his/her choice, unless to do so would infringe iate of an owner who receives any personal the federal or state programs or not covered upon the rights of other residents. Each resi- property or anything else with a value of ten by the facility’s per-diem rate. dent may send and receive his/her personal dollars ($10) or more from a resident shall (D) Each resident shall be informed by a mail unopened. give the resident a written statement giving physician of his/her health and medical con- (M) Each resident may participate in activ- the date it was received, from whom it was dition unless medically contraindicated (as ities of social, religious and community received and its estimated value. documented by a physician in the resident’s groups at his/her discretion, unless con- record); shall be given the opportunity to par- traindicated for reasons documented by a (J) No owner, manager, employee or affil- ticipate in the planning of his/her total care physician in the resident’s medical record. iate of an owner, in one (1) calendar year, and medical treatment and to refuse treat- (N) Each resident may retain and use shall receive any personal property or any- ment; and shall participate in experimental his/her personal clothing and possessions as thing else with a total value exceeding one research only upon his/her informed written space permits. hundred dollars ($100) from a resident of any consent. (O) If married, a resident shall be insured facility. This does not apply to bequests. (E) Each resident shall be transferred or privacy for visits by his/her other spouse; if (K) The recordkeeping and other require- discharged only for medical reasons, for both are residents in the facility, they shall be ments of section (14) of this rule apply only his/her welfare or that of other residents or permitted to share a room unless medically to those personal possessions and funds for nonpayment for his/her stay. contraindicated. which the facility accepts to hold in trust for (F) Each resident shall be encouraged and (P) Each resident shall be allowed to pur- the resident and does not apply to other pos- assisted, throughout his/her period of stay, to chase or rent any goods or services not sessions residents have in their rooms or exercise his/her rights as a resident and as a included in the per-diem or monthly rate as bring into the facility.
28 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
AUTHORITY: sections 192.005.2 and the Department of Health. Approvals for showers, on at least one (1) side of all water 197.080, RSMo 1986.* This rule was previ- deviations shall be in writing and both closets and located in proper positions to ously filed as 13 CSR 50-20.050 and 19 CSR requests and approvals shall become a part of facilitate the bodily movements of residents. 10-20.050. Original rule filed Nov. 29, 1982, the permanent Department of Health records 2. Lavatories shall be positioned to be effective March 11, 1983. Amended: Filed for the facility. accessible to wheelchair residents and shall May 31, 1989, effective Aug. 24, 1989. (D) Alterations or additions to existing not have cabinets underneath or any other Amended: Filed July 12, 1991, effective Feb. units shall be programmed so construction unnecessary obstruction to the maneuverabil- 6, 1992. will minimize disruptions of existing func- ity of wheelchairs. tions. Access to exits and fire protection shall 3. Mirrors shall be provided in each res- *Original authority: 192.005.2, RSMo 1985 and 197.080, be maintained so the safety of the occupants ident room or adjoining toilet room. Mirrors RSMo 1953. will not be jeopardized during construction. shall be a least three feet (3') high and locat- (E) The owner of each new unit or the ed with the bottom edge no more than three 19 CSR 30-20.060 Construction Standards owner of an existing unit being added to or feet four inches (3'4") above the floor or for New Long-Term Care Units in Hospi- undergoing major alterations shall provide a framed tilting mirrors may be used. tals program, scope of services, which describes (B) All new long-term care units shall space requirements, staffing patterns, depart- comply with 19 CSR 30-20.030(4)(A)–(J) PURPOSE: This rule establishes up-to-date mental relationships and other basic informa- with one (1) exception: intermediate-care construction standards for new long-term tion relating to the objectives of the unit. The units and residential-care units are not care units in hospitals to help ensure accessi- program may be general but it shall include a required to comply with subsection (4)(J). ble, functional, fire-safe and sanitary facili- description of each function to be performed, (C) All new long-term care units shall ties. approximate space needed for those functions comply with 19 CSR 30-20.030(5)(A)–(I). and the interrelationship of various functions (D) A separate public area for a long-term (1) New Long-Term Care General Require- and spaces. The program also shall describe care unit shall be provided and shall include ments. how essential services can be expanded in the a waiting room, public toilets for each sex (A) A new long-term care unit is one for future as the demand increases. Appropriate and a public telephone. which plans are submitted to the Department modifications or deletions in space require- (E) An office shall be provided for the of Health for review and approval after the ments may be made when services are shared licensed nurse supervisor of the unit. effective date of this rule for the construction, or purchased provided the program indicates (F) Recreation, occupational therapy, expansion or renovation of a unit or the con- where the services are available and how they activity and residents’ dining space shall be version of an existing unit not previously and are to be provided. provided at a ratio of at least thirty (30) continuously utilized as a long-term care (F) Swing beds located in the acute part of square feet for each resident. unit. New long-term care units and additions the hospital which may be used intermittent- (G) A personal care room with barber and to and major alterations of existing licensed ly for long-term care patients are exempt beauty shop facilities shall be provided. long-term care units shall be designed to pro- from the requirements of this rule. (H) General storage rooms shall be provid- vide all of the facilities required by this rule. ed as follows: ten (10) square feet per bed for Those facilities shall be arranged to accom- (2) Planning and Construction Procedures. the first fifty (50) beds; plus eight (8) square modate with maximum convenience all of the (A) Plans and specifications shall be pre- feet per bed for the next twenty-five (25) functions required by this rule; and to provide pared for the construction of all new long- beds; plus five (5) square feet per bed for any comfortable, sanitary, fire-safe, secure and term care units in hospitals and additions to additional beds. No storage room shall have durable facilities for the patients. In any and major remodeling of existing long-term less than one hundred (100) square feet of major alteration project or addition to an care units. The plans and specifications shall floor space. Storage space for residents’ existing long-term care unit, only those parts be prepared by an architect or a professional clothes and for outdoor equipment is required of a unit affected by the project or addition engineer licensed to practice in Missouri. but may be undivided in the minimum area are subject to this rule. (B) Construction shall be in conformance required for general storage. (B) The minimum requirements of this rule with plans and specifications approved by the (I) If the long-term care unit is designed to are not intended in any way to restrict inno- Department of Health. The Department of have its own dietary facilities, the dietary vations and improvements in design, con- Health shall be notified within five (5) days facilities shall comply with 19 CSR 30- struction or operating techniques. Plans and after construction begins. If construction of 20.030(14). specifications and operational procedures the project is not started within one (1) year (J) If elevators are located in the long-term which contain deviations from these require- after the date of approval of the plans and care unit, they shall comply with 19 CSR 30- ments may be approved if it is determined specifications, the plans and specifications 20.030(21). that the purposes of the minimum require- shall be resubmitted to the Department of (K) Handrails shall be provided on both ments have been fulfilled. Some facilities Health for its approval and shall be amended, sides of all corridors, aisles and stairways. may be subject to the requirements of more if necessary, to comply with the then current Corridor handrails shall have ends returned than one (1) regulating agency. While every rules before construction work commences. to the wall. effort has been made to ensure coordination, facilities making requests for changes in ser- (3) General Design of Long-term Care Units. (4) Fire Prevention and Protection. All new vices and requests for new construction or (A) All new long-term care units shall and existing facilities shall comply with 19 renovations are cautioned to verify require- comply with 19 CSR 30-20.030(3)(B)5. and CSR 30-20.030(24)(A) and (B). ments of other agencies involved. 6. (C) Requests for deviations from the 1. Grab bars or handrails shall be pro- (5) All new units, additions to existing units requirements of this rule shall be in writing to vided adjacent to all bathtubs, within all and major alterations to existing units shall
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 29 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
comply with the life safety requirements in days after the Department of Health receives 19 CSR 30-20.030(24)(C). the application. If denied, specific reasons, with references, shall be given for the denial. (6) All new units, additions to existing units (D) The date of annual registration of a and major alterations to existing units shall licensed hospital as an infectious waste gen- comply with the construction requirements in erator shall be the hospital license renewal 19 CSR 30-20.030(25). date and a nonlicensed hospital shall be assigned an annual registration date. (7) All new units, additions to existing units and major alterations to existing units except AUTHORITY: sections 197.080, RSMo 1986 residential-care units shall comply with the and 260.203, RSMo Supp. 1992.* Original electrical requirements in 19 CSR 30- rule filed Aug. 15, 1988, effective Dec. 29, 20.030(26)(E)5. and 6.; (F)1.; (G)1., 3. and 1988. 4.; (H)1.A. and 2.A.; and (I). *Original authority: 197.080, RSMo 1953 and 260.203, (8) All new units, additions to existing units RSMo 1986, amended 1988, 1992. and major alterations to existing units except residential-care units shall comply with mechanical requirements in 19 CSR 30- 20.030(27).
AUTHORITY: sections 192.005.2 and 197.080, RSMo 1986.* This rule was previ- ously filed as 13 CSR 50-20.060 and 19 CSR 10-20.060. Original rule filed Nov. 29, 1982, effective March 11, 1983.
*Original authority: 192.005.2, RSMo 1985 and 197.080, RSMo 1953.
19 CSR 30-20.070 Standards for Registra- tion as a Hospital Infectious Waste Gener- ator
PURPOSE: This rule establishes standards and procedures for the registration of hospi- tals to ensure a high level of public safety in the handling and disposal of infectious waste.
(1) Application for Registration as a Hospital Infectious Waste Generator. (A) Annually every hospital shall submit to the Department of Health an application for registration as an infectious waste generator. Forms for the application shall be furnished by the Department of Health. (B) Each application shall include: 1. An operational plan for the handling and treatment of infectious waste as specified in 19 CSR 30-20.020(5)(D)1. 2. A statement that the applicant under- stands and complies with sections 260.200– 260.245, RSMo; 19 CSR 30-20.010; 19 CSR 30-20.020; and 10 CSR 80; and 3. The signature of the hospital’s chief executive officer and the director of the infec- tious waste management program. (C) The application shall be submitted annually, three (3) months previous to the registration date. It shall be reviewed and denial or acceptance given within thirty (30)
30 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 31 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
19 CSR 30-20.080 Governing Body of Hos- adopted or specific orders issued by the gov- (17) The governing body shall establish pitals erning body in accordance with its bylaws. mechanisms which assure the hospital’s com- pliance with mandatory federal, state and PURPOSE: This rule defines governing body (9) The Department of Health shall be noti- local laws, rules and standards. and establishes standards for the governing fied of any change in the appointment of the body of hospitals. chief executive officer. (18) Although independent licensed practi- tioners are not authorized membership to the (1) The governing body is defined as an indi- (10) Bylaws of the governing body shall medical staff, the governing body may vidual owner(s), partnership, corporate body, require that the medical staff, hospital per- include provisions within its bylaws to grant association or public agency having legal sonnel and all auxiliary organizations, direct- licensed practitioners clinical privileges, on responsibility for the operation of a hospital ly or indirectly, shall be responsible to the an outpatient basis, for diagnostic and thera- subject to provisions of sections governing body through the chief executive peutic tests and treatment. The privileges 197.020–197.120, RSMo. officer. shall be within the scope and authority of each practitioner’s current Missouri license (2) The governing body shall be the legal (11) Bylaws of the governing body shall and practice act. authority in the hospital and shall be respon- require that a qualified individual be desig- (A) The provisions shall include a mecha- sible for the overall planning, directing, con- nated by the chief executive officer to act in nism to assure that independent practitioners trol and management of the activities and his/her absence. who provide services have clinical privileges delineated by the governing body or designee. functions of the hospital. (12) Duly appointed representatives of the (B) The mechanism shall include criteria for a review of an independent practitioner’s (3) The governing body shall establish and Department of Health shall be allowed to credentials at least every two (2) years. At a adopt bylaws to provide for the appointment inspect the hospital as required in section minimum, the criteria shall include docu- of a qualified chief executive officer and 197.100, RSMo. mentation of a current license, relevant train- members of the medical staff and of the del- ing and experience, and competency. egation of authority and responsibility to (13) Bylaws of the governing body shall pro- each. A copy of the governing body bylaws vide for the selection and appointment of (19) The governing body shall establish and and of all amendments or revisions shall be medical staff members based upon defined implement a mechanism which assures com- submitted to the Department of Health for its criteria and in accordance with an established pliance with the reporting requirements in records. procedure for processing and evaluating section 383.133, RSMo. applications for membership. Applications (4) Meetings of the governing body shall be for appointment and reappointment shall be AUTHORITY: sections 192.006 and 197.080, held at regular, stated intervals and at other in writing and shall signify agreement of the RSMo 2000.* This rule previously filed as 19 times necessary for proper operation of the applicant to conform with bylaws of both the CSR 30-20.021(2)(A). Original rule filed hospital. Minutes of all meetings shall be governing body and medical staff and to June 27, 2007, effective Feb. 29, 2008. kept as permanent records, signed and made abide by professional ethical standards. Initial available to members of the governing body. appointments to the medical staff shall not *Original authority: 192.006, RSMo 1993, amended 1995 exceed two (2) years. Reappointments, which and 197.080, RSMo 1953, amended 1993, 1995. (5) Bylaws of the governing body shall pro- may be processed and approved at the discre- vide for the election of officers and for the tion of the governing body on a monthly or appointment of standing and special commit- other cyclical pattern, shall not exceed two 19 CSR 30-20.082 Chief Executive Officer tees necessary to effectively carry out its (2) years. in Hospitals responsibilities. Written minutes of all com- PURPOSE: This rule specifies the duties of mittee meetings shall be maintained on a con- (14) Bylaws of the governing body shall the chief executive officer of a hospital. fidential basis. require that the medical staff develop and adopt medical staff bylaws and rules which (1) The chief executive officer shall be the (6) Bylaws of the governing body shall estab- shall become effective when approved by the direct representative of the governing body lish a direct and effective means of liaison governing body. and shall be responsible for management of among the governing body, the administration the hospital commensurate with the authority and the medical staff. (15) The governing body, acting upon recom- delegated by the governing body in its bylaws. mendations of the medical staff, shall (7) The governing body shall select and approve or disapprove appointments and on (2) The chief executive officer shall be employ a chief executive officer who should the basis of established requirements shall responsible for maintaining liaison among the be qualified, by education and experience, in determine the privileges extended to each governing body, medical staff and all depart- the field of hospital or health care adminis- member of the staff. ments of the hospital. tration. (16) Bylaws of the governing body shall pro- (3) The chief executive officer shall organize (8) Bylaws of the governing body shall vide that notification of denial of appoint- the administrative functions of the hospital describe and convey authority to the chief ment, reappointment, curtailment, suspen- through appropriate departmentalization and executive officer for the administration of the sion, revocation or modification of privileges delegation of duties and shall establish a sys- hospital in all its activities. The chief execu- shall be in writing and shall indicate the rea- tem of authorization, record procedures and tive officer shall be subject to special policies son(s) for this action. internal controls.
32 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
(4) The chief executive officer shall be governing body to ensure that patients are (16) The chief executive officer shall be responsible for the recruitment and employ- admitted to the hospital only by members of responsible for establishing and implement- ment of qualified personnel to staff the vari- the medical staff and that each patient’s gen- ing a mechanism to assure that all equipment ous departments of the hospital and shall eral medical condition shall be the primary and physical facilities used by the hospital to insure that written personnel policies and job responsibility of a physician member of the provide patient services, including those ser- descriptions are available to all employees. medical staff. vices provided by a contractor, comply with applicable hospital licensing requirements. (5) The chief executive officer shall be (11) The chief executive officer shall bring to responsible for the development and enforce- the attention of the chief of the medical staff AUTHORITY: sections 192.006 and 197.080, ment of written policies and procedures gov- and governing body failure by members of RSMo 2000.* This rule previously filed as 19 erning visitors to all areas of the hospital. that staff to conform with established hospi- CSR 30-20.021(2)(B). Original rule filed tal policies regarding administrative matters, June 27, 2007, effective Feb. 29, 2008. (6) The chief executive officer shall be professional standards or the timely prepara- responsible for establishing effective security tion and completion of each patient’s clinical *Original authority: 192.006, RSMo 1993, amended 1995 measures to protect patients, employees and record. and 197.080, RSMo 1953, amended 1993, 1995. visitors. (12) The chief executive officer shall be (7) The chief executive officer shall maintain responsible for developing and maintaining a 19 CSR 30-20.084 Patients’ Rights in Hos- policies protecting children admitted to or hospital environment which provides for effi- pitals discharged from the hospital. Policies shall cient care and safety of patients, employees provide for at least the following: and visitors. PURPOSE: This rule establishes the mini- (A) A child shall not be released to anyone mum requirements necessary to assure other than the child’s parent(s), legal (13) The chief executive officer shall be patients’ rights are protected. guardian or custodian; responsible for the development and enforce- (B) The social work service personnel shall ment of written policies and procedures (1) The chief executive officer shall be have knowledge of available social services which prohibit the use of tobacco products responsible for establishing and implement- for unmarried mothers and for the placement throughout the hospital and its facilities. At ing a mechanism to assure that patients’ of children; a minimum, such policies and procedures rights are protected. At a minimum, the (C) Adoption placements shall comply shall include a description of the area encom- mechanism shall include the following: with section 453.010, RSMo; and passed by the tobacco-free policy; how (A) The patient has the right to be free (D) The reporting of suspected incidences employees, patients and visitors will be edu- from abuse, neglect or harassment; of child abuse shall be made to the Division cated and informed about the tobacco-free (B) The patient has the right to be treated of Family Services as established under sec- policy; who is responsible for enforcing the with consideration and respect; tion 210.120, RSMo. tobacco-free policy and how the tobacco-free (C) The patient has the right to protective policy will be enforced; how the hospital will oversight while a patient in the hospital; (8) The chief executive officer shall be address an employee’s, patient’s, or visitor’s (D) The patient or his/her designated rep- responsible for developing a written emer- failure to comply with the tobacco-free poli- resentative has the right to be informed cy; and how the hospital, if subject to Medi- gency preparedness plan. The plan shall regarding the hospital’s plan of care for the include procedures which provide for safe care Conditions of Participation for Long- patient; and orderly evacuation of patients, visitors Term Care Facilities, will comply with 42 (E) The patient or his/her designated rep- and personnel in the event of fire, explosion CFR 483.15(b)(3). The chief executive offi- resentative has the right to be informed, upon or other internal disaster. The plan shall also cer shall enforce compliance with the written request, regarding general information per- include procedures for caring for mass casu- policies and procedures prohibiting the use of taining to services received by the patient; alties resulting from any external disaster in tobacco products throughout the hospital and (F) The patient or his/her designated rep- the region. its facilities beginning one (1) year from the resentative has the right to review the effective date of this amendment. (9) The emergency plan in section (8) of this patient’s medical record and to receive copies rule shall be readily available to all person- (14) An annual licensing survey for each fis- of the record at a reasonable photocopy fee; nel. The chief executive officer is responsible cal year shall be filed with the department on (G) The patient or his/her designated rep- for ensuring all employees shall be instructed the survey document provided by the Depart- resentative has the right to participate in the regarding their responsibilities during an ment of Health and Senior Services. The sur- patient’s discharge planning, including being emergency. Drills for internal disasters, such vey shall be due within two (2) months after informed of service options that are available as fires, shall be held at least quarterly for the hospital’s receipt of the survey. to the patient and a choice of agencies which each shift and shall include the simulated use provide the service; of fire alarm signals and simulation of emer- (15) The chief executive officer shall be (H) When a patient has brought personal gency fire conditions. Annual drills for exter- responsible for establishing and implement- possessions to the hospital, s/he has the right nal disasters shall be held in coordination ing a mechanism which will assure that to have these possessions reasonably protect- with representatives of local emergency pre- patient services provide care or an appropri- ed; paredness offices. The movement of hospital ate referral that is commensurate with the (I) The patient has the right to accept med- patients is not required as a part of the drills. patient’s needs. If services are provided by ical care or to refuse it to the extent permit- contract, the contractor shall furnish services ted by law and to be informed of the medical (10) The chief executive officer shall be that permit the hospital to comply with all consequences of refusal. The patient has the responsible for carrying out policies of the applicable hospital licensing requirements. right to appoint a surrogate to make health
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 33 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
care decisions on his/her behalf to the extent for granting initial, renewed or revised clini- vide the necessary equipment or trained staff, permitted by law; cal privileges. contractual agreements, or the conduct or (J) The patient, responsible party or competency of the applicant or medical staff designee has the right to participate in treat- (3) No application for membership on the member. ment decisions and the care planning process; medical staff shall be denied based solely (K) The patient has the right to be upon the applicant’s professional degree or (7) Initial appointments to the medical staff informed of the hospital’s patient grievance the school or health care facility in which the shall not exceed two (2) years. Reappoint- policies and procedures, including who to practitioner received medical, dental, psy- ments, which may be processed and approved contact and how; and chology or podiatry schooling, postgraduate at the discretion of the governing body on a training or certification, if the schooling or monthly or other cyclical pattern, shall not (L) The patient has the right to file a for- postgraduate training for a physician was exceed two (2) years. mal or informal verbal or written grievance accredited by the American Medical Associa- and to expect a prompt resolution of the tion or the American Osteopathic Associa- (8) The medical staff bylaws shall provide grievance, including a timely written notice tion, for a dentist was accredited by the for—an outline of the medical staff organiza- of the resolution. The grievance may be American Dental Association’s Commission tion; designation of officers, their duties and made by a patient or the patient’s representa- on Dental Accreditation, for a psychologist qualifications and methods of selecting the tive. Any patient service or care issue that was accredited with accordance to Chapter officers; committee functions; and an appeal cannot be resolved promptly by staff present 337, RSMo and for a podiatrist was accredit- and hearing process. will be considered a grievance for purposes ed by the American Podiatric Medical Asso- (9) The medical staff bylaws shall provide for of this requirement. The written notice of the ciation. Each application for staff member- an active staff and other categories as may be resolution should include information on the ship shall be considered on an individual designated in the governing body bylaws. The steps taken on behalf of the patient to inves- basis with objective criteria applied equally medical staff bylaws shall describe the voting tigate the grievance, the results of the investi- to each applicant. gation, and the date the investigation was rights, attendance requirements, eligibility completed. If the corrective action is still (4) Each physician, dentist, psychologist or for holding offices or committee appoint- being evaluated, the hospital’s response podiatrist requesting staff membership shall ments, and any limitations or restrictions should state that the hospital is still working submit a complete written application to the identified with location of residence or office to resolve the grievance and the hospital will chief executive officer of the hospital or his practice for each category. follow-up with another written response designee on a form approved by the govern- (10) The organized medical staff shall meet at ing body. Each application shall be accompa- when the investigation is complete or within intervals necessary to accomplish its required nied by evidence of education, training, pro- a specified time frame. functions. A mechanism shall be established fessional qualifications, license and and other for monthly decision-making by or on behalf AUTHORITY: sections 192.006 and 197.080, information required by the medical staff of the medical staff. RSMo 2000.* This rule previously filed as 19 bylaws or policies. CSR 30-20.021(2)(B)17. Original rule filed (11) Written minutes of medical staff meet- (5) Written criteria shall be developed for June 27, 2007, effective Feb. 29, 2008. ings shall be recorded. Minutes containing privileges extended to each member of the peer review information shall be retained on staff. A formal mechanism shall be estab- *Original authority: 192.006, RSMo 1993, amended 1995 a confidential basis in the hospital. The med- and 197.080, RSMo 1953, amended 1993, 1995. lished for recommending to the governing ical staff determine retention guidelines and body delineation of privileges, curtailment, guidelines for release of minutes not contain- suspension or revocation of privileges and ing peer review materials. 19 CSR 30-20.086 Medical Staff in Hospi- appointments and reappointments to the med- tals ical staff. The mechanism shall include an (12) The medical staff as a body or through inquiry of the National Practitioner Data committee shall review and evaluate the qual- PURPOSE: This rule specifies the require- Bank. Bylaws of the medical staff shall pro- ity of clinical practice of the medical staff in ments for the organization of the medical staff vide for hearing and appeal procedures for the hospital in accordance with the medical in a hospital. the denial of reappointment and for the staff’s peer review function and performance denial, revocation, curtailment, suspension, improvement plan and activities. (1) The medical staff shall be organized, shall revocation, or other modification of clinical develop and, with the approval of the govern- privileges of a member of the medical staff. (13) The medical staff shall establish in its ing body, shall adopt bylaws, rules and poli- bylaws or rules criteria for the content of cies governing their professional activities in (6) Any applicant for medical staff member- patients’ records provisions for their timely the hospital. ship who is denied membership or whose completion and disciplinary action for non- completed application is not acted upon in compliance. (2) Medical staff membership shall be limit- ninety (90) calendar days of completion of ed to physicians, dentists, psychologists and verification of credentials data or a medical (14) Bylaws of the medical staff shall require podiatrists. They shall be currently licensed staff member whose membership or privi- that at all times at least one (1) physician to practice their respective professions in leges are terminated, curtailed or diminished member of the medical staff shall be on duty Missouri. The bylaws of the medical staff in any way shall be given in writing the rea- or available within a reasonable period of shall include the procedure to be used in pro- sons for the action or lack of action. The rea- time for emergency service. cessing applications for medical staff mem- sons shall relate to, but not be limited to, bership and the criteria for granting initial or patient welfare, the objectives of the institu- AUTHORITY: sections 192.006 and 197.080, continuing medical staff appointments and tion, the inability of the organization to pro- RSMo 2000 and 197.154, RSMo Supp.
34 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
2007.* This rule previously filed as 19 CSR material, storage conditions and the amount (C) Is qualified by education, training and 30-20.021(2)(C). Original rule filed June 27, of handling of the item. experience in food service management and 2007, effective Feb. 29, 2008. nutrition through an approved course for cer- (8) Central services shall maintain documen- tification by the Dietary Managers Associa- *Original authority: 192.006, RSMo 1993, amended tation from the manufacturer that packaging tion or registration by the Commission on 1995; 197.080, RSMo 1953, amended 1993, 1995; and material utilized for reprocessing is appropri- Dietetic Registration of the American Dietet- 197.154, RSMo 2004. ate for this use. Expiration dates shall comply ic Association, or an associate degree in with the packaging material utilized. dietetics or food systems management; and (D) Has documented evidence of annual 19 CSR 30-20.088 Central Services in Hos- (9) Sterile medical-surgical packaged items continuing education. pitals shall be handled only as necessary and stored in vermin-free areas where controlled ventila- (2) When the director is not a qualified dieti- PURPOSE: This rule specifies the manner in tion, temperature and humidity are main- tian, a qualified dietitian shall be employed which central services shall be organized and tained. The integrity of sterile items shall be on a part-time or consultant basis. The dieti- integrated in a hospital. maintained throughout reprocessing, storage, tian shall make visits to the facility to assist distribution and transportation. (1) Central services shall be organized and in meeting the nutritional needs of the patients and the scope of services offered. integrated with patient care services in the (10) Preventive maintenance of equipment hospital. shall be done as recommended by the manu- (3) The qualified dietitian shall ensure that facturer or as specified by hospital policy. (2) The director of central services shall be high quality nutritional care is provided to Records shall be maintained as specified by qualified by education, training and experi- patients in accordance with recognized hospital policy. Records shall include docu- ence in aseptic technique, principles of steril- dietary practices. When the services of a mentation that items processed by steam have ization and disinfection and distribution of qualified dietitian are used on a part-time or undergone sufficient time, temperature and medical/surgical supplies. The director shall consultant basis, the following services shall pressure and that items processed by ethylene be responsible to an administrative officer or be provided on the premises on a regularly oxide have undergone sufficient time, tem- a qualified designee. scheduled basis: perature, gas concentration and humidity to (A) Continuing liaison with the administra- (3) Sufficient supervisory and support staff obtain pathogenic microbial kill. tion, medical staff and nursing staff; shall be assigned as related to the scope of (B) Approval of planned, written menus, (11) Ethylene oxide sterilized items shall be services provided. including modified diets; and aerated as specified by hospital policy based (C) Evaluation of menus for nutritional (4) Sufficient space and equipment shall be on the manufacturer’s recommendations to adequacy. provided for the safe and efficient operation eliminate the hazards of toxic residue for both of the services as determined by the scope of patient and staff. (4) The consultant or part-time dietitian shall hospital services delivered. assist the director of dietary services to (12) Principles of sterilization and disinfec- ensure— (5) Policies and procedures shall define the tion as approved by the hospital’s infection (A) Patient and family counseling and diet activities of all services provided. Steriliza- control committee shall apply throughout the instructions; tion and disinfection standards of practice hospital when central services activities are (B) Nutritional screening within three (3) shall be established. The principles of the decentralized. days of admission to identify patients at nutri- Association for Practitioners in Infection tional risk. The hospital shall develop criteria AUTHORITY: sections 192.006 and 197.080, Control, Association of Operating Room to use in conducting the nutritional screening RSMo 2000 and 197.154, RSMo Supp. Nurses, Center for Disease Control and Pre- and staff who conduct the screening shall be 2007.* This rule previously filed as 19 CSR vention, American Society for Healthcare trained to use the criteria; 30-20.021(3)(A). Original rule filed June 27, Central Service Personnel, Association for (C) Comprehensive nutritional assess ments 2007, effective Feb. 29, 2008. the Advancement of Medical Instrumenta- within twenty-four (24) hours after screens on patients at nutritional risk, including tion, and others may be utilized to establish *Original authority: 192.006, RSMo 1993, amended facility standards of practice for central ser- 1995; 197.080, RSMo 1953, amended 1993, 1995; and height, weight and pertinent laboratory tests; vices. 197.154, RSMo 2004. (D) Documentation of pertinent informa- tion in patient’s records, as appropriate; (6) Written procedures shall specify how (E) Participation in committee activities items stored in central services can be 19 CSR 30-20.090 Dietary Services in Hos- concerned with nutritional care; and obtained when central services is considered pitals (F) Planned, written menus for regular closed. and modified diets. PURPOSE: This rule specifies the manner in (7) Reprocessed packaged item(s) shall be which dietary services shall be organized and (5) The director of dietary services or his/her identified as to content, show evidence of integrated in a hospital. designee shall be responsible for— sterilization and be labeled indicating the (A) Representing the dietary service in sterilizer used and the load/cycle number. A (1) The hospital shall have a full-time interdepartmental meetings; policy on the shelf life of a packaged sterile employee designated who— (B) Recommending the quantity and quali- item shall be established in accordance with (A) Serves as director of dietary services; ty of food purchased; acceptable standards of sterilization and (B) Is responsible for the daily manage- (C) Participating in the selection, orienta- dependent on the quality of the packaging ment of the dietary services; tion, training, scheduling and supervision of
ROBIN CARNAHAN (1/30/08) CODE OF STATE REGULATIONS 35 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
dietary personnel; (14) When there is a contract to provide implementing rules of the medical staff relat- (D) Interviewing the patients for food pref- dietary services to a hospital, the hospital is ing to patient safety and privileges and to the erences and tolerances and providing appro- responsible for assuring that contractual ser- quality and scope of emergency services. priate substitutions; vices comply with rules concerning dietary (B) A qualified registered nurse shall (E) Monitoring adherence to the written services in hospitals. supervise and evaluate the nursing and patient planned menu; and care provided in the emergency area by nurs- (F) Scheduling dietary services meetings. AUTHORITY: sections 192.006 and 197.080, ing and ancillary personnel. Supervision may RSMo 2000 and 197.154, RSMo Supp. be by direct observation of staff or, at a min- (6) When the qualified dietitian serves as a 2007.* This rule previously filed as 19 CSR imum, the nurse shall be immediately avail- consultant, written reports shall be submitted 30-20.021(3)(B). Original rule filed June 27, able in the institution. to and approved by the chief executive officer 2007, effective Feb. 29, 2008. (C) Any person assigned to the emergency or designee concerning the services provided. services department administering medica- *Original authority: 192.006, RSMo 1993, amended tions shall be a licensed physician, registered 1995; 197.080, RSMo 1953, amended 1993, 1995; and (7) The director of dietary services shall be 197.154, RSMo 2004. nurse, EMT-paramedic or appropriately responsible for developing and implementing licensed or certified allied health practitioner written policies and procedures and for mon- and shall administer medications only within itoring to assure they are followed. Policies 19 CSR 30-20.092 Emergency Services in his/her scope of practice except for students and procedures shall be kept current and Hospitals who are participating in a training program to approved by the chief executive officer or become physicians, nurses, emergency medi- designee. PURPOSE: This rule establishes the require- cal technician-paramedics who may be ments for emergency services in a hospital. allowed to administer medication under the (8) Dietary services shall be staffed with a supervision of their instructors as a part of sufficient number of qualified personnel. (1) Each hospital providing general services their training. Trained individuals from the to the community shall provide an easily respiratory therapy department may be (9) Menus shall be planned, written and fol- accessible emergency area which shall be allowed to administer aerosol medications lowed to meet the nutritional needs of the equipped and staffed to ensure that ill or when a certified respiratory therapy assistant patients as determined by the recommended injured persons can be promptly assessed and is not available. dietary allowances (RDA) of the Food and treated or transferred to a facility capable of Nutrition Board of the National Research providing needed specialized services. In (4) Any hospital which provides emergency services and does not maintain a physician Council, National Academy of Sciences or as multiple-hospital communities where written in-house twenty-four (24) hours a day for modified by physician’s order. agreements have been developed among the hospitals in accordance with an established emergency care shall have a call roster which lists the name of the physician who is on call (10) Diets shall be prescribed in accordance community-based hospital emergency plan, and available for emergency care and the with the diet manual approved by the quali- individual hospitals may not be required by dates and times of coverage. A physician who fied dietitian and the medical staff. The diet the Department of Health to provide a fully is on call and available for emergency care manual shall be available to all medical, nurs- equipped emergency service. shall respond in a manner which is reason- ing and food service personnel. (2) A hospital shall have a written hospital able and appropriate to the patient’s condition after being summoned by the hospital. (11) At least three (3) meals or their equiva- emergency transfer policy and written trans- fer agreements with one (1) or more hospitals lent shall be served approximately five (5) within its service area which provide services (5) Any hospital with surgical services that hours apart with supplementary feedings as not available at the transferring hospital. also provide emergency surgical services necessary. There shall not be more than four- Transfer agreements shall be established shall have a general surgical call roster which teen (14) hours between a substantial evening which reflect the usual and customary refer- lists the name of the general surgeon who is meal and breakfast. ral practice of the transferring hospital, but on call for emergency surgical cases, and the are not intended to cover all contingencies. dates and times of coverage. The surgeon (12) Dietary records shall be maintained who is on call for emergency surgical cases which include: food specifications and pur- (3) Hospital emergency services shall be shall arrive at the hospital within thirty (30) chase orders; meal count; standardized under the medical direction of a qualified minutes of being summoned. Patients arriv- recipes; menu plans; nutritional evaluation of staff physician who is board-certified or ing at a hospital that does not provide emer- menus; and minutes of departmental and in- board-admissible in emergency medicine and gency surgical services and are found upon service education meetings. maintains a knowledge of current ACLS and examination to require emergency surgery ATLS standards or a physician who is expe- shall be immediately transferred to a hospital (13) The dietary services shall comply with rienced in the care of critically ill and injured with the necessary services. 19 CSR 20-1.010 Sanitation of Food Services patients and maintains current verification in Establishments. Foods shall be prepared by ACLS and ATLS. In pediatric hospitals, (6) All patients admitted to the emergency methods that conserve nutritive value, flavor PALS shall be substituted for ACLS. With the service shall be assessed prior to discharge by and appearance and shall be attractively explicit advanced approval of the Department a physician or registered professional nurse. served at acceptable temperatures. Potentially of Health, a hospital may contract with a hazardous foods shall be served at tempera- qualified consultant physician to meet this (7) If discharged from the emergency depart- tures specified in 19 CSR 20-1.010(4)(I) and requirement. ment, other than to the inpatient setting, the (J), (5)(B)1.–3. and (H). (A) That physician shall be responsible for patient or responsible person shall be given
36 CODE OF STATE REGULATIONS (1/30/08) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
written instructions for care and an oral prevent a diversion from occurring; in eight (8) hours of the termination of the explanation of those instructions. Documen- 4. Include that all ambulance services diversion. This termination report shall con- tation of these instructions shall be entered on within a defined service area will be notified tain the time the diversion plan was imple- the emergency service medical record. of the intent to implement the diversion plan mented, the reason for the diversion, the upon the actual implementation. Ambulances name of the individual who made the deter- (8) There shall be a quality improvement pro- that have made contact with the hospital mination to implement the diversion plan, the gram for the emergency service which before the hospital has declared itself to be on time the diversion status was terminated, and includes, but is not limited to, the collection diversion shall not be redirected to other hos- the name of the individual who made the and analysis of data to assist in identification pitals. In areas served by a real time, elec- determination to terminate the diversion. In of health service problems, and a mechanism tronic reporting system, notification through areas served by real time, electronic reporting for implementation and monitoring appropri- such system shall meet the requirements of system, reporting through such system shall ate actions. The quality improvement pro- this provision so long as such system is avail- meet the requirements of this provision so gram shall include the periodic evaluation of able to all EMS agencies and hospitals in the long as such system generates reports as at least the following: length of time each defined service area; required by the department. patient is in the emergency room, appropri- 5. Include procedures for assessment, (E) Each hospital shall implement a triage ateness of transfers, physician response time, stabilization and transportation of patients in system within its emergency department. The provision for written instructions, timeliness the event that services, including but not lim- triage methodology shall continue to apply of diagnostic studies, appropriateness of ited to, ICU beds or surgical suites become during periods when the hospital diversion treatment rendered, and mortality. unavailable or overburdened. These proce- plan is implemented. dures must also include the evaluation of ser- (F) Any hospital that has a written (9) Written policies shall be adopted to assure vices and resources of the facility that can approved policy, which states that the hospi- that notification procedures are implemented still be provided to patients even with the tal will not go on diversion or resource diver- concerning the significant exposure of pre- implementation of the diversion plan; sion, except as defined in the hospital’s dis- hospital emergency personnel to communica- 6. Include procedures for implementa- aster plan in the event of a disaster, is exempt ble diseases as required in 19 CSR 30- tion of a resource diversion in the event that from the requirements of 19 CSR 30- 40.047. specialized services are overburdened or tem- 20.021(3)(C)12. porarily unavailable; and (G) If a hospital chooses to participate in a (10) The emergency service medical record 7. Include that all other acute care hos- community wide plan, the requirements of shall contain patient identification, time and pitals within a defined service area will be number of hospitals to remain open, defined method of arrival, history, physical findings, notified upon the actual implementation of service areas, as well as community notifica- treatment and disposition and shall be authen- the diversion plan. For defined service areas tion may be addressed within the community ticated by the physician. These records, with more than two (2) hospitals, if more plan. Community plans must be approved by including an ambulance report when applica- than one-half (1/2) of the hospitals implement the department. Community plans must ble, shall be filed under supervision of the their diversion plans, no hospital will be con- include that each hospital has a policy medical records department. sidered on diversion. For a defined service addressing diversion and the criteria used by area with two (2) hospitals, if both hospitals each hospital to determine the necessity of (11) There shall be a mechanism for the implement their diversion plans, neither will implementing a diversion plan. Participation review and evaluation on a regular basis of be considered on diversion. Participation in a in a community plan does not exempt a hos- the quality and appropriateness of emergency real time, electronic reporting system shall pital of the requirement to notify the depart- services. meet the notification requirements of this sec- ment of a diversion plan implementation. tion. If a hospital participates in an approved (12) A hospital shall have a written plan that community wide plan, the community wide AUTHORITY: sections 192.006 and 197.080, details the hospital’s criteria and process for plan may set the requirement for the number RSMo 2000 and 197.154, RSMo Supp. diversion. The plan must be reviewed and of hospitals to remain open. 2007.* This rule previously filed as 19 CSR approved by the Missouri Department of (B) Each incident of diversion plan imple- 30-20.021(3)(C). Original rule filed June 27, Health prior to being implemented by the mentation must be reviewed by the hospital’s 2007, effective Feb. 29, 2008. hospital. A hospital may continue to operate existing quality assurance committee. Min- *Original authority: 192.006, RSMo 1993, amended under a plan in existence prior to the effec- utes of these review meetings must be made 1995; 197.080, RSMo 1953, amended 1993, 1995; and tive date of this section while awaiting available to the Missouri Department of 197.154, RSMo 2004. approval of its plan by the department. Health and Senior Services upon request. (A) The diversion plan shall: (C) The hospital shall assure compliance 1. Identify the individuals by title who with screening, treatment and transfer 19 CSR 30-20.094 Medical Records in Hos- are authorized by the hospital to implement requirements as required by the Emergency pitals the diversion plan; Medical Treatment and Active Labor Act 2. Define the process by which the deci- (EMTALA). PURPOSE: This rule establishes minimum sion to divert will be made; (D) A hospital or its designee shall report requirements for medical records kept in hos- 3. Specify that the hospital will not to the department, by phone or electronically, pitals. implement the diversion plan until the autho- upon actual implementation of the diversion rized individual has reviewed and document- plan. This implementation report shall con- (1) The director of the medical record ser- ed the hospital’s ability to obtain additional tain the time the plan will be implemented. vices shall be appointed by the chief execu- staff, open existing beds that may have been The hospital or its designee shall report to the tive officer or chief operating officer. This closed or take any other actions that might department, by phone or electronically, with- director may be a qualified registered record
ROBIN CARNAHAN (5/31/09) CODE OF STATE REGULATIONS 37 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
administrator, an accredited record technician (7) Written consent of the patient or the (15) The patient’s medical records shall be or an individual with demonstrated compe- patient’s legal representative is required for maintained to safeguard against loss, deface- tence and knowledge of medical record access to or release of information, copies or ment and tampering and to prevent damage department activities supervised by a quali- excerpts from the medical record to persons from fire and water. Medical records shall be fied consultant who is a registered record not otherwise authorized to receive this infor- preserved in a permanent file in the original, administrator or accredited record technician. mation. on microfilm or other electronic media. Patients’ medical records shall be retained for (2) Patient care by members of the medical (8) Patient records shall be considered com- a minimum of ten (10) years, except that a staff, nursing staff and allied health profes- plete for filing when the required contents are minor shall have his/her record retained until sionals shall be entered in the patient’s med- assembled and authenticated. Hospital policy his/her twenty-third birthday, whichever ical record in a timely manner. Documenta- shall define circumstances in which incom- occurs later. Preservation of medical records may be extended by the hospital for clinical, tion shall be legible, dated, authenticated and plete medical records may be filed perma- educational, statistical or administrative pur- recorded in ink, typewritten or recorded elec- nently by order of the medical record com- poses. tronically. mittee. (16) There shall be a mechanism for the (3) All orders shall be dated and authenticat- (9) An inpatient’s medical record shall ed by the ordering practitioner and shall be review and evaluation on a regular basis of include: a unique identifying record number; the quality of medical record services. kept in the patient’s medical record. Verbal pertinent identifying and personal data; his- orders shall be authenticated by the prescrib- tory of present illness or complaint; if injury, (17) Should the hospital cease to be licensed, ing practitioner or attending physician within how the injury occurred; past history; family arrangements for disposition of the patient the time frame that is defined by the medical history; physical examination; admitting medical records shall be made with nearby staff in cooperation with nursing and admin- diagnosis; medical staff orders; progress hospitals, the patient’s physician or a reliable istration. Authentication shall include written notes; nurses’ notes; discharge summary; storage company. Notification of the disposi- signatures, initials, computer-generated sig- final diagnosis; and evidence of informed tion is to be provided to the department. nature codes or rubber stamp signatures by consent. Where applicable, medical records the medical members and authorized persons shall contain reports such as clinical labora- (18) A history and physical examination shall whose signatures the stamp represents. The tory, X-ray, consultation, electrocardiogram, be completed on each inpatient within twen- use of rubber stamps is discouraged, but surgical procedures, therapy, anesthesia, ty-four (24) hours of admission, or a history where authorized, a signed statement shall be pathology, autopsy and any other reports per- and physical examination shall have been maintained in the administrative offices with tinent to the patient’s care. completed or updated within the seven (7) a copy in the medical records department days prior to admission. A history and phys- stating that the medical staff member whose (10) Admission forms shall be designed to ical which is performed up to and no more stamp is involved is the only one who has the record pertinent identifying and personal than thirty (30) days before admission may be stamp and is the only one authorized to use utilized provided that the patient is reassessed data. it. The duplication of signature stamps and and an update note is written, signed and the delegation of their use by others is pro- dated to reflect the patient’s status within (11) A certificate of live birth shall be pre- hibited. seven (7) days prior to, or within twenty-four pared for each child born alive and shall be (24) hours after, admission. (4) Only abbreviations and symbols approved forwarded to the local registrar within seven by the medical staff may be used in the med- (7) days after the date of delivery. If the (19) A patient’s records shall be completed ical records. Each abbreviation or symbol physician or other person in attendance does within thirty (30) days of discharge. shall have only one (1) meaning and an not certify to the facts of birth within five (5) explanatory legend shall be available for use days after the birth, the person in charge of AUTHORITY: sections 192.006 and 197.080, by all concerned. There shall be a list of the institution shall complete and sign the RSMo 2000 and 197.154, RSMo Supp. abbreviations and symbols that shall not be certificate. 2007.* This rule previously filed as 19 CSR used in handwritten communications. 30-20.021(3)(D). Original rule filed June 27, (12) When a dead fetus is delivered in an 2007, effective Feb. 29, 2008. (5) The medical record of each patient shall institution, the person in charge of the insti- be maintained in order to justify admission tution or his/her designated representative *Original authority: 192.006, RSMo 1993, amended shall prepare and, within seven (7) days after 1995; 197.080, RSMo 1953, amended 1993, 1995; and and continued hospitalization, support the 197.154, RSMo 2004. diagnosis, describe the patient’s progress and delivery, file a report of fetal death with the response to medications and services and to local registrar. facilitate rapid retrieval and utilization by 19 CSR 30-20.096 Nursing Services in Hos- authorized personnel. (13) Medical records of deceased patients pitals shall contain the date and time of death, (6) Medical records are the property of the autopsy permit, if granted, disposition of the PURPOSE: This rule establishes the require- hospital and shall not be removed from the body, by whom received and when. ments for nursing services in a hospital. hospital premises except by court order, sub- poena, for the purposes of microfilming or (14) The State Anatomical Board shall be (1) The nursing service shall be integrated for off-site storage approval by the governing notified of an unclaimed dead body. A record and identified within the total hospital orga- body. of this notification shall be maintained. nizational structure.
38 CODE OF STATE REGULATIONS (5/31/09) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
(2) The nursing service shall have a written be made, the hospital may require the nurse (12) The nursing service administrator shall organizational structure that indicates lines of currently providing the patient care to fulfill participate in the formulation of hospital poli- authority, accountability, and communication. his or her obligations based on the Missouri cies and the development of long-range plans Nurse Practice Act by performing the patient relating to patient care. (3) The organization of the nursing service care which is required; shall conform with the variety of patient care (C) The prohibition of mandatory overtime (13) The nursing service administrator, or services offered and the range of nursing care does not apply to overtime work that occurs designee, shall represent nursing at all appro- activities. because of an unforeseeable emergency or priate meetings of the medical staff and gov- when a hospital and a subsection of nurses erning board of the hospital. (4) Nursing policies and standards of practice commit, in writing, to a set, predetermined describing patient care shall be in writing and staffing schedule or prescheduled on-call (14) The nursing service administrator shall be kept current. time. An unforeseeable emergency is defined be accountable for the selection, promotion as a period of unusual, unpredictable, or and termination of all nursing personnel (5) Policies shall provide for the collaboration unforeseeable circumstances such as, but not under the authority of nursing service. of nursing personnel with members of the limited to, an act of terrorism, a disease out- medical staff and other health care disciplines break, adverse weather conditions, or natural (15) The nursing service administrator shall regarding patient care issues. disasters which impact patient care and which have sufficient time to perform the necessary prevent replacement staff from reporting for managerial duties and functions of the posi- (6) Nursing service policies shall establish an duty; tion. appropriate committee structure to oversee (D) The facility is prohibited from requir- and assist in the provision of quality nursing ing a nurse to work additional consecutive (16) A qualified registered professional nurse care. The purpose and function of each com- hours and from taking action against a nurse shall be designated and authorized to act in mittee shall be defined and a record of its on the grounds that a nurse failed to work the the absence of the nursing service adminis- activities shall be maintained. additional hours or when a nurse declines to trator. work additional consecutive hours beyond the (7) Policies shall make provision for nursing nurse’s predetermined schedule of hours (17) Nursing personnel shall hold a valid and personnel to be participants of hospital com- because doing so may, in the nurse’s judge- current license in accordance with sections mittees concerned with patient care activities. ment, jeopardize patient safety; 335.011–335.096, RSMo. (E) Subsection (8)(D) is not applicable if (8) Policies shall be developed regarding the overtime is permitted under subsections (18) There shall be a job description for each use of overtime. The policies shall be based (8)(A), (B), and (C); classification of nursing personnel which on the following standards: (F) Nurses required to work more than delineates the specific qualifications, licen- (A) Overtime shall not be mandated for twelve (12) consecutive hours under subsec- sure, certification, authority, responsibilities, any licensed nursing personnel except when tions (8)(A), (B), or (C) shall be provided the functions, and performance standards for that an unexpected nurse staffing shortage arises option to have at least ten (10) consecutive classification. Job descriptions shall be that involves a substantial risk to patient safe- hours of uninterrupted off-duty time immedi- reviewed annually and revised as necessary to ty, in which case a reasonable effort must be ately following the worked time; and reflect current job requirements. applied to secure safe staffing before requir- (G) The nursing service shall maintain and ing the on-duty licensed nursing personnel to make available upon request to the depart- (19) There shall be scheduled annual evalua- work overtime. Reasonable efforts undertak- ment a list of qualified nurses, nurse reg- tions of job performance for all classifica- en shall be verified by the hospital. Reason- istries, and per diem nurses that may be tions of nursing personnel. able efforts shall include pursuing all of the called upon to provide replacement staff in following: the event of sickness, vacations, vacancies, (20) All nursing personnel shall be oriented 1. Reassigning on-duty staff; disasters, and other absences of direct care to the hospital, nursing services, their posi- 2. Seeking volunteers to work extra time nursing staff. tion classification, the use of overtime, and from all available qualified nursing staff who the nursing service regulation 19 CSR 30- are presently working; (9) The nursing service shall be administered 20.096. The orientation shall be of sufficient 3. Contacting qualified off-duty employ- and directed by a qualified registered profes- length and content to prepare nursing person- ees who have made themselves available to sional nurse with appropriate education, nel for their specified duties and responsibil- work extra time, per diem staff, float pool, experience and demonstrated ability in nurs- ities. Competency shall be validated prior to and flex team nurses; and ing practice and management. assuming independent performance in actual 4. Seeking personnel from a contracted patient situations. temporary agency or agencies when such (10) The nursing service administrator shall staffing is permitted by law or an applicable be responsible to the chief executive officer (21) For specialized nursing units and those collective bargaining agreement and when the or chief operating officer. units providing specific clinical services, employer regularly uses the contracted tem- written policies and procedures, including porary agency or agencies; (11) The nursing service administrator shall standards of practice, shall be available and (B) In the absence of nurse volunteers, be a full-time employee and shall have the current. float pool nurses, flex team nurses, or con- authority and be accountable for assuring the tracted temporary agency staff secured by the provision of quality nursing care for those (22) Nursing personnel meetings shall be con- reasonable efforts as described in subsection patient areas delineated in the organizational ducted at intervals necessary for leadership (8)(A) and if qualified reassignments cannot structure. and to communicate management information.
ROBIN CARNAHAN (10/31/11) CODE OF STATE REGULATIONS 39 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
Separate meetings for the various job classifi- (26) The hospital shall, in consultation with twenty-four (24) hours of admission as an cations of personnel may be conducted. Min- its direct care nursing staff, monitor and eval- inpatient. The registered professional nurse utes of all meetings shall be maintained and uate the hospital-wide staffing plan and nurs- may be assisted in the process by other qual- reflect attendance, scope of discussion, and ing sensitive outcomes for effectiveness on a ified nursing staff members. action(s) taken. The minutes shall be filed continual basis and revise the plan annually according to hospital policy. and as necessary. (34) Patient education and discharge needs shall be addressed and appropriately docu- (23) Every hospital shall develop, implement, (27) Each facility shall develop and utilize a mented in the medical records. and submit to the department by April 1, methodology which ensures it is staffed with 2009, and annually thereafter at the start of sufficient numbers and skill mix of appropri- (35) The necessary types and quantities of the hospital’s fiscal year, a written hospital- ately qualified direct care nursing staff in supplies and equipment shall be available to wide staffing plan for nursing services. Every each unit to meet the unit population and meet the current needs of each patient. Ref- hospital shall have a process that ensures the individualized care needs of the patients. erence materials pertinent to patient care consideration of input from direct care nurs- Each unit shall document actual staffing and shall be readily accessible. ing staff from each unit within the hospital. patient census during every shift. AUTHORITY: sections 192.006 and 197.080, (24) The hospital-wide staffing plan for nurs- (28) At a minimum, there shall be a sufficient RSMo 2000 and section 197.154, RSMo ing services shall: number of registered professional nurses on Supp. 2008.* This rule previously filed as 19 (A) Include the number, skill mix, and duty at all times to provide patient care CSR 30-20.021(3)(E). Original rule filed qualifications of direct care nursing staff requiring the judgment and skills of a regis- June 27, 2007, effective Feb. 29, 2008. needed for each unit of the hospital; tered professional nurse and to supervise the Amended: Filed Oct. 22, 2008, effective June (B) Be based on the expected nursing care activities of all nursing personnel. 30, 2009. required by the unit population and individu- (29) There shall be sufficient licensed and *Original authority: 192.006, RSMo 1993, amended al needs of each patient. The expected unit 1995; 197.080, RSMo 1953, amended 1993, 1995; and ancillary nursing personnel on duty on each population and individual nursing care needs 197.154, RSMo 2004. of each patient shall be the major considera- nursing unit to meet the needs of each patient tion in determining the number and skill mix in accordance with accepted standards of of direct care nursing staff needed; nursing practice. 19 CSR 30-20.097 Safe Patient Handling (C) Identify relevant factors in each hospi- and Movement in Hospitals (30) Each nursing unit shall post in a visible tal unit including, but not limited to, the location on the nursing unit or make available number of patients in a unit; intensity of care PURPOSE: This rule specifies the require- to the patient(s) or patient’s authorized repre- required; skill and experience of care givers ments for safe patient handling and movement sentative a copy of the unit’s hospital-wide including registered nurses, licensed practical practices in a hospital. staffing plan for nursing services and docu- nurses, ancillary personnel, and other mem- mentation of actual daily staffing levels. (1) There shall be an active multidisciplinary bers of the patient care team consistent with committee responsible for implementing and the level of authority and responsibility dele- (31) Patient care assignments shall be consis- monitoring the safe patient handling and gated under state licensure; admission, dis- tent with the qualifications of the nursing per- movement program. At least one-half (1/2) of charge, and transfers; nonpatient care duties; sonnel and the identified patient needs. Nurs- the members of the committee shall be front- geography of a unit; and the availability of es included in the count of direct care nursing line non-managerial employees who are technological support; and staff in a unit of a hospital for purposes of involved in patient care handling activities. (D) Provide for documentation of the actu- compliance with the hospital-wide staffing al staffing plan. plan shall have appropriate licensing, train- (2) This program shall include: ing, and orientation to ensure that the nurses (A) A safe patient handling policy for all (25) Every hospital shall establish nursing are capable of providing competent nursing shifts that will achieve elimination of manual sensitive indicators and monitor outcomes of care to the patients in the unit. Hospitals shall lifting, transferring, and repositioning of all these indicators to evaluate the adequacy of also verify that nurses included in the count or most of a patient’s weight, except in emer- the hospital-wide staffing plan for nursing are capable of providing competent nursing gency, life-threatening, or otherwise excep- services. At least one (1) of each of the fol- care to the patients in the unit. Nurses includ- tional circumstances; lowing three (3) types of outcomes shall be ed in the count shall spend a minimum of sev- (B) A patient-handling hazard assessment used to evaluate the adequacy of the staffing enty-five percent (75%) of their time provid- that considers such variables as patient-han- plan: ing direct patient care. dling tasks, types of nursing units, patient (A) Patient outcomes such as patient falls, populations, and the physical environment of adverse drug events, injuries to patients, skin (32) Documentation in the patient’s medical patient care areas; breakdown, infection rates, length of stay, or record shall reflect use of the nursing process (C) A process which assesses patient’s patient readmissions; in the delivery of care throughout the needs for safe patient handling and move- (B) Operational outcomes such as work- patient’s hospitalization. ment; related injury or illness, vacancy and turnover (D) Educational materials for patients and rates, nursing care hours per patient day, on- (33) A registered professional nurse shall their families to help orient them to the hos- call use, or overtime rates; and assess the patient’s needs for nursing care in pital’s safe patient handling program; (C) Validated patient complaints related to all settings where nursing care is provided. A (E) An annual evaluation of the program staffing levels. nursing assessment shall be completed within utilizing measurable outcome measures
40 CODE OF STATE REGULATIONS (10/31/11) ROBIN CARNAHAN Secretary of State Chapter 20—Hospitals 19 CSR 30-20
including but not limited to employee and (5) The laboratory shall perform tests for and program shall be validated twice per year. patient injuries, lost work days, and workers’ examine specimens from hospital patients Records shall be maintained for at least two compensation claims; and only on the order of a medical staff member (2) years. (F) Evidence of changes based on the pro- or authorized personnel as stated in the med- gram evaluation. ical staff bylaws. The laboratory shall per- (11) All specimens, except for teeth and for- form tests and examine specimens from other eign objects, removed during a surgical, diag- (3) All employees involved in patient care sources only on the order of a medical staff nostic, or other procedure shall be submitted handling activities are to be trained and member or authorized personnel as stated in for pathologic examination, except for speci- demonstrate competence on safe patient han- the medical staff bylaws. Test orders received mens that have been previously determined to be exempt. Specimens submitted for patho- dling policies, equipment, and devices before by the laboratory shall clearly identify the logical examination shall be accompanied by implementation, annually, and as changes are patient, the source of the order, the tests pertinent clinical information. Specimens made to the program. required, and the date. Orders for examina- tions of surgical specimens shall contain nec- exempted from pathologic examination shall be those for which examination does not add essary clinical information. AUTHORITY: section 197.080, RSMo 2000.* to the diagnosis, treatment or prognosis, shall Original rule filed April 29, 2011, effective be determined by the medical staff in consul- Nov. 30, 2011. (6) The laboratory shall maintain complete written or electronic instructions for speci- tation with the pathologist, and shall be doc- umented in writing. When the specimen is *Original authority: 197.080, RSMo 1953, amended men collection and processing, storage, test- ing, and reporting of results. The instructions not submitted for pathological examination, a 1993, 1995. report of the removal must be present in the shall at a minimum follow the manufacturer’s patient’s medical record. Specimens requir- recommendation and include, but not be lim- ing only a gross description and diagnosis ited to, a step-by-step description of the test- 19 CSR 30-20.098 Pathology and Medical shall be determined by the medical staff in ing procedure, reagent use and storage, con- Laboratory Services consultation with the pathologist and shall be trol and calibration procedures, and pertinent documented in writing. PURPOSE: This rule establishes the require- literature references. ments for pathology and medical laboratory (12) An autopsy service shall be available to (7) Dated reports of all laboratory examina- services in a hospital. meet the needs of the hospital. Each autopsy tions shall become a part of the patient’s shall be performed by, or under the supervi- medical record. If the original report from a (1) Provision shall be made, either on the sion of, a pathologist or a physician whose reference laboratory is not part of the premises or by contract with a reference labo- credentials document his/her qualifications in ratory, for the prompt performance of adequate patient’s record, the original shall be retained and retrievable for a period of not less than anatomical pathology. All microscopic inter- examinations in the fields of hematology, clin- two (2) years. Dated reports of tests on out- pretations shall be made by a pathologist who ical chemistry, urinalysis, microbiology, patients and from referring laboratories shall is qualified in anatomical pathology. immunology, anatomic pathology, cytology be sent promptly to the individual or facility and immunohematology. ordering the test. Copies of all laboratory (13) At all times there shall be an established tests and examinations shall be retained and procedure for obtaining a supply of blood and (2) The medical director of the pathology and retrievable for at least two (2) years. blood components. Facilities for the safe- medical laboratory services shall be a physi- keeping and safe administration of blood and cian who is a member of the medical staff (8) Instruments and equipment shall be eval- blood products shall be provided. Positive and appointed by the governing body. If the uated following the manufacturer’s recom- patient identification shall be provided director is not a pathologist, a pathologist mendations at a minimum to insure that they through two (2) unique patient identifiers. shall be retained on a part-time basis as a function properly at all times. Records shall The refrigerator used for the routine storage consultant on-site. Consultation shall be pro- be maintained per hospital’s record retention of blood for transfusion shall maintain a tem- vided no less than monthly. A written report policy for each piece of equipment, showing perature between one degree and six degrees of the consultant’s evaluation and recommen- the date of inspection, calibration, perfor- Celsius (1°–6° C) and this temperature shall dations shall be submitted after each visit. mance evaluation, and action taken to correct be verified by an outside recording ther- deficiencies. Temperatures shall be recorded mometer. This refrigerator shall be constant- (3) Pathology and medical laboratory ser- daily for all temperature-controlled instru- ly monitored by an audible and visible alarm vices shall be integrated with other hospital ments. that is located in an area that is staffed at all times. The alarm shall be battery-operated or services. The pathologist(s) shall have an powered by a circuit different from the one active role in in-service educational programs (9) Each section of the pathology and medi- cal laboratory shall have a written quality supplying the refrigerator. This refrigerator and in medical staff functions, the laboratory control program to verify accuracy, measure shall be on the power line supplied by the quality assurance program and shall partici- precision, and detect error. Quality control emergency generator. pate in committees that review tissue, infec- results shall be documented and retained for tion control, and blood usage. at least two (2) years. (14) The hospital shall provide safety equip- ment for laboratory employees that includes, (4) There shall be sufficient qualified labora- (10) The hospital laboratory shall successful- but is not limited to, appropriate personal tory technologists and supportive technical ly participate in a proficiency testing program protective equipment. staff currently competent in their field to per- covering all anatomical and clinical special- form the tests required. Laboratory personnel ties in which the laboratory performs tests (15) Laboratories employing quantities of shall have the opportunity for continuing edu- and in which proficiency testing is available. flammable, combustible, or hazardous mate- cation. Laboratory tests without a proficiency testing rials which are considered a severe hazard
JASON KANDER (12/31/13) CODE OF STATE REGULATIONS 41 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
shall be protected in accordance with the under the supervision of a pharmacist and shall be acquired according to the hospital’s Safety Standards for Laboratories in Health- shall not be assigned duties that by law must policies and procedures. Related Institutions 1980 which are incorpo- be performed by a pharmacist. Interpreting rated by reference in this rule and is pub- medication orders, selecting, compounding, (9) Records shall be maintained of medica- lished by the National Fire Protection packaging, labeling and the dispensing of tion transactions, including: acquisition, Association, Chapter 8 of NFPA 101 Life medications by pharmacy staff shall be per- compounding, repackaging, dispensing or Safety Code, 2000 Edition, NFPA Headquar- formed by or under the supervision of a phar- other distribution, administration and con- ters, 1 Batterymarch Park, Quincy, MA trolled substance disposal. Persons involved macist. Interpretation of medication orders by 02169. This rule does not incorporate any in compounding, repackaging, dispensing, support personnel shall be limited to order subsequent amendments or additions. administration and controlled substance dis- processing and shall not be of a clinical posal shall be identified and the records shall (16) The hospital shall provide reports to the nature. be retrievable. Retention time for records of department as required by 19 CSR 10-33.050 (4) Hours shall be established for the provi- bulk compounding, repackaging, administra- and section 192.131, RSMo. sion of pharmacy services. A pharmacist tion, and all controlled substance transactions shall be available to provide required phar- shall be a minimum of two (2) years. Reten- AUTHORITY: section 192.006, RSMo 2000, macy services during hours appropriate for tion time for records of dispensing and and sections 197.080 and 197.154, RSMo necessary contact with medical and nursing extemporaneous compounding, including Supp. 2013.* This rule previously filed as 19 staff. A pharmacist shall be on call at all sterile medications, shall be a minimum of CSR 30-20.021(3)(F). Original rule filed other times. six (6) months. June 27, 2007, effective Feb. 29, 2008. Amended: Filed June 6, 2013, effective Jan. (5) Space, equipment and supplies shall be (10) Security and record keeping procedures 30, 2014. available according to the scope of pharmacy in all areas shall ensure the accountability of services provided. Office or other work space all controlled substances, shall address *Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995, 2013; shall be available for administrative, clerical, accountability for other medications subject and 197.154, RSMo 2004. clinical and other professional services pro- to theft and abuse and shall be in compliance vided. All areas shall meet standards to main- with 19 CSR 30-1.030(3). Inventories of tain the safety of personnel and the security Schedule II controlled substances shall be 19 CSR 30-20.100 Pharmacy Services and and stability of medications stored, handled routinely reconciled. Inventories of Schedule Medication Management in Hospitals and dispensed. III–V controlled substances outside of the pharmacy shall be routinely reconciled. PURPOSE: This rule establishes the require- (6) The pharmacy and its medication storage Records shall be maintained so that invento- areas shall have proper conditions of sanita- ments for pharmacy services and medication ries of Schedule III–V controlled substances tion, temperature, light, moisture, ventilation management in a hospital. in the pharmacy shall be reconcilable. and segregation. Refrigerated medication shall be stored separate from food and other (11) Controlled substance storage areas in the (1) Pharmacy services shall be identified and substances. The pharmacy and its medication integrated within the total hospital organiza- pharmacy shall be separately locked and storage area shall be locked and accessible accessible only to authorized pharmacy staff. tional plan. Pharmacy services shall be only to authorized pharmacy and supervisory Reserve supplies of all controlled substances directed by a pharmacist who is currently nursing personnel. The director of pharmacy in the pharmacy shall be locked. Controlled services, in conjunction with nursing and licensed in Missouri and qualified by educa- substance storage areas outside the pharmacy administration, shall be responsible for the tion and experience. The director of pharma- shall be separately locked and accessible only authorization of access to the pharmacy by cy services shall be responsible for the provi- to persons authorized to administer them and sion of all services required in subsection supervisory nursing personnel to obtain doses for administering when pharmacy services to authorized pharmacy staff. (4)(G) of this rule and shall be a participant are unavailable. in all decisions made by pharmacy services or (12) Authorization of access to controlled committees regarding the use of medications. (7) Medication storage areas outside of the substance storage areas outside of the phar- With the assistance of medical, nursing and pharmacy shall have proper conditions of san- macy shall be established by the director of administrative staff, the director of pharmacy itation, temperature, light, moisture, ventila- pharmacy services in conjunction with nurs- services shall develop standards for the selec- tion and segregation. Refrigerated medica- ing and administration. The distribution and tion, distribution and safe and effective use of tions shall be stored in a sealed compartment accountability of keys, magnetic cards, elec- tronic codes or other mechanical and elec- medications throughout the hospital. separate from food and laboratory materials. Medication storage areas shall be accessible tronic devices shall occur according to the hospital’s policies and procedures. (2) Additional professional and supportive only to authorized personnel and locked when appropriate. personnel shall be available for services pro- (13) All variances involving controlled sub- vided. Pharmacists shall be currently (8) The evaluation, selection, source of sup- stances—including inventory, security, record licensed in Missouri and all personnel shall ply and acquisition of medications shall occur keeping, administration and disposal—shall possess the education and training necessary according to the hospital’s policies and pro- be reported to the director of pharmacy ser- for their responsibilities. cedures. Medications and supplies needed on vices for review and investigation. Loss, an emergency basis and necessary medica- diversion, abuse or misuse of medications (3) Support pharmacy personnel shall work tions not included in the hospital formulary shall be reported to the director of pharmacy
42 CODE OF STATE REGULATIONS (12/31/13) JASON KANDER Secretary of State Chapter 20—Hospitals 19 CSR 30-20
services, administration, and local, state and (18) Radiopharmaceuticals shall be acquired, and monitoring of emergency and non-emer- federal authorities as appropriate. stored, handled, prepared, packaged, labeled, gency floorstock medications shall occur administered and disposed of according to the according to the hospital’s policies and pro- (14) The provision of pharmacy services in hospital’s policies and procedures and only cedures. Supplies of emergency medications the event of a disaster, removal from use of by or under the supervision of personnel who shall be available in designated areas. medications subject to product recall and are certified by the Nuclear Regulatory Com- reporting of manufacturer drug problems mission. (25) All medication storage areas in the hos- shall occur according to the hospital’s poli- pital shall be inspected at least monthly by a cies and procedures. (19) A medication profile for each patient pharmacist or designee according to the hos- shall be maintained and reviewed by the phar- pital’s policies and procedures. (15) Compounding and repackaging of medi- macist and shall be reviewed by the pharma- cations in the pharmacy shall be done by cist upon receiving a new medication order (26) The pharmacist shall be responsible for pharmacy personnel under the supervision of prior to dispensing the medication. The phar- the acquisition, inventory control, dispens- a pharmacist. Those medications shall be macist shall review the prescriber’s order or ing, distribution and related documentation labeled with the medication name, strength, a direct copy prior to the administration of requirements of investigational medications lot number, expiration date and other perti- the initial dose, except in an emergency or according to the hospital’s policies and pro- nent information. Record keeping and quality when the pharmacist is unavailable, in which cedures. A copy of the investigational proto- control, including end-product testing when case the order shall be reviewed within sev- col shall be available in the pharmacy to all appropriate, shall occur according to the hos- enty-two (72) hours. health care providers who prescribe or pital’s policies and procedures. administer investigational medications. The (20) Medications shall be dispensed only identity of all recipients of investigational (16) Compounding, repackaging or relabeling upon the order of an authorized prescriber medications shall be readily retrievable. of medications by nonpharmacy personnel with the exception of influenza and pneumo- shall occur according to the hospital’s poli- coccal polysaccharide vaccines, which may (27) Sample medications shall be received cies and procedures. Medications shall be be administered per physician-approved poli- and distributed by the pharmacy according to administered routinely by the person who cy/protocol after an assessment for con- the hospital’s policies and procedures. prepared them, and preparation shall occur traindications, and only dispensed by or just prior to administration except in circum- (28) Dispensing of medications by the phar- under the supervision of the pharmacist. stances approved by the director of pharmacy, macist to patients who are discharged from nursing and administration. Compounded (21) All medications dispensed for adminis- the hospital or who are outpatients shall be in sterile medications for parenteral administra- compliance with 4 CSR 220. tion prepared by nonpharmacy personnel tration to a specific patient shall be labeled with the patient name, drug name, strength, shall not be administered beyond twenty-four (29) Persons other than the pharmacist may (24) hours of preparation. Labeling shall expiration date and, when applicable, the lot provide medications to patients leaving the include the patient’s name, where appropri- number and other pertinent information. hospital only when prescription services from ate, medication name, strength, beyond use a pharmacy are not reasonably available. (22) The medication distribution system shall date, identity of the person preparing and Medications shall be provided according to provide safety and accountability for all med- other pertinent information. the hospital’s policies and procedures, includ- ications, include unit of use and ready to ing: circumstances when medications may be (17) Compounded sterile medications shall administer packaging, and meet current stan- provided, practitioners authorized to order, be routinely prepared in a suitably segregated dards of practice. specific medications and limited quantities, area in a Class 100 environment by pharma- prepackaging and labeling by the pharmacist, cy personnel. Preparation by nonpharmacy (23) To prevent unnecessary entry to the final labeling to facilitate correct administra- personnel shall occur only in specific areas or pharmacy, a locked supply of routinely used tion, delivery, counseling and a transaction in situations when immediate preparation is medications shall be available for access by record. Final labeling, delivery and counsel- necessary and pharmacy personnel are authorized personnel when the pharmacist is ing shall be performed by the prescriber or a unavailable and shall occur according to poli- unavailable. Removal of medications from the registered nurse. cies and procedures. All compounded cyto- pharmacy by authorized supervisory nursing toxic/hazardous medications shall be pre- personnel, documentation of medications (30) Current medication information resources pared in a suitably segregated area in a Class removed, restricted and unrestricted medica- shall be maintained in the pharmacy and II biological safety cabinet or vertical airflow tion removal, later review of medication patient care areas. The pharmacist shall pro- hood. The preparation, handling, administra- orders by the pharmacist, and documented vide medication information to the hospital tion and disposal of sterile or cytotoxic/haz- audits of medications removal shall occur staff as requested. ardous medications shall occur according to according to the hospital’s policies and pro- policies and procedures including: orientation cedures. The nurse shall remove only (31) The director of pharmacy services shall and training of personnel, aseptic technique, amounts necessary for administering until the be an active member of the pharmacy and equipment, operating requirements, environ- pharmacist is available. therapeutics committee or its equivalent, mental considerations, attire, preparation of which shall advise the medical staff on all parenteral medications, preparation of cyto- (24) Floorstock medications shall be limited medication matters. A formulary shall be toxic/hazardous medications, access to emer- to emergency and nonemergency medications established which includes medications based gency spill supplies, special procedures/prod- which are authorized by the director of phar- on an objective evaluation of their relative ucts, sterilization, extemporaneous macy services in conjunction with nursing therapeutic merits, safety and cost and shall preparations and quality control. and administration. The criteria, utilization be reviewed and revised on a continual basis.
JASON KANDER (12/31/13) CODE OF STATE REGULATIONS 43 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
A medication use evaluation program shall be phone or verbal orders shall be accepted only incidents shall be reported to the appropriate established which evaluates the use of select- by authorized staff, immediately written and committee. Adverse medication reactions ed medications to ensure that they are used identified as such in the medical record and shall be reported to the prescriber and the appropriately, safely and effectively. Follow- signed by the ordering practitioner within a director of the pharmacy services. The medi- up educational information shall be provided time frame defined by the medical staff. cation administered and medication reaction in response to evaluation findings. shall be recorded in the patient’s medical (35) Medication orders shall be written record. Adverse medication reactions shall be (32) The pharmacist shall be available to par- according to policies and procedures and reviewed by the pharmacy and therapeutics ticipate with medical and nursing staff those written by persons who do not have committee and other medical or administra- regarding decisions about medication use for independent statutory authority to prescribe tive committees when appropriate. individual patients, including: not to use shall be included in the quality improvement medication therapy; medication selection, program. AUTHORITY: sections 192.006 and 197.080, dosages, routes and methods of administra- RSMo 2000 and 197.154, RSMo Supp. tion; medication therapy monitoring; provi- (36) Automatic stop orders for all medica- 2007.* This rule previously filed as 19 CSR sion of medication-related information; and tions shall be established and shall include a 30-20.021(3)(G). Original rule filed June 27, counseling to individual patients. The phar- procedure to notify the prescriber of an 2007, effective Feb. 29, 2008. macist or designee shall personally offer to impending stop order. A maximum stop provide medication counseling when dis- order shall be effective for all medications *Original authority: 192.006, RSMo 1993, amended charge or outpatient prescriptions are filled. which do not have a shorter stop order. Auto- 1995; 197.080, RSMo 1953, amended 1993, 1995; and The pharmacist shall provide requested coun- matic stop orders are not required when the 197.154, RSMo 2004. seling. pharmacist continuously monitors medica- tions to ensure that they are not inappropri- (33) Medication orders shall be initiated or ately continued. 19 CSR 30-20.102 Radiology Services in modified only by practitioners who have Hospitals independent statutory authority to prescribe (37) Medications shall be administered only or who are legally given authority to order by persons who have statutory authority to PURPOSE: This rule establishes the require- medications. That authority may be given administer or who have been trained in each ments for radiology services in a hospital. through an arrangement with a practitioner pharmacological category of medication they who has independent statutory authority to administer, and administration shall be limit- (1) Radiographic and fluoroscopic diagnostic prescribe and who is a medical staff member. ed to the scope of their practice. Persons services shall be provided in each hospital. The authority may include collaborative prac- who do not have statutory authority to admin- tice agreements, protocols or standing orders ister shall not administer parenteral medica- (2) The director of radiology services shall be and shall not exceed the practitioner’s scope tions, controlled substances or medications a qualified physician member of the medical of practice. Practitioners given this authority that require professional assessment at the staff and appointed by the governing body. who are not hospital employees shall be time of administration. A person who has This physician shall be responsible for imple- approved through the hospital credentialing statutory authority to administer shall be menting the rules of the medical staff govern- process. When hospital-based agreements, readily available at the time of administra- ing the quality and scope of radiology ser- protocols or standing orders are used, they tion. Training for persons who do not have vices and safety precautions to protect shall be approved by the pharmacy and thera- statutory authority to administer shall be doc- patients and personnel. peutics or equivalent committee. umented and administration by those persons shall be included in the quality improvement (3) Radiotherapy services shall be adminis- (34) All medication orders shall be written in program. Medications shall be administrated tered only under the supervision of a physi- the medical record and signed by the ordering only upon the order of a person authorized to cian appropriately qualified by special train- practitioner with the exception of influenza prescribe or order medications. Administra- ing and experience. and pneumococcal polysaccharide vaccines, tion by all persons shall occur according to which may be administered per physician- the hospital’s policies and procedures. approved hospital policy/protocol after an (4) Requests for radiology services shall be assessment for contraindications. When med- (38) Medications brought to the hospital by authenticated in the patient’s medical record ication therapy is based on a protocol or patients shall be handled according to poli- by the attending physician, licensed house standing order and a specific medication cies and procedures. They shall not be staff or other medical staff member autho- order is not written, a signed copy of the pro- administered unless so ordered by the pre- rized to request radiologic services. tocol or of an abbreviated protocol containing scriber and identified by the pharmacist or the medication order parameters or of the the prescriber. (5) A written interpretation, authenticated by standing order shall be placed in the medical a radiologist or other medical staff member record with the exception of physician- (39) Medications shall be self-administered appropriately trained and qualified through approved policies/protocols for the adminis- or administered by a responsible party only the medical staff credentialing process, shall tration of influenza and pneumococcal upon the order of the prescriber and accord- be made for all radiological diagnostic ser- polysaccharide vaccines after an assessment ing to policies and procedures. vices. for contraindications. The assessment for contraindications shall be dated and signed by (40) Medication incidents, including medica- (6) Documentation of each radiotherapy treat- the registered nurse performing the assess- tion errors shall be reported to the prescriber ment shall be authenticated and become a ment and placed in the medical record. Tele- and the appropriate manager. Medication part of the patient’s medical record.
44 CODE OF STATE REGULATIONS (12/31/13) JASON KANDER Secretary of State Chapter 20—Hospitals 19 CSR 30-20
(7) A qualified radiologic technologist shall CSR 30-20.021(3)(I). Original rule filed June (3) Each hospital shall develop a mechanism be on duty or on call at all times. Emergency 27, 2007, effective Feb. 29, 2008. for the identification and abatement of occu- radiologic services shall be available at all pant safety hazards in their facilities. Any times. *Original authority: 192.006, RSMo 1993, amended 1995 safety hazard or threat to the general safety of and 197.080, RSMo 1953, amended 1993, 1995. patients, staff or the public shall be correct- (8) Protection from radiation to patients and ed. personnel shall comply with 19 CSR 20- 19 CSR 30-20.106 Inpatient Care Units in 10.010–19 CSR 20-10.190. Hospitals (4) Each hospital shall develop and maintain current a disaster plan which is specified to (9) There shall be periodic inspection of PURPOSE: This rule establishes classifica- its facility for response to man-made or natu- equipment by a medical physicist qualified to tions for hospitals. ral disasters. Annex 1 of NFPA 99, 1993 furnish complete evaluation. Documentation shall be used as a guide in the preparation shall be maintained and available for two (2) (1) A facility to be classified as a general hos- and revision of the hospital’s health care dis- years. pital shall provide inpatient care for medical aster plan. or surgical patients, or both, and may include AUTHORITY: sections 192.006 and 197.080, pediatric, obstetrical and newborn, psychi- AUTHORITY: sections 192.006 and 197.080, RSMo 2000 and 197.154, RSMo Supp. atric or rehabilitation patients. To be classi- RSMo 2000.* This rule previously filed as 19 2007.* This rule previously filed as 19 CSR fied a specialized pediatric, psychiatric or CSR 30-20.021(3)(K). Original rule filed 30-20.021(3)(H). Original rule filed June 27, rehabilitation hospital, a facility shall provide June 27, 2007, effective Feb. 29, 2008. 2007, effective Feb. 29, 2008. inpatient care in an exclusive specialty such as pediatrics, psychiatry or rehabilitation and *Original authority: 192.006, RSMo 1993, amended 1995 *Original authority: 192.006, RSMo 1993, amended shall have a medical staff and other profes- and 197.080, RSMo 1953, amended 1993, 1995. 1995; 197.080, RSMo 1953, amended 1993, 1995; and sional or technical personnel especially qual- 197.154, RSMo 2004. ified in the particular specialty for which the hospital is operated. 19 CSR 30-20.110 Orientation and Contin- uing Education 19 CSR 30-20.104 Social Work Services in AUTHORITY: sections 192.006 and 197.080, Hospitals RSMo 2000 and 197.154, RSMo Supp. PURPOSE: This rule specifies the require- 2007.* This rule previously filed as 19 CSR ments for orientation and continuing educa- PURPOSE: This rule establishes the require- 30-20.021(3)(J)1. Original rule filed June 27, tion programs in hospitals. ments for social work services in a hospital. 2007, effective Feb. 29, 2008. (1) There shall be an orientation and contin- (1) The program shall include: a method of *Original authority: 192.006, RSMo 1993, amended uing education program for the development 1995; 197.080, RSMo 1953, amended 1993, 1995; and screening to determine the social service and improvement of necessary skills and 197.154, RSMo 2004. needs of the patient; a method of providing knowledge of the facility personnel. appropriate social work interventions, includ- ing discharge planning and counseling; and a 19 CSR 30-20.108 Fire Safety, General (2) The orientation program shall be of the mechanism for referrals to community agen- Safety and Operating Features for Hospi- scope and duration necessary to effectively cies when appropriate. tals prepare personnel new to a unit for their assigned duties and responsibilities based on (2) The social service program shall be iden- PURPOSE: This rule specifies the require- job descriptions. Temporary personnel shall tified and integrated in the total hospital orga- ments for fire safety, general safety and oper- have documented evidence of hospital and nizational plan. Social work services shall be ating features in a hospital. unit specific orientation prior to providing provided under the direction of a qualified direct patient care. social services worker. When the individual (1) Each hospital shall comply with the is not a qualified social worker, a qualified “Operating Features” requirements of Chap- (3) Educational programs shall be conducted social worker shall be employed on a part- ter 31 of NFPA 101, 1994. New hospitals or using internal or external resources and shall time or consultant basis. portions of hospitals constructed or remod- be planned and documented. Documentation eled after the effective date of this amend- on the topic, presenter, date/time of presenta- (3) Social work services including discharge ment shall be maintained so that the building tion, and the program attendance shall be planning shall be integrated with other direct and its various operating systems comply available. patient-care services of the hospitals. The with NFPA 99, 1993 and NFPA 101, 1994. social work assessment and plan of action Existing hospital facilities constructed prior (4) Educational resources and suitable refer- shall be implemented for each patient who to the effective date of this amendment shall ences shall be identified and supplied as has need for social services. maintain and operate the building in compli- needed for the staff of each department or ance with the design and safety regulations in unit that provides direct patient care. (4) Written policies and procedures relating effect at the time of their construction. to the quality and scope of social work ser- (5) The orientation and continuing education vices shall be kept current. (2) Each hospital shall be maintained in good program shall participate in the performance repair to facilitate the maintenance of an improvement process and shall provide evalu- AUTHORITY: sections 192.006 and 197.080, appropriate health care delivery environment ation opportunities appropriate to its goals RSMo 2000.* This rule previously filed as 19 and to minimize hazards. and objectives.
JASON KANDER (12/31/13) CODE OF STATE REGULATIONS 45 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
(6) The orientation and continuing education (2) This plan shall be designed to measure, 19 CSR 30-20.114 Environmental Waste program shall include, as appropriate for the assess, and improve the quality of patient care Management and Support Services job, but not be limited to: as evidenced by patient health outcomes or (A) Problems and needs of specific age improvement in processes, or both. PURPOSE: This rule specifies the require- groups, chronically ill, acutely ill, and dis- ments for environmental and support services abled patients; (3) The performance improvement plan shall provided by a hospital. (B) Prevention, cause, effect, transmis- be written and shall include: sion, and control of infections including uni- (A) Description of the plan purpose, objec- (1) Each hospital shall have an organized ser- versal precautions; tives, organizations, scope, authority, respon- vice which maintains a clean and safe envi- (C) Reporting employee infections and sibility, and mechanisms of a planned system- ronment. injuries; atic, organization-wide approach to designing, (A) Housekeeping Services. (D) Customer service, teamwork, and measuring, assessing, and improving perfor- 1. The housekeeping services shall have communication skills; mance; a director who is qualified by education, (E) Fire prevention, safety, and accident (B) Assurance of collaborative participa- training, and experience in the principles of prevention; tion from appropriate departments and ser- hospital housekeeping. This individual shall (F) Patient rights including dignity, han- vices, both clinical and nonclinical, including report to a designated administrative officer dling grievances, Health Insurance Portabili- those services provided directly and under or his or her designee. ty and Privacy Act of 1996 (HIPAA), and pri- contract; 2. Approved written policies and proce- vacy issues; (C) Provision for assessment and coordina- dures shall define and describe the scope of (G) Licensed nursing personnel training on tion of quality improvement activities through housekeeping services. These shall be basic cardiac life support and choking pre- an established oversight team that meets on reviewed in cooperation with the infection pre- vention and intervention; an established periodic basis; vention control program, kept current per hos- (H) Prevention, identification, minimiza- (D) Assurance of ongoing communication, pital policy, and be readily available to staff. tion, and reporting of patient and employee reporting, and documentation of patient-care 3. Adequate space for housekeeping ser- safety risks; issues and quality improvement activities and vices shall be provided. (I) Prevention, detection, intervention, and their effectiveness to the governing body and 4. There shall be sufficient trained per- reporting abuse and neglect; medical staff at least quarterly; and sonnel to meet the needs of housekeeping ser- (J) Responsibilities during internal and (E) Development of an annual assessment vices. of the effectiveness of the plan. external disasters; 5. All solid waste generated within the (K) Tobacco-free policy; and hospital shall be collected in appropriate con- (4) At a minimum, the plan shall include: (L) Any other educational need identified tainers for disposal. (A) Organization-wide design, measure- through the quality improvement activities 6. There shall be a process for the review ment, assessment, and improvement of patient and those generated by advances made in and evaluation on a regular basis of the quali- care and organizational functions; health care science and technology. ty of housekeeping services provided. (B) Review of care that includes outcomes (B) Laundry and Linen Services. of care provided by the medical and nursing (7) Competency of all employees shall be 1. The hospital shall have organized ser- staff and by other health care practitioners evaluated annually based on job description vices which ensure that adequate supplies of employed or contracted by the hospital; and necessary job skills and knowledge. clean linens are available. There shall be spe- (C) Measurements of quality of care which cific written procedures for the processing, are outcome- or process-based, specific to AUTHORITY: section 192.006, RSMo 2000, distribution, and storage of linen. These shall the hospital, and to identified needs and and section 197.080, RSMo Supp. 2013.* be reviewed in cooperation with the infection expectations of the patients and staff; control committee and kept current. This rule previously filed as 19 CSR 30- (D) Review on a continuing basis of the 20.021(3)(L). Original rule filed June 27, 2. Soiled linen processing functions processes that affect a large percentage of shall be physically separated from both clean 2007, effective Feb. 29, 2008. Amended: patients, that place patients at risk or that Filed June 6, 2013, effective Jan. 30, 2014. linen storage and soiled linen holding areas. have caused or are likely to cause quality Only commercial laundry equipment shall be problems; and *Original authority: 192.006, RSMo 1993, amended 1995 used to process hospital linen. (E) The performance improvement plan and 197.080, RSMo 1953, amended 1993, 1995, 2013. 3. Clean linen shall be stored and dis- shall be designed to review activity, actions tributed to the point of use in a way that min- initiated, and reassessments. Documentation imizes microbial contamination from surface 19 CSR 30-20.112 Quality Assessment and shall be maintained on these activities. contact or airborne particles. Performance Improvement Program 4. Soiled linen shall be collected at the AUTHORITY: section 192.006, RSMo 2000, point of use and transported to the soiled and sections 197.080 and 197.154, RSMo PURPOSE: This rule specifies the require- linen holding room in a manner that mini- Supp. 2013.* This rule previously filed as 19 ments for quality improvement programs in a mizes microbial dissemination into the envi- CSR 30-20.021(3)(M). Original rule filed hospital. ronment. June 27, 2007, effective Feb. 29, 2008. 5. If a commercial laundry service is Amended: Filed June 6, 2013, effective Jan. (1) The governing body shall ensure the used, verification shall be provided to assure 30, 2014. development and implementation of an effec- the hospital that the processing and handling tive, ongoing, systematic hospital-wide, *Original authority: 192.006, RSMo 1993, amended of linen complies with paragraphs (1)(B)1.–4. patient-oriented quality assessment and per- 1995; 197.080, RSMo 1953, amended 1993, 1995, 2013; of this rule and by following manufacturer formance improvement plan. and 197.154, RSMo 2004. recommendations.
46 CODE OF STATE REGULATIONS (12/31/13) JASON KANDER Secretary of State Chapter 20—Hospitals 19 CSR 30-20
6. There shall be a process for the tious waste is compacted, the mechanical waste generated off-site may be accepted by a review and evaluation on a regular basis of device shall contain the fluids and aerosols hospital only if packaged according to 10 the quality of laundry and linen services pro- and shall not release aerosols or fluids when CSR 80-7.010(2)(A)–(D). vided. opened and the container is removed. Provi- (D) Medication Waste Management. (C) Infectious Waste Management sions for waste stored seventy-two (72) hours 1. Disposal of unwanted medications 1. The director of this program shall be or more shall be separately addressed in the and medication waste shall be identified in qualified by education, training, and experi- infectious waste management plan to include the following categories: general, controlled ence in the principles of infectious waste proper storage, handling, and disposal by substances, radiologic, infectious, and haz- management. commercial vendors when utilized. ardous. Medication waste shall include mate- 2. Every hospital shall write an infec- 6. Hospital infectious waste treated on tious waste management plan with an annual site shall be rendered innocuous, using one rials contaminated with such medications. review identifying infectious waste generated (1) of the following methods: A. Specific waste streams shall be on-site, the scope of the infectious waste pro- A. Sterilization of the waste in an identified for each category including storage gram, and policies and procedures to imple- autoclave is permitted, provided that the unit container type, storage prior to disposal, and ment the infectious waste program. The plan is operated in accordance with the manufac- final disposition. shall include at least the following: turer’s recommendations and that the auto- B. Medications shall be returned to A. Contact information for responsible clave’s effectiveness is verified at least week- the pharmacy for disposal except— individuals; organizational chart; schematic(s) ly with a biological spore assay containing (I) Single doses that may be dis- of waste disposal routes; definition of those Bacillus Stearothermophilus. If the autoclave posed of by medication staff at the time of wastes handled by the system; department and is used for other functions, the infectious administration; individual responsibilities; hospital policies waste management plan will develop specific (II) Doses that are an infectious and procedures for waste identification, segre- guidelines for its use; hazard; and gation, containment, transport, treatment, and B. Decontamination of the infectious (III) Radiopharmaceuticals. disposal; emergency and contingency proce- waste by other technologies in a manner C. Medications shall be disposed of dures; training and educational procedures; acceptable to the Department of Health and according to the Missouri Department of Nat- and appendices (rules and other applicable Senior Services shall be permitted; institutional policy statements). C. Bulk blood, suctioned fluids, ural Resources, the United States Food and B. Any hospital exempt from infec- excretions, and secretions may be carefully Drug Administration, and the United States tious waste processing facility permit require- poured down a drain connected to a sanitary Environmental Protection Agency. ments of 10 CSR 80-7.010 and that accepts sewer; or D. Disposal of controlled substances infectious waste from off-site shall include in D. Infectious waste rendered innocu- shall be according to 19 CSR 30-1.078. its plan requirements for storage, processing, ous by the methods in subparagraphs E. Unused radiopharmaceuticals shall and record keeping of this waste and the (1)(C)6.A. or B. of this rule shall be disposed be returned to the supplier or held and dis- cleanup of potential spills in the unloading of in accordance with the requirements of 10 posed of according to Nuclear Regulatory area. CSR 80-7.010. Commission guidelines. C. Manufacturers’ specifications for 7. An infectious waste treatment pro- F. Disposal of hazardous medications temperature, residence time, and control gram shall include records of biological spore including, but not limited to, antineoplastic devices for any infectious waste processing assay tests if required by treatment methods medications shall be handled as follows: devices shall be included in the plan. and the approximate amount of waste disin- (I) Personnel who handle hazardous 3. A trained operator shall operate the fected per hour measured by weight per load. medications and/or medication waste shall be equipment during any infectious waste treat- The program director shall maintain records trained regarding collection, transportation, ment procedures. demonstrating the proper operation of the dis- 4. Infectious waste shall be segregated infection equipment. containment, segregation, manifest, and dis- from other wastes at the point of generation 8. All infectious waste when transported posal; and and shall be placed in distinctive, clearly off the premises of the hospital shall be pack- (II) Waste shall be contained and marked, leakproof containers or plastic bags aged and transported as provided in sections segregated from other waste in leak proof appropriate for the characteristics of the 260.200–260.207, RSMo. containers clearly labeled with a statement infectious waste. Containers for infectious 9. Any hospital which accepts infectious such as CAUTION: HAZARDOUS CHEMI- waste shall be identified with the universal waste from small quantity generators as CAL WASTE and held in a secure place until biological hazard symbol. All packaging shall defined by 10 CSR 80-7.010 or from other disposed. maintain its integrity during storage and Missouri hospitals—in quantities exceeding transport. Infectious waste shall not be placed fifty percent (50%) of the total poundage of AUTHORITY: section 192.006, RSMo 2000, in a gravity waste disposal chute. infectious waste generated on-site at the hos- and sections 197.080 and 197.154, RSMo 5. Pending disposal, infectious waste pital—shall notify the Department of Natural Supp. 2013.* This rule previously filed as 19 shall be stored, separated from other wastes, Resources and comply with permitting CSR 30-20.021(5)(A), (C), and (D). Original in a limited-access enclosure posted with the requirements of sections 260.200–260.207, rule filed June 27, 2007, effective Feb. 29, biological hazard symbol. This enclosure RSMo. The weight of infectious waste gener- 2008. Amended: Filed June 6, 2013, effective shall afford protection from vermin, be a dry ated on-site shall be calculated by multiplying Jan. 30, 2014. area, and be provided with an impervious one and five-tenths (1.5) pounds per day floor with a perimeter curb. The floor shall times the number of beds complying with *Original authority: 192.006, RSMo 1993, amended slope to a drain connected to the sanitary Department of Health and Senior Services 1995; 197.080, RSMo 1953, amended 1993, 1995, 2013; sewage system or collection device. If infec- standards for hospital licensure. Infectious and 197.154, RSMo 2004.
JASON KANDER (12/31/13) CODE OF STATE REGULATIONS 47 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
19 CSR 30-20.116 Infection Control in incorporate any subsequent amendments or rules of the medical staff governing the qual- Hospitals additions. At a minimum, the program shall ity and scope of outpatient services provided. require every health care worker to properly PURPOSE: This rule specifies the require- wash or sanitize his or her hands immediate- (2) Outpatient services shall be integrated ments for infection control practices in a hos- ly before and immediately after each and with other hospital services as required to pital. every episode of patient care. Procedures meet the needs of the patient. shall include, at a minimum, requirements PUBLISHER’S NOTE: The secretary of state for the facility’s infection control program to (3) Nursing personnel assigned to outpatient has determined that the publication of the conduct surveillance of personnel in accor- services shall be under the supervision of a entire text of the material which is incorpo- dance with section 197.150, RSMo. Surveil- qualified registered professional nurse with rated by reference as a portion of this rule lance procedures may also include monitor- relevant education, experience, and demon- would be unduly cumbersome or expensive. ing the employees’ and medical staff’s use of strated current competency. This material as incorporated by reference in hand hygiene products. A mechanism (4) Approved written policies and procedures this rule shall be maintained by the agency at approved by the hospital infection control shall describe the scope of outpatient care its headquarters and shall be made available committee for reporting and monitoring provided. Policies and procedures shall be to the public for inspection and copying at no patient and employee infections shall be reviewed, kept current per hospital policy, more than the actual cost of reproduction. developed for all patient care and support and made readily available to staff. This note applies only to the reference mate- departments in the hospital. rial. The entire text of the rule is printed (5) Outpatient services shall be staffed by here. (4) Orientation and ongoing education shall personnel qualified by education, training, be provided to all patient care and patient- and experience to provide safe patient care. (1) There shall be an active multidisciplinary care support personnel on the cause, effect, infection control committee responsible for transmission, prevention and elimination of (6) Patient’s medical records shall reflect out- implementing and monitoring the infection infections. Records of employee attendance patient care and treatment provided. These control program. The committee shall shall be retained and available for inspection. records shall be filed and maintained under include, but not be limited to, the infection A mechanism for monitoring compliance supervision of the medical records depart- control officer, a member of the medical with infection control policies and procedures ment. staff, registered professional nursing staff, shall be coordinated with administrative staff, quality improvement staff and administration. personnel staff and the quality improvement (7) There shall be a process for the review This program shall include measures for pre- program. and evaluation on a regular basis of the qual- venting, identifying, and investigating health- ity and appropriateness of outpatient services care-associated infections and shall establish (5) Infection control committee meetings provided. procedures for: collecting data, conducting shall be held quarterly. Minutes shall be root cause analysis, reporting sentinel events, retained. AUTHORITY: section 192.006, RSMo 2000, and implementing corrective actions. These and sections 197.080 and 197.154, RSMo measures and procedures shall be applied (6) There shall be an annual review and eval- Supp. 2013.* This rule previously filed as 19 throughout the hospital, including as a part of uation of the quality of the infection control CSR 30-20.021(4)(A). Original rule filed the employee health program. program. June 27, 2007, effective Feb. 29, 2008. Amended: Filed June 6, 2013, effective Jan. (2) The infection control committee shall AUTHORITY: sections 192.006 and 197.080, 30, 2014. conduct an ongoing review and analysis of RSMo 2000 and 197.150 and 197.154, RSMo healthcare-associated infections (HAI) data Supp. 2007.* This rule previously filed as 19 *Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995, 2013; and risk factors. Priorities and goals related CSR 30-20.021(5)(B). Original rule filed and 197.154, RSMo 2004. to preventing the acquisition and transmission June 27, 2007, effective Feb. 29, 2008. of potentially infectious agents will be estab- lished based on risks identified. *Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; 19 CSR 30-20.120 Anesthesia Services in 197.150, RSMo 2004; and 197.154, RSMo 2004. Hospitals (3) Hospitals shall implement written policies and procedures outlining infection control PURPOSE: This rule specifies the require- measures. These measures shall include, but 19 CSR 30-20.118 Outpatient Services in ments for anesthesia services in a hospital. are not limited to, a hospital-wide hand Hospitals hygiene program that complies with the (1) Anesthesia services, if provided, shall be October 25, 2002 Centers for Disease Con- PURPOSE: This rule specifies the require- under the medical direction of a qualified trol and Prevention (CDC) Guideline for ments for outpatient services provided by a physician member of the medical staff and Hand Hygiene in Health-Care Settings, hospital. appointed by the governing body. This physi- which is incorporated by reference in this cian shall be responsible for implementing rule. A copy of the CDC Guideline for Hand (1) Outpatient services, if provided through the rules of the medical staff governing the Hygiene in Health-Care Settings may be an organized department of the hospital, shall quality and scope of anesthesia care provid- obtained from the Superintendent of Docu- be under the medical direction of qualified ed. ments, U.S. Government Printing Office physician member(s) of the medical staff and (GPO), Washington, DC 20402-9371; tele- appointed by the governing body. The physi- (2) Approved written policies and procedures phone: (202) 512-1800. This rule does not cian(s) shall be responsible for implementing shall include: patient and employee safety,
48 CODE OF STATE REGULATIONS (12/31/13) JASON KANDER Secretary of State Chapter 20—Hospitals 19 CSR 30-20
pre- and post-anesthesia evaluation, care of AUTHORITY: sections 192.006 and 197.080, dents to perform uncomplicated nursing pro- equipment, storage of anesthesia agents and RSMo 2000, and section 197.154, RSMo cedures and assist in direct patient care. the administration of anesthesia. Supp. 2007. This rule previously filed as 19 CSR 30-20.021(4)(C). Original rule filed (1) Definitions Relating to this Rule. (3) Anesthesia shall be administered only by June 27, 2007, effective Feb. 29, 2008. (A) Acute care unit—an area of a hospital qualified anesthesiologists, physicians or den- Rescinded: Filed June 6, 2013, effective Jan. that provides care primarily for patients with tists trained in anesthesia, certified nurse 30, 2014. acute diseases or conditions. This does not anesthetists or supervised students in an include care provided in a long-term care unit approved educational program. such as a skilled nursing, intermediate care 19 CSR 30-20.124 Medical Services and residential care units. (4) An anesthesia record documenting the (B) Unlicensed Assistive Personnel care given shall be a permanent part of the PURPOSE: This rule specifies the require- (UAP)—unlicensed health care personnel patient’s medical record. ments for medical services in a hospital. who provide direct patient care twenty-five percent (25%) or more of the time, under the (5) The pre-anesthesia patient evaluation shall (1) Medical services, if provided, shall be delegation and supervision of a registered be accomplished by a physician and docu- under the medical direction of a qualified nurse. Individuals who provide a specific job mented within forty-eight (48) hours before physician member of the medical staff and function such as, but not limited to, phle- surgery and shall include the history and appointed by the governing body as chief of botomist, radiology technician or patient physical examination; anesthetic, drug and the medical services. This director shall be transporter are not included in this definition. allergy history; essential laboratory data; and responsible for implementing the rules of the other diagnostic test results to establish medical staff governing medical privileges (2) The hospital training policy for UAPs potential anesthetic risks. These procedures and the quality of medical care provided. shall include the following minimum stan- may be waived in the event of a life threaten- dards: ing emergency, provided the surgeon so certi- (2) Medical services shall be responsible for (A) The curriculum of the UAP Program fies on the patient medical record. the medical care of all patients except those shall consist of a standard plan of instruction under the care of physicians or other services (6) A post-anesthesia evaluation shall be doc- to include: as defined in the medical staff or governing 1. A minimum of seventy-five (75) umented in the patient’s medical record with- body bylaws. in twenty-four (24) hours after surgery. hours of classroom instruction. 2. Computer or paper-based learning (3) The activities of medical services shall be modules that provide documentation of com- (7) The use of flammable anesthetic agents integrated with other services in the hospital. shall be limited to those areas of the hospital pletion may be substituted for up to sixty (60) hours of classroom time. which comply with all applicable require- (4) There shall be a process for the review 3. A minimum of one hundred (100) ments of the Standard for Inhalation Anes- and evaluation on a regular basis of the qual- hours of clinical practicum. thetics 1980 published by the National Fire ity and appropriateness of medical services 4. Curriculum content of the program Protection Association. provided. shall include procedures and instructions on (8) Prior to surgery, the patient’s medical basic nursing skills including but not limited AUTHORITY: section 192.006, RSMo 2000, record shall contain evidence that the patient to the areas of: and sections 197.080 and 197.154, RSMo has been advised regarding the surgical pro- A. The Role of the UAP (ethics, law, Supp. 2013.* This rule previously filed as 19 cedure(s) contemplated, the type of anesthe- team member communication, observation, CSR 30-20.021(4)(D). Original rule filed sia to be administered and the risks involved reporting, documentation, medical terminol- June 27, 2007, effective Feb. 29, 2008. with each. Evidence that informed consent ogy); Amended: Filed June 6, 2013, effective Jan. has been given shall become a part of the B. Patient/Client Rights (Health 30, 2014. patient’s medical record. Insurance Portability and Accountability Act *Original authority: 192.006, RSMo 1993, amended (HIPAA), privacy, confidentiality, advanced (9) There shall be a mechanism for the review 1995; 197.080, RSMo 1953, amended 1993, 1995, 2013; directives, abuse and neglect, age specific and evaluation on a regular basis of the qual- and 197.154, RSMo 2004. care, cultural diversity, pain management, ity and scope of anesthesia services. restraint-free care, end-of-life care, death and dying, do not resuscitate (DNR) orders, post- AUTHORITY: sections 192.006 and 197.080, 19 CSR 30-20.125 Unlicensed Assistive mortem care); RSMo 2000 and 197.154, RSMo Supp. Personnel Training Program C. Vital Signs; 2007.* This rule previously filed as 19 CSR D. Basic Human Needs (age specific 30-20.021(4)(B). Original rule filed June 27, PURPOSE: This rule requires hospitals to cognitive/psychological/social needs, activi- 2007, effective Feb. 29, 2008. have a personnel training policy that requires ties of daily living, ambulation, positioning, unlicensed health care personnel who provide *Original authority: 192.006, RSMo 1993, amended personal care, elimination and toileting, 1995; 197.080, RSMo 1953, amended 1993, 1995; and direct patient care under the delegation and nutrition, hydration, feeding, bed making); 197.154, RSMo 2004. supervision of a registered nurse to complete E. Infection Control (universal pre- the Unlicensed Assistive Personnel (UAP) cautions, blood-borne pathogens, safe needle Training Program, which shall be used to devices, aseptic technique, hand washing, 19 CSR 30-20.122 Home-Care Services in prepare individuals for employment in hospi- gloving, isolation); Hospitals tals. This program shall be designed to teach F. Skin Care (wound care, pressure (Rescinded January 30, 2014) the knowledge and skills that will qualify stu- ulcers and prevention); and
JASON KANDER (12/31/13) CODE OF STATE REGULATIONS 49 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
G. Safety (cardiopulmonary resusci- tion; PURPOSE: This rule specifies the require- tation (CPR), allergies, fall prevention, envi- (B) Instructors shall hold a current license ments for obstetrical and newborn services in ronmental safety issues, fire/electrical, haz- or temporary permit to practice as a regis- a hospital. ardous materials transportation safety tered nurse in Missouri and have a minimum information (HAZMAT), emergency proce- of two (2) years of nursing experience in an (1) Obstetrical services, if provided, shall be dures, body mechanics). acute care, long-term care or ambulatory under the medical direction of a qualified 5. The clinical practicum of one hundred surgery facility within the prior five (5) physician member of the medical staff and (100) hours shall start after the student has years, or an experience as a clinical faculty appointed by the governing body. This physi- enrolled and started the course curriculum. member in a nursing program within the cian shall be responsible for implementing 6. Skill validation and knowledge verifi- prior five (5) years. An instructor’s nursing the rules of the medical staff governing cation is to be used to determine student com- license shall not be under current disciplinary obstetrical privileges, quality of obstetrical petence. action; care and patient safety. 7. Annual in-service training also shall (C) A clinical supervisor’s or preceptor’s occur as required under 19 CSR 30- nursing license shall not be under current dis- (2) Obstetrical services shall be supervised 20.021(3)(L)6. and 7. and (5)(B)4. ciplinary action or investigation; and by a qualified registered professional nurse (D) UAPs who have satisfied the training with relevant education, experience and (3) The hospital training policy for UAPs requirements of this rule and Licensed Prac- demonstrated current competency. shall begin three (3) months after the effec- tical Nurses may assist with the clinical tive date of this rule. UAP training shall be practicum under the direction of the course (3) The obstetrical nursing supervisor shall completed within ninety (90) days of employ- coordinator. have the authority to implement and enforce ment for any individual who is hired as a hospital policies and procedures governing UAP. UAPs from staffing agencies shall com- (5) A hospital or ambulatory surgical center obstetrical services and shall have the respon- ply with this regulation. A UAP shall not that provides training for UAPs shall meet the sibility for evaluating the competency of nurs- work in direct patient care, except as part of following training site requirements: ing personnel assigned to obstetrical services. their supervised practicum, until the entire (A) Provide designated space sufficient to UAP training requirements have been met. accommodate the classroom teaching portion (4) Facilities for obstetrical services shall be Hospitals shall not be required to meet the of the course or have a written agreement designed to prevent unauthorized traffic. UAP training requirements if an employee with another acute care hospital, an area demonstrates competency in the content areas vocational-technical school, a high school (5) Undelivered patients receiving intravenous required by this rule; in the duties specific to offering a health service occupation program, oxytocin shall be under continuous observa- their job and the patient population assigned a community college or a provider agency to tion by trained personnel. Induction or aug- mentation of labor with oxytocin may be ini- and: provide the classroom portion of the course; tiated only after a qualified physician has (A) Is enrolled in a professional or practi- (B) Provide on-the-job clinical practicum evaluated the patient, determined that induc- cal nursing education program and has or will or have a written agreement with one (1) or tion or augmentation is beneficial to the moth- complete within ninety (90) days a funda- more hospitals or ambulatory surgical centers er, fetus, or both, recorded the indication and mentals of nursing course; or in their vicinity to do so; established the plan of management. The (B) Was a professional nursing or practical (C) Assess and review the program and physician initiating these procedures shall be outcomes of any training provided by another nursing licensure candidate who failed to pass readily accessible to manage complications facility to ensure that all of the requirements the state licensure examinations in the past that arise during infusion and a physician of this rule have been met; three (3) years; or who has privileges to perform Caesarean (D) Maintain, either electronically or on (C) Is certified as a nursing assistant as deliveries shall be in consultation and readily paper in the employee’s personnel file, defined in section 198.082, RSMo; or accessible in order to manage any complica- records of course completion and competen- (D) Has documented experience as a nurse tions that require surgical intervention. assistant, emergency medical technician or cy for a minimum of three (3) years. Records surgical technician in the past three (3) years; shall be signed and dated by the course coor- (6) There shall be provision for isolation of or dinator and each of the instructors and clini- infants with known or suspected infections or cal supervisors verifying classroom time, (E) Has proof of completion of UAP train- communicable diseases. Policies and proce- clinical time and competency for each stu- ing program in Missouri or another state dures regarding isolation shall be integrated dent; and which meets the requirements of this rule with the hospital infection control program. (E) Provide a signed copy of the course within the last three (3) years; or completion and competency record to the stu- (F) Has completed a professional or dent, that includes the elements in subsection (7) Each newborn shall be identified by an licensed practical nursing program outside (5)(D) of this rule. acceptable method which includes the name, the United States and is awaiting the licensure date and time of birth, the infant’s sex and the examination in this country. AUTHORITY: section 197.287, RSMo 2000.* mother’s hospital number. Original rule filed Jan. 31, 2008, effective (4) The hospital training policy for UAPs Sept. 30, 2008. (8) A delivery room record shall be main- shall meet the following faculty qualifications tained. and responsibilities: *Original authority: 197.287, RSMo 2000. (A) A registered nurse shall be designated (9) A nursery shall be provided for care of the as the course coordinator and shall be respon- newborn. sible for all aspects of the course, and must 19 CSR 30-20.126 Obstetrical and New- supervise all classroom and clinical instruc- born Services in Hospitals (10) Hospitals with an obstetrical service
50 CODE OF STATE REGULATIONS (12/31/13) JASON KANDER Secretary of State Chapter 20—Hospitals 19 CSR 30-20
shall have at least one (1) premature-care ments for pediatric services in a hospital. (2) A qualified registered professional nurse incubator by an independent testing laborato- shall direct and evaluate the nursing care pro- ry. (1) The pediatric unit, if provided, shall be vided by post-anesthesia recovery services. under the medical direction of a qualified (11) All cases of acute infectious conjunctivi- physician member of the medical staff and (3) A post-anesthesia recovery record docu- tis (Ophthalmia neonatorum) shall be report- appointed by the governing body. This physi- menting patient care shall be a permanent ed immediately to the individual(s) responsi- cian shall be responsible for implementing part of the patient’s medical record. ble for the infection control program and to the rules of the medical staff governing the the local or district health department in quality and scope of pediatric services. (4) Patients receiving post-anesthesia recov- accordance with section 210.080, RSMo. ery care shall be closely observed by quali- (2) The pediatric unit shall be supervised by fied personnel until each patient is stabilized (12) All cases of epidemic diarrhea of the a qualified registered professional nurse with for safe transfer. Written procedures for dis- newborn shall be reported immediately to the relevant education, experience and demon- charge from the post-anesthesia recovery ser- individual(s) responsible for the infection strated current competency. vice shall be approved by the medical staff. control program and the local or district health department. (3) The pediatric supervisor shall have the (5) There shall be a mechanism for the review authority to implement and enforce hospital and evaluation on a regular basis of the qual- (13) Resuscitation, suction, oxygen, monitor- policies and procedures governing pediatric ity and appropriateness of post-anesthesia ing and newborn temperature control equip- services and shall have the responsibility for recovery services provided. ment shall be available for the care of new- evaluating the competency of nursing person- born. Supplies for the proper care of newborn nel assigned to pediatric services. AUTHORITY: sections 192.006 and 197.080, shall be available. RSMo 2000 and 197.154, RSMo Supp. (4) The pediatric unit shall be designed for 2007.* This rule was previously filed as 19 (14) An incubator or bassinet with controlled specific needs of children and located apart CSR 30-20.021(4)(G). Original rule filed temperature shall be available for each deliv- from adult patients and the newborn. June 27, 2007, effective Feb. 29, 2008. ery room and for transport to the nursery. (5) The pediatric unit shall have at least one *Original authority: 192.006, RSMo 1993, amended (15) Space shall be provided for the prepara- (1) room suitable for isolation. 1995; 197.080, RSMo 1953, amended 1993, 1995; and tion or the handling and storage of formula. 197.154, RSMo 2004. Separate refrigeration shall be provided for (6) Supplies and equipment required for formula. emergencies shall be readily available in the 19 CSR 30-20.132 Psychiatric Services in pediatric unit. (16) Eye care of newborn shall be in accor- Hospitals dance with section 210.070, RSMo. (7) There shall be a mechanism for the review PURPOSE: This rule specifies the require- (17) Written policies and procedures shall be and evaluation on a regular basis of the qual- ments for psychiatric services in a hospital. established to provide safe transport of ity and appropriateness of pediatric services infants within the hospital or to another provided. (1) Emergency psychiatric care. health-care facility. (A) If the hospital does not have a psychi- AUTHORITY: sections 192.006 and 197.080, atric unit, written policies and procedures (18) Written policies and procedures govern- RSMo 2000 and 197.154, RSMo Supp. shall be developed to provide for the safe ing special care programs shall be approved 2007.* This rule previously filed as 19 CSR management of patients requiring psychiatric by the medical staff and governing body. 30-20.021(4)(F). Original rule filed June 27, services until they can be safely transferred to 2007, effective Feb. 29, 2008. an appropriate facility. (19) There shall be a mechanism for the (B) Written policies shall be established review and evaluation on a regular basis of *Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; and regarding the use of restraints or seclusion. the quality of obstetrical and newborn ser- 197.154, RSMo 2004. These restraints or seclusion shall be used vices provided. only on the order of a physician. In the absence of a physician, a registered profes- AUTHORITY: sections 192.006 and 197.080, 19 CSR 30-20.130 Post-Anesthesia Recov- sional nurse shall make the decision that the RSMo 2000 and 197.154, RSMo Supp. ery Services in Hospitals use of a physical restraint or seclusion is the 2007.* This rule previously filed as 19 CSR least restrictive procedure appropriate at the 30-20.021(4)(E). Original rule filed June 27, PURPOSE: This rule specifies the require- time of the emergency situation. The physi- 2007, effective Feb. 29, 2008. ments for post-anesthesia recovery services in cian shall be notified immediately and a physician’s order obtained as soon as possible *Original authority: 192.006, RSMo 1993, amended a hospital. 1995; 197.080, RSMo 1953, amended 1993, 1995; and after the occurrence of an emergency. Physi- 197.154, RSMo 2004. (1) Post-anesthesia recovery services, if pro- cians’ orders for use of physical restraints or vided, shall be under the medical direction of seclusion shall be rewritten every twenty-four a qualified physician member of the medical (24) hours. A full record of any restriction of 19 CSR 30-20.128 Pediatric Services in staff and appointed by the governing body. activity for any patient shall be recorded on Hospitals This director shall be responsible for imple- the nurses’ notes and shall include the reason menting the rules of the medical staff govern- for restriction, the type of restriction used, PURPOSE: This rule specifies the require- ing post-anesthesia recovery services. the time of starting and ending the restriction
JASON KANDER (12/31/13) CODE OF STATE REGULATIONS 51 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
and regular observations of the patient while for patients; (7) The qualified therapist shall evaluate and restricted. (H) Activity therapy services shall be avail- reevaluate the therapy administered and this able with the services provided under the shall be documented in the patient’s medical (2) Acute psychiatric services. If a psychiatric direction of a qualified therapist. All therapy record. unit is designed within the hospital, it shall shall be given on the written order of a physi- comply with the following requirements as a cian and documented in the patients’ clinical (8) Space and equipment shall be provided to minimum: records; and meet the needs of rehabilitation services. (A) Psychiatric services shall be under the (I) There shall be a mechanism for the Space, supplies and equipment shall be main- medical direction of a qualified physician review and evaluation on a regular basis of tained to ensure patient safety. member of the medical staff and appointed by the quality and appropriateness of psychiatric (9) There shall be a mechanism for the review the governing body. The director shall be services provided. responsible for implementing rules of the and evaluation on a regular basis of the qual- ity and appropriateness of rehabilitation ser- medical staff governing psychiatric privi- AUTHORITY: sections 192.006 and 197.080, vices provided. leges, quality and scope of care and patient RSMo 2000 and 197.154, RSMo Supp. safety; 2007.* This rule previously filed as 19 CSR AUTHORITY: sections 192.006 and 197.080, (B) Psychiatric services shall be supervised 30-20.021(4)(H). Original rule filed June 27, RSMo 2000 and 197.154, RSMo Supp. by a qualified registered professional nurse 2007, effective Feb. 29, 2008. 2007.* This rule previously filed as 19 CSR with relevant education, experience and 30-20.021(4)(I). Original rule filed June 27, demonstrated current competency; *Original authority: 192.006, RSMo 1993, amended 2007, effective Feb. 29, 2008. (C) The psychiatric nursing supervisor 1995; 197.080, RSMo 1953, amended 1993, 1995; and 197.154, RSMo 2004. shall have the authority to implement and *Original authority: 192.006, RSMo 1993, amended enforce hospital policies and procedures gov- 1995; 197.080, RSMo 1953, amended 1993, 1995; and erning psychiatric care and shall have the 197.154, RSMo 2004. responsibility for evaluating the competency 19 CSR 30-20.134 Rehabilitation Services of all nursing personnel assigned to psychi- in Hospitals 19 CSR 30-20.136 Respiratory Care Ser- atric services; vices in Hospitals (D) Appropriate registered nurse staffing PURPOSE: This rule specifies the require- patterns shall be developed to meet the care ments for rehabilitation services in a hospi- PURPOSE: This rule specifies the require- needs and activity demands of each patient in tal. ments for respiratory care services in a hos- the psychiatric unit; pital. (E) New employees shall attend appropri- (1) The rehabilitation services, if provided, ate orientation, in-service and staff develop- shall be under the medical direction of a qual- (1) Respiratory care services, if provided, ment programs prior to being considered part ified physician member of the medical staff shall be under the medical direction of a qual- of the staff required to meet the minimum and appointed by the governing body. The ified physician member of the medical staff standards of patient care; director shall be responsible for implement- and appointed by the governing body. The (F) Written policies shall be established ing rules of the medical staff governing the director shall be responsible for implement- regarding the use of restraints or seclusion. quality and scope of rehabilitation services. ing rules of the medical staff governing the These restraints or seclusion shall be used quality and scope of respiratory care ser- only on the order of a physician. In the (2) Rehabilitation services shall be super- vices. absence of a physician, a registered profes- vised by a qualified physician or a qualified sional nurse shall make the decision that the therapist with relevant education and experi- (2) Respiratory care services shall be inte- use of a physical restraint or seclusion is the ence. grated within the total hospital organizational least restrictive procedure appropriate at the plan. time of the emergency situation. The physi- (3) Rehabilitation services shall be integrated (3) Respiratory care services shall be admin- cian shall be notified immediately and a within the total organizational plan and the istered under the direction of a qualified reg- physician’s order obtained as soon as possible director shall assist in the formulation of poli- istered or certified respiratory therapist or a after the occurrence of an emergency. Physi- cies and development of long-range planning registered professional nurse with relevant cian’s orders for use of physical restraints or affecting patient care. education and experience. seclusion shall be rewritten every twenty-four (24) hours. A full record of any restriction of (4) Therapy shall be administered in accor- (4) Therapy shall be administered in accor- activity for any patient shall be recorded on dance with a physician’s written orders and dance with a physician’s written orders and the nurses’ notes and shall include the reason shall be documented in the patient’s medical shall be documented in the patient’s medical for restriction, the type of restriction used, record. record. the time of starting and ending the restriction and regular observations of the patient while (5) Rehabilitation services shall be provided (5) Respiratory care services shall be provid- restricted; by qualified personnel. In-service shall be ed by qualified personnel. In-service shall be (G) The social work services staff shall be ongoing and documented. ongoing and documented. available to participate as members of the treatment team, exchanging information and (6) Approved written policies and procedures (6) Approved written policies and procedures evaluations with the attending physician and which define and describe the scope and con- which define and describe the scope and con- other professional disciplines in order to duct of rehabilitative care shall be reviewed duct of respiratory care shall be reviewed insure a comprehensive treatment program annually and revised as necessary. annually and revised as necessary.
52 CODE OF STATE REGULATIONS (12/31/13) JASON KANDER Secretary of State Chapter 20—Hospitals 19 CSR 30-20
(7) A qualified registered or certified respira- (6) A multi-disciplinary committee, chaired to be administered and the risks involved with tory therapist or a registered professional by the director, shall develop protocols for the each. Evidence that informed consent has nurse shall evaluate and reevaluate the thera- conduct of patient care in each special care been given shall become a part of the py administered and this shall be documented unit. This committee shall meet at least quar- patient’s medical record. in the patient’s medical record. terly and minutes shall be kept and filed on a confidential basis. (7) An operating room record documenting (8) Space and equipment shall be provided to the patient care provided shall become a part meet the needs of respiratory care services. (7) There shall be a mechanism for the review of the patient’s medical record. The record and evaluation on a regular basis of the qual- Space, supplies and equipment shall be main- shall contain at least the name of the patient, ity and appropriateness of care provided in tained to ensure patient safety. the patient’s hospital number, the name of the each special care area. surgeon, name of surgical procedure(s), the date, time surgery began and ended, names (9) There shall be a mechanism for the review AUTHORITY: sections 192.006 and 197.080, and evaluation on a regular basis of the qual- and titles of persons assisting with the proce- RSMo 2000 and 197.154, RSMo Supp. dure and the verification of countable materi- ity and appropriateness of respiratory care 2007.* This rule previously filed as 19 CSR als. services provided. 30-20.021(4)(K). Original rule filed June 27, 2007, effective Feb. 29, 2008. (8) There shall be a mechanism for the review AUTHORITY: sections 192.006 and 197.080, and evaluation on a regular basis of the qual- RSMo 2000 and 197.154, RSMo Supp. *Original authority: 192.006, RSMo 1993, amended ity and appropriateness of surgical services. 2007.* This rule previously filed as 19 CSR 1995; 197.080, RSMo 1953, amended 1993, 1995; and 197.154, RSMo 2004. 30-20.021(4)(J). Original rule filed June 27, AUTHORITY: sections 192.006 and 197.080, 2007, effective Feb. 29, 2008. RSMo 2000 and 197.154, RSMo Supp. 19 CSR 30-20.140 Surgical Services in 2007.* This rule previously filed as 19 CSR *Original authority: 192.006, RSMo 1993, amended Hospitals 30-20.021(4)(L). Original rule filed June 27, 1995; 197.080, RSMo 1953, amended 1993, 1995; and 2007, effective Feb. 29, 2008. 197.154, RSMo 2004. PURPOSE: This rule specifies the require- ments for surgical services in a hospital. *Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; and 19 CSR 30-20.138 Special Patient Care (1) Surgical services, if provided, shall be 197.154, RSMo 2004. Services in Hospitals under the medical direction of a qualified physician member of the medical staff and PURPOSE: This rule specifies the require- appointed by the governing body. This physi- 19 CSR 30-20.142 Variance Requests ments for special patient care services in a cian shall be responsible for implementing hospital. rules of the medical staff governing the qual- PURPOSE: This rule specifies the manner ity and scope of surgical services. through which hospitals may request a vari- (1) Special care units, if provided, shall be ance from 19 CSR 30-20.001 through 19 CSR under the medical direction of a qualified (2) Approved written policies and procedures 30-20.140. physician, member of the medical staff and shall define and describe the scope and con- (1) Requests for variance from the require- appointed by the governing body. duct of surgical services. These shall be reviewed annually and revised as necessary. ments of 19 CSR 30-20.015 through 19 CSR 30-20.140 shall be in writing to the Depart- (2) Patient care in each special care unit shall ment of Health and Senior Services. Depart- be integrated with the other nursing services (3) The surgical suite shall be supervised by ment determinations in response to variance and supervised by a qualified registered a qualified registered professional nurse with relevant education, experience and demon- requests shall be in writing and both requests professional nurse with relevant education, strated current competency. This supervisor and determinations shall be made a part of experience and demonstrated current compe- shall have the authority to implement hospital the Department of Health and Senior Ser- tency. policies and procedures for the surgical suite vices permanent records for the facility. and shall have the responsibility for evaluat- (A) Requests shall contain at a minimum— (3) Approved written policies and procedures ing all nursing personnel assigned to the sur- 1. The section number and text of the shall define and describe the scope and con- gical suite. rule in question; duct of each special patient-care service. 2. Specific reasons why compliance These shall be reviewed annually and revised (4) A qualified registered professional nurse with the rule would impose an undue hard- as necessary. shall be assigned circulating duties for surgi- ship on the operator, including an estimate of cal procedures performed. any additional cost which might be involved; (4) Qualifications of personnel for assignment 3. An explanation of the extenuating fac- to each special care unit shall be delineated in (5) Accepted standards of patient care, steril- tors which may be relevant; writing. Orientation, in-service training and ity and aseptic techniques shall be main- 4. A complete description of the indi- continuing education shall be provided and tained. vidual characteristics of the facility or documented. patients or any other factors which would ful- (6) Prior to surgery, the patient’s medical fill the intent of the rule in question to safe- (5) Registered nurse staffing patterns shall be record shall contain evidence that the patient guard the health, safety, and the welfare of developed to meet the needs of each patient in has been advised as to the surgical proce- the patient, staff, or public if the variance special care units. dure(s) contemplated, the type of anesthesia from the requirement is granted; and
JASON KANDER (12/31/13) CODE OF STATE REGULATIONS 53 Secretary of State 19 CSR 30-20—DEPARTMENT OF HEALTH AND SENIOR SERVICES Division 30—Division of Regulation and Licensure
5. A length of time the variance is being requested.
(2) The department’s written determination shall identify a variance expiration date, if approved. The facility may re-apply for a variance up to ninety (90) days prior to the expiration of a department-approved vari- ance.
(3) Any facility granted a variance by the department shall inform the department in writing if the conditions warranting the vari- ance change. This written notification to the department shall be made within thirty (30) days of the change affecting the variance. The department may revoke the granted variance if the changes in conditions detrimentally impact the health, safety, and the welfare of the patient, staff, or public, as determined by the department.
(4) All previously approved variances shall be submitted at the time of annual licensure renewal.
AUTHORITY: section 192.006, RSMo 2000, and sections 197.080 and 197.154, RSMo Supp. 2013.* This rule previously filed as 19 CSR 30-20.021(1) and (1)(A). Original rule filed on June 27, 2007, effective Feb. 29, 2008. Amended: Filed June 6, 2013, effective Jan. 30, 2014.
*Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995, 2013; and 197.154, RSMo 2004.
54 CODE OF STATE REGULATIONS (12/31/13) JASON KANDER Secretary of State